MUMPS, MUMPS, DIPHTERIA, DIPHTERIA,
TETANUS AND TETANUS AND PERTUSISPERTUSIS
Prof. Dr. Ayça VİTRİNEL
MUMPS Mumps virus RNA virus of the genus
paramyxovirus in the family paramixo-viridae which also includes parainfluenza viruses.
Spread from human reservoir by direct contact, airborne droplets fomites contaminated by saliva and possibly urine.
Peak age: 5-9 yr (before vaccinatum)
MUMPS
Virus has been isolated from as long as 6 days up to 9 days after appereance of salivary gland swelling.
Isolated from urine from the 1st –14th day after the onset of salivary gland swelling .
Transmission doesn’t seen to occur more than 24 hr before the appereance of the swelling or later than 3 days after it has subsided.
MUMPS
Clinical Manifestations: Incubation period 14-24 days Prodrome : rare Salivary glands: Pain and swelling in
one /both parotid glands Swollen tissues push the ear lobe upward
and outward
MUMPS Angle of the mandible is no longer visible Swelling subsides within 3-7 days Swollen area is tender and painful pain being
elicited especially by tasting sour liquids such as lemon juice or vinegar
Redness and swelling about the opening of the Stenon duct are common
Edema over the manibrium and upper chest wall may occur lymphatic obstruction.
MUMPS
Swelling of submandibular glands occur frequently and usually accompany the parotid gland.
Least commonly the sublingual glands are infected.
MUMPS
Diagnosis: Clinical symptoms Physical appereance Laboratory : leukopenia (lymphocytosis)
elevations of serum amylase
Serology: IgM (in the first days) and IgG
Culture: saliva, CSF, blood, urine.
MUMPS
Treatment: no spesific antiviral treatment Supportive Complications: Meningoencephalomyelitis: most frequently
complication. Male/female: 3/1 Primary infection of nerves at the same time or
before primer parotitis Postinfectious encephalitis with demyelination
follows parotitis by an avarage of 10 days
MUMPS
Orchitis and epididymitis : adolescent and adults. Follows parotitis within 8 days.
Oophoritis Pancreatitis Thyroiditis Myocarditis Deafness Ocular complication Arthritis Prevention: mumps vaccine.
TETANUS
Acute spastic paralytic illness caused by tetanus toxin (tetanospasmin) a neurotoxin
C.tetani Gr (+), spore forming, obligate anaerobe. Natural habitat is soil, dust, alimentary tracts of various animals drumstic/tennis racket appereance micros-copically.
TETANUS
1) Neonatal 2) Nonneonatal travmatic injury,
penetrating injury infected by a dirty object use of contaminated suture material
Tetanus toxin binds at the neuromusculer junction endocytosed by the motor nerve axonal transport cytoplasm of motor neuron prevents neurotransmitter release
TETANUS
Blocks the normal inhibition of antagonis-tic muscles {basis of voluntary coordinated movement} : affected muscles sustain maximal contraction.
Clinical manifestations: 1) Localized 2) generalized: more common
TETANUS Incubation period: 2-14 days Trismus (masseter muscle spasm:
lockjaw) is presenting symptom Headache, restlessness, irritability
stiffness, difficulty chewing, disphagia, sardonic smile
Opistotonos : arched posture, neck muscle spasm
Laringeal and respiratory muscle spasm : airway obstruction
TETANUS
Patient remains conscious (tetanus toxin doesn’t affect sensory nerves or cortical function)
Smallest disturbance by slight sound, touch : trigger a tetanic spasm
Dysuria, urinary retention, forced defecation
Fever
TETANUS
Tachycardia, arythmics Labile hypertension Tetanic paralysis more severe in the 1st
week stabilizes in the 2nd week Localized: painful spasm of muscles
adjacent to the wound site
TETANUS
Cephalic tetanus: Rare form of localized tetanus involving the bulbar musculature that occurs with wound or foreign bodies in the head, nostrils or face.
Association with chronic otitis media. Retracted eyelids + trismus + risus sardo-
nicus + spastic paralysis of tongue and pharyngeal musculature.
