Diphteria

Introduction
• Definition: Infection caused by
Corynebactirium diphteriae
• Toxin-producing bacteria
• Gram positive rod
• Multisystem: upper respiratory tract, heart,
nerve
 Definition
• Acute infection caused by Corynebacterium
diptheriae which produced pseudomembrane
on skin or mucosae
 Epidemiology
• Worldwide
• Decreased after World War II, when tetanus
toxoid was introduced
• More than 80 percent of cases occurred
younger than 15 years old
 People at Risk
• Havent got vaccination
• Overcrowded
• Immunocompromized
• Travelling to endemic area
Epidemiology in Indonesia(2010-2017)
Case Fatality Rate
 Microbiology
• Corynebacterium diphteriae
• Gram positive rod, immotile, uncapsulated,
unsporulated
• Toxin-producing
• Microscopic appearance: palisading(V or L
letter) or Chinese letters
• 3 types: gravis, intermedius, mitis
• Spread through droplet
 Diphteria Toxin
• Exotoxin
• 62.000 dalton
• Heat-labile
• Cosisted of 2 fragmens, fragmen A (amino-
terminal) and fragmen B (karboksi-terminal)
 Pathogenesis
• Droplet contain diphteriae contact human
respiratory tract
• Bacteria stay in pharinx and reproduce
• Some toxin may enter blodstream
• Toxin cause inhibitory effect to human cell
protein synthesis
• Fragment B serves as adherence factor
• Fragment A enter human cell and block
tranlocastion
• Bacteria cause necrosis
• Accumulation of necrosis = pseudomembrane
• Toxin can cause myocarditis or nerve
degeneration
 Clinical Manifestation
• Multisystem
• Classification according to target organ
– Nasal diphtheria
– Tonsilopharynx diphtheria
– Larynx diphteria
– Skin and other mucosa diphteria
– Heart
– Nerve
 Nasal diphtheria
• Symptoms: like common cold, nasal secretion
may become serosanguineous and
mucopurulent
• Pseudomembrane may present
 Tonsilopharynx diphteria
• Prodromal: malaise, fever, odinophagia, sore
throat
• Pseudomembrane after prodromal phase
• Pseudomembrane varying in its extent, may
obstruct the airway
• Limphadenitis
• Bull neck
 Larynx diphteria
• Extention from pharynx diphteria
• Stridor, dispneu, disphonia
 Cardiac Diphteria
• Myocarditis(most common): CHF, dispneu
• AV block
• Endocarditis
 Neural Diphteria
• Chance to occur increase as the increase of
tonsilopharynx diphteria severity
• Neuropaty, cranial nerve defisit, neuritis
 Laboratory Examination
• Leucocytosis
• Anemia
• Increase of protein in CSF(only in neuritis)
• Culture
 DIAGNOSIS
• Combination of clinical and laboratory data
• Definite diagnosis: culture on Loeffler media
 Differential Diagnosis
• Nasal dyphteria: rhinorrhea (common cold, sinusitis,
adenoiditis), foreign body in the nose, snuffles (congenital
lues) ·
• Diphtheria Faring: acute membranous tonsillitis caused by
Streptococci (acute tonsillitis, septic afternoon throat),
infectious mononucleosis, non-bacterial membranous
tonsillitis, primary herpetical tonsillitis, moniliasis, blood
dyscrasia, post tonsillectomy. •
• Laryngeal dysteria: laryngitis, can resemble other infectious
croups, namely spasmodic croup, angioneurotic edema of
the larynx, and foreign bodies in the larynx. ·
• Skin dysteria: impetigo and skin infections caused by
streptococci and staphylococci.
 Complication
• Airway obstruction
• Neurologic defisit
• Secondary infection
 Treatment
• Supportive care
– Oxygen
– Nutrition
– rehidration
• Specific treatment
– Antitoxin
– antibiotik
 Antitoxin
• Need to be given in every case
• Dose varied according to severity
• Prevent the effects of diphteri toxin
• Antitoxin= anti diphteria serum(ADS)
• Caution: may cause allergy or anaphylaxis
– Skin test before full dose injection
 DOSE
TYPE DOSE OF ADS
Nose, skin, conjungtiva 20.000 unit im
Moderate: tonsil, laryns 40.000 unit iv
Severe: pseudomembrane extend beyond 100.000-120.000 unit iv
tonsil, bull neck, systemic complication of
toxin
 Antibiotic
• Erythromicin 50mg/kg Weigth/day divided in
4 doses for 14 days
• Penicilin may also be used
 Carrier
• People who doesn’t have clinical
manifestation but have bacteria colonization
based on microbiologycal examination
• Treatment: antibiotic as people who get sick,
but only for 7 days
 Prevention
• The main prevention is immunisation
• Indonesia program: DPT vaccination in 2,3,4
months of age or 2,4,6
 Prognosis
• Varying, but usualy good. Mortality below 1
percent
• Factors affecting mortality:
– Type of infection
– Age
– The baseline condition
– Time to antitoxin injection