Diphteria 2015

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DIPHTERIADivision of Tropical and Infectious Diseases

Department of Internal MedicineBrawijaya University !aiful Anwar "eneral Hospital

Malan#

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A 16-year-old girl with a history of incomplete childhood immunization (shehad received only the first of three doses of the diphtheriapertussistetanusvaccine), residing in Malang, presented to the emergency department of the

aiful Anwar !eneral "ospital during the rainy season#

he had had a fever, severe sore throat, $ull nec%, hoarse voice, andshortness of $reath for & days# he appeared sic%, tachycardia with heartrate 11' $eats min normal $lood pressure 11' ' mm"g, respiratory ratewas *+ $reaths min, stridor and retraction at intercostals space was noted,she also had $ilateral, yellowish white pharyngeal patches with congestion#

A illar temperature * #*./, and a0+ 2 on room air#

3a$oratory results shows elevated white $lood cell count ++,66' 43 with

'2 polymorphonuclear cells, +&2 $and forms, and +2 lymphocytes# 5loodgas analysis shows p" #++, a/0+ +& mm"g, a0+ * mm"g#

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Questions ?Whats the problem?

Why the patient sufered?

How is the laboratory results?Whats the diferential diagnosis?

Do we need urther examination to con rm the

diagnose?Whats the complications next??

Whats your treatment, and how is her

prognosis?

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pidemiologyHumans are the only !nown natural hosts

"# diphteria $ spread %ia upper respiratorytract droplets, but it can also be spread bydirect contact with s!in lesions

organism itsel can sur%i%e or & ' months indust ser%e as the %ehicle or transmission

(mmuni)ation against diphtheria toxinpre%ents the serious complications o disease

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*icrobiology" diphtheriae is a gram+positi%e rod with club+shapedswellings at each end# *ost strains produce an exotoxin,diphtheria toxin, which is encoded by a gene carried by alysogenic bacteriophage and is responsible or thedisease

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Pat$o#enesis

Early sta#es% ore throat, -ow e%er, wollen nec! glands#

&ate sta#es% .irway obstruction and breathing di/culty# hoc!

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Diphtheria Toxin (DT)"lea%ed to yield .01 ragment, 2oined by + bond

+ A 3catalytic domain4+ B 3transmembrane and receptor binding domains4

Receptor $ heparin+binding epidermal growth actor + rich on cardiac cells andner%e cells

To'in di(uses t$rou#$out )ody via )lood + "ardiac, neurologic complications + Heart0respiratory damage, paralysis

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"linical 5indings

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Dip$teria *lassi+edbased on site o in ection

6espiratory Diphteria

7haryngeal0 8onsillar Diphteria

9asal Diphteria-aryngeal Diphteria

"utaneous Diphteria

:ther "linical *ani estations $

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Dip$teria *lassi+edbased on site o in ection

P$aryn#eal Tonsillar Dip$teria %*ost common site

(nsidious onsetarly symptoms $ malaise, sore throat, anorexia,

low grade e%er5ew days later $ membrane appears inpharyngeal0 tonsillar area

e%ere disease $ submandibular and anteriornec! edema, along with lymphadenopathy

Bullneck appearance

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Dip$teria *lassi+edbased on site o in ection

,asal Dip$teria %.nterior nares, serosanguinous or seropurulent nasal

discharge, subtle whitish mucosal membrane, particularlyon septum

&aryn#eal Dip$teria %

xtension o the pharyngeal or be the only site in%ol%edypmtoms $ e%er, hoarseness and a bar!ing cough

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Dip$teria *lassi+edbased on site o in ection

*utaneous Dip$teria %;ariable dermatosis7unched out ulcerati%e lession, with necroticsloughing or pseudomembrane ormation: ten associated with S. aureus and group A

streptococci-t$er *linical Manifestations %

6are cases o endocarditis, septic arthritis,

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pseudomem)rane

*utaneous Dip$teria

Bull nec.

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Diagnosis

. dar! pharyngeal membrane that cannot beremo%ed without bleeding

ystemic toxicity, neurologic abnormalities such asth cranial ner%e de cits, and0orelectrocardiograph changes

8he microbiology laboratory$ special media,3-oe er@s or tellurite selecti%e media4 must beused to pre%ent o%ergrowth o normal Aora

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Case Defnition*on+rmed *ase

"linical (llness or systemic mani estations compatible withdiphtheria in a person with an upper respiratory tract in ection orin ection at another site 7-B at least one o the ollowing$

-aboratory con rmation o in ection using the modi ed - C assayor assay or presence o the diphtheria tox gene, which, idetected, should be tested or expression o diphtheria toxin usingthe modi ed - C assay$

isolation o "orynebacterium diphtheriae with con rmation o

toxin rom an appropriate clinical specimen, including theexudati%e membrane :6Histopathologic diagnosis o diphtheria

:6

pidemiological lin! to a laboratory+con rmed case# 3contactwithin wee!s prior to onset o symptoms4

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Case Defnition

Pro)a)le *ase

"linical illness in the absence o laboratory con rmationor epidemiologic lin! to a laboratory+con rmed case#

!uspect *ase

Bpper respiratory tract in ection 3naso+pharyngitis,laryngitis, or tonsillitis4 with nasal, tonsillar, pharyngealand0or laryngeal membrane#

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8reatmentT$erap

y*$ildren Adults

/irst*$oice

.ntitoxin7haryngeal0laryngeal disease 3FG h4,

>,>>>+G>,>>> B (;9asopharynx disease, G>,>>>+'>,>>>B (;

xtensi%e disease or IJ d, >,>>>+= >,>>> B (; P&U!

rythromycin, G>+K> mg0!g0d 3max, g0d4

.s or children3erythromycin, g0din G doses4

!econdc$oice

7enicillin L, =>>,>>>+=K>,>>> B0!g0d

di%ided e%ery ' h 3max =# million B4-R 7enicillin aMueous procaine,

K,>>>+K>,>>> B0!g0d di%ided e%ery= h 3max =# million B4

.s or children

3penicillin L,= + > million B0ddi%ided e%ery G+' h4

Penicillin

Aller#icrythromycin rythromycin

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Vaccination

D8a7 3 ull+le%el diphtheria and tetanus toxoids andacellular pertussis %accine, adsorbed4 the currentlyrecommended %accine or children up to the age o N

D8a7 replaced D87 3diphtheria and tetanus toxoids andwhole+cell pertussis %accine4 in =

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Vaccination

(n >>' $ recommended that3=4 adults =

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Prophylaxis o Contacts

"lose contacts o diphtheria cases $throat culture to determine whether they are carriers#antimicrobial prophylaxis $ e%en those who are

culture+negati%e#NO=> days o oral erythromycin or one dose o (* ben)athinepenicillin L 3=# million units or persons ' years old or '>>,>>> units

or children F' years old4#

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Prophylaxis o Contacts

"ontacts o diphtheria cases who ha%e anuncertain immuni)ation status $

diphtheria toxoidOcontaining %accine#

8dap 3rather than 8d4 is now recommended as thebooster %accine o choice or adults who ha%e notrecently recei%ed an acellular pertussisOcontaining%accine#

"arriers o "# diphtheriae in the community should betreated and %accinated when identi ed#

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Terima.asi$