TETANUS
Neonatal tetanus: 3-12 days after birth Difficulty in feeding Paralysis or diminished movement Stiffness to the touch Diagnosis: Clinically CSF: NORMAL
TETANUS
Differential diagnosis: acute encephalitis Rabies: CSF pleocytosis, hydrophobia Strychnine poisoning Hypocalsemia Retropharengeal, dental abscess: trismus
TETANUS
Treatment: eradication of C. tetani Neutralization of all accessible tetanus
toxin Control of seizure Supportive care Prevention of recurrences TIG (longer half life): Neutralizes the toxin
in the circulation before binding [3000-6000 U IM recommended ]
TETANUS TAT: bovine derived 50.000 – 100.000 U
½ IM + ½ IV risk of serum sickness. IVIG: Contains 4-90 U/ml TIG optimal
dosage is not known Antibiotics: Pen G : 100.000 U/kg/ 24 hr :
4-6 hr intervals 10-14 days Metronidazole: 500 mg of 8 hr equally
effective Erythromycin and tetracycline are
alternative for penicillin allergic patients.
TETANUS
Muscle relexants: diazepam: relexation and seizure control [0,1-0,2 mg/kg every 3-6 hr IV: 2-6 weeks] { 2yr ; 8mg/kg/day }
Baclofen : only in intensive care unit Neromuscular blocking agents M.V. Phenobarbital and morphine may also be
used as an adjunctive therapy
TETANUS
Prognosis: recovery in tetanus occurs through regeneration of synapses, within the spinal cord and restoration of muscle relexation . Episode of tetanus doesn’t result in the production of toxin neutralizing Abs : active immunization with tetanus toxoid at discharge
TETANUS
Favorable prognosis: long incubation period, absence of fever, localized disease
Prevention: active immunization, maternal immunization with at least 2 doses of tetanus toxoid, tetanus prophylaxis in wound management
Clean minor wound
Other wounds
Prior tetanus doses
Td TIG Td TIG
Uncertain or 3
Yes No Yes Yes
Three or more
No No No No
Yes if 10 yr since last dose
Yes if 5 yr since last dose
DIPHTERIA Acute toxicoinfection caused by Corynebacte-
rium diphteriae Gr (+) bacilli, aerobic Three biotypes mitis, gravis-least, intermedius-
most common Spread by airborne respiratory droplets , direct
contact with respiratory droplets, direct contact with respiratory secretions of symp individuals. Exudate from infected skin lesions
Asymtomatic respiratory tract carriers are important in transmission.
Entry of C. Diphtheriae in nose/mouth localized on the mucosal surface of URT toxin is adsorbed to cell membrane tissue necrosis patchy exudate initially be removed
As the toxin production increases the area of infection widens and deepens and a fibrinous exudate develops tough adherent pseudo-membrane is formed that varies from gray to black attemps to remove it are followed by bleeding.
DIPHTERIA
DIPHTERIA
Edema of the soft tissues bull neck appereance
Clinical manifestations: depend on the site of infection
Incubation period: 1-6 days Nasal diphteria: mild rhinorrhea nasal
discharge serosaguineous mucopurulent excoriates the nares, upper lip
DIPHTERIA
White membrane on the nasal septum Most often in infants Slow absorbtion of toxin lack of
systemic symptoms Tonsillar and/or pharyngeal diphteria: most
common site of disease Anorexia, malaise, low grade fever, pha-
rangitis [1-2 days] thin-gray membrane
DIPHTERIA adherent membrane may spread to cover
the tonsils and pharyngeal wall may progress [bleeding] in to the larynx and trachea
Cervical lymphadenitis : bull neck appere-ance
Respiratory and circulatory collaps may occur
Palatal paralysis may occur Stuppor, coma, death : wihin 7-10 days
DIPHTERIA
Laryngeal diphteria: represents a downward extension of the membrane for the pharynx
Occasionally only laryngeal involvement is present
Noisy breathing Progresive stridor, hoarseness Suprasternal, subcostal, supraclavicular
retractions
DIPHTERIA
Cutaneous diphteria: an ulcer with a sharpy defined border ,important source of person to person transmission
Conjunctival lesions: red, edematous, membranaeous , corneal erosion
Aural diphteria: otitis externa with a persistenly purulent and frequently faul smelling discharge
DIPHTERIA
Diagnosis: isolation of C. diphteria ( Loeffler, tellurite and blood agar)
WBC N/ Anemia; result of rapid hemolysis Toxigenicity by inoculating 2 guinea pigs
ID suspension of microorganism ( antitoxin/no antitoxin) 24 hr inflamatory lesion , 72 hr necrotic lesion
DIPHTERIA Complications: Myocarditis: 2nd week (1-6 wk)
ST-T changes 1st degree heart block, hearth failure, myocardial enzymes
Neurologic complications: Bilateral, usually resolve competely. Paralysis of the soft palate and pharengeal muscles (1-3 wk ). Ocular muscle and ciliar paralysis (5th wk). Paralysis of diaphragm (5-7 wk). Paralysis of the limbs with loss of deep tendon reflexes (2-7 wk)
Elevation of CSF protein, pleocytosis Hypotension, cardiac failure, gastritis, hepatitis,
nephritis
DIPHTERIA
Prevention: Immunization Contacts: Isolation of patient; three consecutive
(-) cultures. Cultures schould be taken from close contacts, observed for 7 days if C. diphteria is recovered treatment schould be instituted
Asymptomatic immune close contacts: receive a booster of DT, Td, if they haven’t received booster within 5 yr.
