DIPHTHERIAICD 10 A36

DR NURDALILA SAHIDANKK KG GIALJUNE 2016

WHAT IS?

• Bacterial Infections- affecting nose and throat• Corynaebacterium diphtheria-produce toxin• Highly contagious• Is prevented with vaccination• Can also affecting skin- cutaneous diphtheria- action by

c.diphtheria and occasionaly by c. ulcerans*

THE BACTERIA• nonsporulating, unencapslated, non motile gram positive bacteria• It has 4 subspecies ( for now)-c.d gravis ,c.d. mitis, c.d. intermedius, and

c.d belfanti• It can be toxigenic= diphtheria ( alter protein fx in the host,inactivate

elongation factor EF-2)**• It can be nontoxigenic-mild sorethroat, rarely membranous pharyngitis*• Host can be carrier without sx• Humans are the only natural host

HOW IT IS SPREAD

• Droplets• Close physical contact• Direct contact with nasopharyngeal secretion of an

infected person• Skin abrasion

• (i) the catarrhal form (erythema of pharynx, no membranes)• (ii) the follicular form (patches of exudates over pharynx

and the tonsils)• (iii) the spreading form (membranes covering the tonsils

and posterior pharynx)• (iv) the combined form (more than one anatomical site

involved, for example throat and skin)

INCUBATION PERIOD

• 2 to 7 days or longer• Respiratory dipththeria usually occur after 5 days• Onset is slow from moderate fever and mild exudative

pharyngitis• Severe case- develop pseudomembrane

WHO CAN BE INFECTED?

• Immunised person• Partially immunised• Unimmunised

Less severe

HISTORY• 1613- epidemic in spain- the year of strangulation• 1735- epidemic in New England• 1826- pseudomembrane was described by Pierre Bretonneou• 1856- epidemic in California• 1878- Queen Victoria’s daughter Princess Alice infected. 2 royal family dead• 1883-Edwin Klebs identified the bacteria• 1888-1926- trials anti toxin, n thousand of deaths around the globe• 1946- outbreak after war in Europe. 1 million case, 50000 death• 1994-39703 in Russia• 2010- 1 case during Haiti earth quake• 2013- 3 children died in India• 2015- 1 case in Spain. First case after 1986• 2016- 2 children died in Malaysia- Malacca n Kedah

HOW ABOUT MALAYSIA?

SIGNS AND SYMPTOMS

• Respiratory• Cutaneous

Airway obstructi

on

Cutaneous

• caused by either toxigenic or nontoxigenic strains • is usually mild, typically consisting of nondistinctive sore

or shallow ulcers • rarely involving toxic complications (1- 2% of infections

with toxigenic strains).

Complications

• paralysis due to demyelinating peripheral neuritis • Myocarditis• Airway Obstruction• Renal insufficient• Toxaemia • Death

LAB DIAGNOSIS

• Swab from nose and throat ( or wound and skin)• Use polyester, nylon or rayon swab• Place in transport media such as Amies/ stuart and sent to

lab with ice pack• Dry swabs should be submitted in silica gel satchet• Pseudo membrane tissue- put in sterile saline and sent

with ice packs

TREATMENT

• Antibitotic• Anti-toxin

Antibiotic Dose Route Duration of treatment

Erythromycin Parentally: 40 to 50 mg / kg / day, maximum2 g / day When patient can swallow, take orally in 4 divided doses (or oral penicillin) 125 to 250 mg, 4 times a day

14 days

Aqueous crystalline Penicillin IM; 100,000 to 150,000 U/kg/day, in 4 divided doses

14 days

Aqueous Procaine Penicillin IM: Children: 25,000 to 50,000 U/kg/day, maximum 1.2 million U, in four divided doses Adults: 1.2 million U daily

14 days

No Types of diphtheria Dose (units) route

1 Nasal 10,000 – 20,000 i/m

2 Tonsillar 15,000 – 25,000 i/m or i/v

3 Pharyngeal or laryngeal 20,000 – 40,000 i/m or i/v

4 Combined types or delay diagnosis

40,000 – 60,000 i/v

5 Extensive disease of > 3 days duration and/or severe swelling of neck (bull-neck)

80,000 – 100,000 i/v or part i/v and part i/m

Anti-Toxin

• Resolved= two successive pairs of nose and throat cultures (and cultures of skin lesions in cutaneous diphtheriae) obtained ≥ 2 weeks after completion of abx therapy and ≥ 24 hours apart are negative

Important Points• Case definition:An illness of the upper respiratory tract characterised by

laryngitis or pharyngitis or tonsilitis and adherent membrane of the tonsils, pharynx and/or nose

• Cutaneous diphtheriae alone need not be reported• Close contacts are defined as those who sleep in the same house or who share

food, drink or eating / drinking utensils with the case. Definition includes health workers in contact with the case’s oral or respiratory secretions.

• Anyone who has been in close contact with a case of diphtheria caused by toxigenic C. diphtheriae or C. ulcerans (whatever the clinical presentation) in the previous seven days should be considered as potentially at risk

• Treatment for close contact: EES for 7 to 10 days (1 gram a day for adults, 40 mg/kg day in divided doses for children).

• Flow chart

• Flow Chart • Missed Vaccine

Vaccine save lives, fear endangers them. It’s a simple message parents need to

keep hearing.Those who ignore the history are doomed

to repeat it