Diphtheria

Although diphtheria is not very common but its also not very uncommon. Although there is immunization regarding diphtheria in expanded program of immunization in Pakistan but still we find cases off and on

1. Diphtheria BRIG(R) ANWAR UL HAQ ASSOCIATE PROFESSOR ENT CMH LAHORE MEDICAL COLLEGE

2. INTRODUCTION • Diphtheria is an highly infectious and communicable disease . Characteristics Involvement of the respiratory system Local production of membrane General symptoms caused by absorption of toxin

3. E P I D E M I O L O G I C A L T R I A D Agent ( Corny bacterium) Host Factors ( Children <5) Envrnt factors ( Winter month)

4. A g e n t C ornybacterium diphtheria Sources are cases and carriers Organism will be present in the nasopharyngeal secretions, skin lesion discharge, contaminated fomites and infected dust Period of infectivity is 14-28 days from the onset of diseases

5. H o s t f a c t o r s • • Affects children of 1-5 years of age It effects both sexes. Environmental factors All seasons Most common in winter

6. Mode of transmission • • • Droplet nuclie Infected cutaneous lesions Infected object or dust, contaminated with nasopharyngeal secretions

7. P o r t a l o f e n t r y Incubation period 2-6 days • • Respiratory route skin cuts and wounds Pharyngotonsillar diphtheria Laryngotracheal diphtheria Nasal diphtheria Cutaneous diphtheria Types of diphtheria

8. S i gn / sy m p t o m s P haryngotonsillar diphtheria Sore throat Difficulty in swalloing Low grade fever Membrane

9. Characristics of membrane In early stages Whitish membrane Wiped off easily over pharynx or tonsil Later stages Thick Blue –white to grey – black Adherent Difficult to remove If removed it will bleeding

10. Mucosal erythema around the membrane Edema of submandibular area Bull neck appearance

11. Laryngo tracheal diphtheria It is preceded by pharyngo-tosilar Charactristics Hoarseness of voice Brassy cough

12. Nasal Diphtheria Unilateral or bilateral Serosanguineous Blood and serous nasal discharge Excoriation of upper lip Toxemia is minimal

13. Cutaneous diphtheria  May occasionally involve skin or conjunctiva.

14. Differential diagnosis Membranous Tonsillitis Vincent’s Angina Infectious mononucleosis Agranulocytosis Leukemia Aphthous ulcers Traumatic ulcer Foreign body (Nasal Diphtheria)

15. D i a g no s i s Schick test Schick test toxin .2 ml is injected in to forearm as test arm and in to opposite arm control arm same amount of inactivated toxin ( IM) Positive Reaction Test arm- with in 24-36hrs, a circumscribed red flash of 10-15 diameter. It reaches maximum by 4 th to 7 th day and later on slowly fades in to brown patch Control arm- No change occurs

16. Prevention and control Early detection of cases and carriers Isolation Treatment Diphtheria antitoxins ranging 10,000 to 80,000 units or more are administered iv or im depending on severity of care 2.5 lakh unit penicillin QID for 5 days 250mg erythromycin QID

17. Treatment C a rr i e rs Oral erythromycin for 10 days C on t a cts If immunized previously with in 2 year No action needed If immunized long back ( more than 2 years) DT booster dose If not immunized at all Prophylactic benzathine penicillin or erythromycin + active immunization

18. Immunization Combined v accine as per national schedule Note- Vaccine should be kept in 4-8⁰C Use within a week from day of issue to sub centre

19. • A nt i s e r u m For treatm ent purpose Anti sera Purpose Dose Route Diphtheria anti toxin prophylactic 500-2000 unit S ubCut / IM Diphtheria anti Treatment 10,000 to IM toxin 30,000 unit or IV 40,000 to 1,00,000 unit ( 2 Doses with an interval of ½ to 2 hrs)

20. COMPLICATIONS Respiratory Failure – Occlusion of the airway by the membrane. Myocarditis – Occurs by 2 nd week. Can lead to CHF, arrhythmia or sudden death. Neurological – Palatal palsy Ocular Palsy Loss of accommodation Polyneuritis 4. Renal Complications – Oliguria / Proteinuria

21. SUMMARY • • • • Diphtheria is a endemic, respiratory tract , communicable disease comes under six killer disease caused by corny bacterium diphtheriae. Commonly seen in children less than five years and in winter season Mainly four types . Pharyngotonsilar, l ary n g o tr a c hea l , n a s a l an d c u t a n eou s . Diagnosed by Schick test / Albert stain / Culture. Early detection and treatment is the best way of prevention and control.