Diphtheria

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pathogen

• small gram positive bacilli

• Corynebacterium diphtheriae
  • droplet infection - human to human
  • congestion/overcrowding is a risk factor
  • incubation 2-5 days (1-10 days)

• Corynebacterium ulcerans
  • also produces toxin and causes clinical diphtheria
  • cattle
  • dogs and cats
  • especially in UK

• Corynebacterium pseudotuberculosis
  • very rarely

epidemiology

• mostly in younger children
• mortality among hospitalized patients in San Lazaro Hospital in the Philippines
  • 43.8%

outbreaks

• former Soviet Union in 1990s after collapse of the Union
• refugee/emergency settings
  • Yemen
  • Rohingya in Myanmar
  • Venezuela
  • Haiti

clinical picture

• pseudomembrane
  • both in pharynx and lower respiratory tracts
• anterior cervical lymphadenopathy
• Bull's neck
• laryngeal involvement leading to stridor and airway obstruction
• nasal discharge
  • earlier serous, later bloody
• sometimes skin ulceration for long time

complication

• myocarditis
  • due to heart block
  • 1-6 weeks after onset
  • ST segment abnormalities in EKG
  • tachycardia or bradycardia
• Demyelinating peripheral neuritis
  • 10 days - 3 months after onset
  • palatal palsy
  • cranial nerve palsy
  • limb weakness
  • respiratory muscles weakness

diagnosis

• throat culture
  • Hoyles Tellurite selective agar
  • black colored colonies
• ELEK test
  • to identify toxin production
  • not all Corynebacterium produce toxin
  • difficult and tricky

treatment

• Diphtheria antitoxin (DAT)
  • hose serum
  • beware of anaphylaxis
  • worldwide shortage is problem
• antibiotics
  • benzyl penicillin
  • macrolides
  • 14 days
• immunization after treatment
  • infection does not guarantee immunity

control

• investigation of close contact to diagnosed patients
  • immunization
  • throat culture and treat positive (=asymptomatic carrier) with erythromycin for 7 days