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    DIPHTHERIA_10_6_14

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    Ashraf Albhla

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    DIPHTHERIA_10_6_14

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    Ashraf Albhla
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    1 views4 pages

    DIPHTHERIA_10_6_14

    Uploaded by

    Ashraf Albhla

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    © All Rights Reserved
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    DIPHTHERIA

    Diphtheria is an infection caused by the gram-positive bacillus Corynebacterium


    diphtheriae. Infection is usually manifested by respiratory disease less commonly
    by skin disease or an asymptomatic carrier state. Spread occurs via close contact
    with infectious material from respiratory secretions by either direct or via airborne
    droplet or from skin lesions. Asymptomatic adults who have had the disease and
    are immune can carry the bacterium in their throat and spread the disease to
    children. Diphtheria remains a threat through most of the developing world.
    Diphtheria is a notifiable disease: alert your medical coordinator or medical
    supervisor.

    Clinical Features and symptoms of diphtheria


    Incubation: two to five days
    Local
    • Inflammation of the respiratory tract (most common) and pseudomembrane
    formation leading to TOXIN production
    • Inflammation of the skin: cutaneous diphtheria (less common):
    Chronic, non-healing sores or shallow ulcers with a dirty grey membrane OR
    Infection of pre-existing skin lesions (malnutrition)
    The severity of disease correlates with the severity of toxin production as well as
    the time between the onset of symptoms and administration of antitoxin

    From the circulating diphtheria toxin


    • Myocarditis:
    Mild: decreased heart sounds, gallop rhythm and dyspnoea
    Severe: heart arrhythmias, heart failure, and circulatory collapse (7 -14 days
    after the onset of respiratory symptoms)
    • Neurologic symptoms are more common in severe diphtheria
    Paralysis of the soft palate à hoarseness, stridor, swallowing difficulty
    Paralysis of cranial nerves (eye and swallowing dysfunction)
    Peripheral neuritis weeks to months after respiratory symptoms (mild
    weakness to total paralysis)
    • Kidney failure

    History:
    • Sore throat (most common)
    • Malaise
    • Cervical lymphadenopathy
    • Low-grade fever

    Physical Exam
    • Red throat (early)
    • Progressing to spots of grey and white exudate then to
    • Grey pseudomembrane, which adheres to the tonsils and bleeds with scraping
    • Can also have pseudo membrane on pharynx, palate or nasal membranes
    • In “malignant diphtheria” also have
    Massive swelling of the tonsils, uvula, cervical lymph nodes, submandibular
    region, and anterior neck (the so-called "bull neck" of toxic diphtheria)à
    Respiratory STRIDORà respiratory FAILURE or suffocation by aspiration of
    the membrane

    Prognosis
    If treated rapidly (within 24 hours) with appropriate antibiotics à infection lasts 4
    days
    If patients present to the hospital ≥4 days after onset of symptoms à greater
    mortality

    Diagnosis
    Is CLINICAL
    Make the diagnosis if pseudomembrane (bleeds when it is scraped) and clinical
    symptoms are present AND
    The child is UNIMMUNIZED (or incompletely immunized child) AND/OR
    Any of the symptoms above caused by the toxin

    Laboratory confirmation (usually not available at MSF)


    • Culture of C. diphtheriae from a throat swab

    Differential diagnosis
    • Infectious mononucleosis
    • Group A streptococcal tonsillo-pharyngitis
    • Epiglottitis

    Treatment
    • ISOLATE THE CHILD FOR AT LEAST 4 DAYS after start treatment with antibiotics
    • Alert the medical coordinator or medical supervisor
    • ABCD
    • Careful airway management àrisk of airway obstruction
    • Monitor neurologic exam
    • If available: Diphtheria antitoxin administered according to the Besredka
    method:
    Give to any child suspected of diphtheria
    Inject 0.1 ml subcutaneously and wait 15 minutes
    If there is no allergic reaction (redness at the site or flat erythema < 0.5 cm
    in diameter à Inject a further 0.25 ml subcutaneously
    If there is no reaction after 15 minutesà inject the rest of the dose IM or IV
    depending of the volume to be administered

    Diphtheria antitoxin administration


    Dose in Units Administration route
    Laryngitis or pharyngitis 20 000-40 000 Depends on the volume to
    Rhinopharyngitis 40 000- 60 000 administer.
    Severe diphtheria OR 80 000 up to IM if < 20 00 Units
    If treatment is started > 48 100 000 IV if > 20 000 Units as infusion
    diluted in 200 ml 0.9% NaCl over 1
    hours after onset of symptoms
    hour
    If the child appears to have an allergic reaction treat as in anaphylaxis protocol (see
    page xx)
    • Antibiotic therapy
    Benzathine Benzyl Penicillin IM
    Children < 6 years: 600 000 International Units (IU) as a single dose
    Children > 6 years: 1.2 million IU as a single dose
    OR
    Procaine benzyl penicillin IM
    50 000 IU/kg 1 x/day for 7 days
    For Penicillin allergic children
    Erythromycin PO 25 mg/kg/dose 2 x/day for 7 days
    MSF catalogue:
    DINJPENB1V- BENZATHINE BENZYLPENICILLIN, 1.2 M IU, powder, vial
    DINJPENB2V- BENZATHINE BENZYLPENICILLIN, 2.4 M IU, powder, vial
    DINJPENP4V- PENICILLIN PROCAINE 3 MIU / PENI G 1 MIU, (PPF) powder vial
    DORAERYT1S1- ERYTHROMYCIN ethyl succinate 125mg/5ml, powder oral
    susp.100ml bottle
    DORAERYT2T- ERYTHROMYCIN stearate, eq. 250 mg base, tablet
    DORAERYT5T- ERYTHROMYCIN stearate, eq. 500 mg base, tablet

    Management of close contacts and contacts of healthy carriers


    • Nose and throat cultures
    • Daily throat examination and temperature for 7 days.
    • Antibiotic treatment: see above
    • Check immunization status:
    If less than 3 injections: complete with DTP, DT or Td depending on age
    3 injections: if the last injection was given more than one year before, give a
    booster dose

    Key ongoing management considerations


    • Isolate the child and implement droplet precaution procedures
    o Prevent unnecessary visitors from visiting
    o When in proximity to the child parents should wear a Surgical mask
    (see below MSF catalogue)
    • Catch up on missing vaccinations (confirm with medical officer)

    Provide supportive care


    • Encourage the child to stay in bed and support them with basic needs
    (toileting, dressing, feeding)

    Monitor closely
    • Check vital signs 4x/day and watch closely for signs of respiratory
    deterioration
    o Increased use of accessory muscles
    o Decreased SaO2
    o Report any abnormalities immediately to the medical officer
    o In case of respiratory deterioration, apply oxygen whilst waiting for
    the medical officer
    MSF Catalogue
    ELINMASS3-- MASK, SURGICAL, IIR type,

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