DIPHTERIA
Asymptomatic close contact is not immunized or the immunization status is unknown. He/she should be closely observed and started erythromicin (7 days) or benzathine pen G : culture should be obtained before and after treatment ,active immunization should be given.
DIPHTERIA
Treatment : Antitoxin must be administired as early as posible by IV route and in a dose sufficient to neutralize all free toxins
Desensitization must be done 20.000-40.000 U for pharyngeal/laryngeal 40.000-60.000 U nasopharyngeal 80.000-100.000 U extensive disease
DIPHTERIA
Penicillin (procain 300.000/600.000 U IM) erythromicin (40 mg/kg/day) 14 days
End point of therapy : three consecutive negative culture
Bed rest 2-3 wk Hydration Laryngeal diphteria; tracheostomy
PERTUSIS = WHOOPING COUGH
Acute respiratory infection Bordetella pertusis (B. Parapertusis, B.
Bronchiseptica) Gr (-) cocobacils Recovered best in Bordet Gengou media
(glyserin, patato, blood agar) Humans are the only known host Spread occurs by direct contact, by
respiratory droplets
PERTUSIS
Transplacental passage of maternal Ab does not protect the NB
Severe neonatal pertusis can be acquired from a mildly symptomatic mother.
Pathology: peribronchial lymphoid hyperplasia necrotizing process
Bronchopneumonia develops with necrosis and desquamation of superficial epithelium of small bronchi.
PERTUSSIS
Bronchiolar obstruction and atelectasis accumulation of mucus secretions
Bronchiectasis may develop Microscobic or gross cerebral hemorrhages
may be seen, cortical atrophy has been observed
Fatty infiltration of the liver B. Pertussis produces many biologically
active factors that are responsible for disease
PERTUSIS
Pertussis toxin, filamentous hemaglutinin etc Clinical manifestations: inc period : 6-20 days 1) catarhal stage: 1-2 wk rhinorhea, conjuctival
injection, lacrimation, mild cough, low grade fever
2) paroxysmal stage: 2-4 wk Repetitive series of 5-10 forceful cough during a
single expiration sudden massive inspiratory effort.
PERTUSIS
Prominent during attack: Facial redness/cyanosis Bulging eyes Protrusion of tongue Lacrimation, salivation Distention of neck veins
PERTUSIS
Attacks may be trigerred : yawning, sneezing, eating, drinking
Petechial/ conjuctival hemorrhages may be noted on the head and neck
Diagnosis: cough more than 2 wk duration with posttussive emesis is an important diagnostic clue.
PERTUSIS
Leukocytosis (20.000-50.000 /mm³) Absolute lymphocytosis Chest roentgen: perihilar infiltrates,
atelectasis, emphysema Spesific diagnosis: recovery of the
organism nasopharingeal swabs ELISA (IgM, IgG, IgA) PCR
PERTUSIS
Complications: 1) respiratory: pneumonia, atelectasis,
emphysema, pneumothorax, bronchiectasis, otitis media, epistaxis
2) pressure: intracranial hemmorhagea, subconjuctival hemmorhagea, epistaxis, rupture of diaphragma, umbical hernia, inguinal hernia, rectal prolapsus
3) other: convulsions, dehydration, nutritional dis
PERTUSIS
Prevention: vaccination Erythromycin effective in preventing
pertusis. Close contacts of less than 7 yr of age who
have been immunized previously booster dose, erythromicin 14 days 7yr , immunized erthromycin 14 days Treatment: erythromycin 50 mg/kg/day
(d4) 14 day
Teenager.wmv
Hispanic toddler.wmv
Toddler in crib_nofade.wmv