- What is Diphtheria (cough tetanus)?
- Causes of Diphtheria
- Classification of diphtheria
- Symptoms of Diphtheria
- Types of Diphtheria
- Diphtheria Diagnosis
- Diphtheria Treatment
- Complications of Diphtheria
- Prevention of Diphtheria
What is Diphtheria (cough tetanus)?
Diphtheria is a serious and highly infectious disease, which is now rare in developed countries because of immunisation.
Characterized by the development of fibrinous inflammation in the area of the pathogen (primarily the upper respiratory tract, the mucous membrane of the oropharynx are affected). Diphtheria is transmitted by airborne and airborne dust. Infection can affect the oropharynx, larynx, trachea and bronchi, eyes, nose, skin and genitals. Diagnosis of diphtheria is based on the results of a bacteriological examination of a smear with an affected mucosa or skin, examination data and laryngoscopy. When there is a myocarditis and neurological complications, consultation of the cardiologist and neurologist is required.
Death rates range from 3-25% and are especially high if the heart is involved early. The disease is epidemic in Russia and Eastern Europe.
Because of the success of the immunisation programme in the Western world, generations of parents have grown up knowing nothing about this disease. This leads to the risk that they may neglect immunisation.
Outbreaks in Scandinavia have shown that even if the rate of immunisation in children is high, levels of immunity can fall off in adult life enough to allow the disease to occur. Re-immunisation in adults every ten years is advised by some experts.
Causes of Diphtheria
Diphtheria causes Corynebacterium diphtheriae – a gram-positive immobile bacterium that looks like a rod, at the ends of which the volute grains settle, giving it the appearance of a mace. Diphtheria bacillus is represented by two main biovars and several intermediate variants.
The pathogenicity of the microorganism consists in the isolation of a potent exotoxin, in toxicity second only to tetanus and botulinum toxicity. Non-diphtheria toxin-producing strains of the bacterium do not cause disease.
The causative agent is resistant to the influence of the external environment, it is able to persist on objects in dust for up to two months. Well tolerates a lowered temperature, dies when heated to 60 ° C after 10 minutes. Ultraviolet irradiation and chemical disinfectants (lysol, chlorine-containing agents, etc.) act on the diphtheria rod is fatal.
The reservoir and source of diphtheria is a sick person or a carrier that releases pathogenic strains of diphtheria bacillus. In the overwhelming majority of cases, infection comes from sick people, the most epidemiological importance is worn out and atypical clinical forms of the disease. Excretion in the period of convalescence can last 15-20 days, sometimes extending to three months.
Diphtheria is transmitted by aerosol mechanism mainly by airborne or airborne dust. In some cases it is possible to implement a contact-household way of infection (when using contaminated household items, dishes, transfer through dirty hands). The causative agent is able to multiply in food products (milk, confectionery), contributing to the transmission of infection by alimentary route.
People have a high natural susceptibility to infection, after the transfer of the disease, antitoxic immunity is formed that does not interfere with the carrier of the pathogen and does not protect against re-infection, but promotes easier flow and absence of complications in case of its occurrence.
Children of the first year of life are protected by antibodies to diphtheria toxin, transferred from the mother transplacentally.
Classification of diphtheria
Diphtheria differs depending on the localization of the lesion and clinical course on the following forms:
- diphtheria of the oropharynx (localized, widespread, subtoxic, toxic and hypertoxic);
- diphtheria croup (localized laryngeal cortex, common croup in lesions of the larynx and trachea and descending croup in spreading to the bronchi);
- diphtheria of the nose, genitals, eyes, skin;
- combined defeat of various organs.
Localized diphtheria of the oropharynx can flow through the catarrhal, islet and pleated variant. Toxic diphtheria is divided into the first, second and third degrees of severity.
Symptoms of Diphtheria
Diphtheria has one of the shortest incubation periods of all infectious diseases and the onset is very sudden. A child may become seriously ill within a day of developing the first symptoms.
The disease starts one to four days after contact, with fever, sore throat, headache, difficulty in swallowing and enlarged lymph nodes in the neck. The germ normally attacks the throat, but in rare cases may involve the skin, especially open wounds or burns.
It produces a powerful poison (exotoxin) which is released into the surrounding tissues, killing cells and causing a kind of membrane to be exuded that is formed of clotted serum (fibrin), white cells, bacteria and dead surface-tissue cells.
This throat membrane usually covers the tonsils and is a dirty grey colour. It sticks so firmly to the surface that any attempt to remove it with forceps causes bleeding. The immediate danger from the membrane is to the upper air passages, which may become blocked, necessitating an emergency artificial opening into the windpipe (a tracheostomy).
The neck lymph nodes may be so swollen as to widen the neck, often referred to as bull-neck.
Localized diphtheria of the oropharynx manifests itself in the form of characteristic fibrinous raids in a third of adults, in other cases, the plaque is loose and easily removable, leaving no bleeding after it. Such are the typical diphtheria raids after 5-7 days from the onset of the disease.
Inflammation of the oropharynx is usually accompanied by a moderate increase and sensitivity to palpation of the regional lymph nodes. The inflammation of the tonsils and regional lymphadenitis can be either unilateral or bilateral. Lymphonoduses are affected asymmetrically.
Localized diphtheria rarely occurs in the catarrhal form. In this case, there is a subfebrile condition, or the temperature remains within normal limits, intoxication is poorly expressed, when the oropharynx is examined, hyperemia of the mucosa and some swelling of the tonsils are noticeable. Pain when swallowing is moderate. This is the easiest form of diphtheria.
Localized diphtheria usually ends in recovery, but in some cases (without proper treatment) can progress to more common forms and contribute to the development of complications. Usually, fever lasts for 2-3 days, raids on tonsils – for 6-8 days.
The widespread diphtheria of the oropharynx is quite rare, not more than 3-11% of cases. With this form, the attacks are detected not only on the tonsils, but also spread to the surrounding mucous membranes of the oropharynx. In this case, the general toxicity syndrome, lymphadenopathy and fever are more intense than in the case of localized diphtheria.
Subtoxic form of diphtheria of the oropharynx is characterized by intense pain when swallowing in the throat and neck area. When examining the tonsils, they have a pronounced purple color with a cyanotic hue, covered with plaque, which are also noted on the tongue and palatine arch. This form is characterized by swelling of the subcutaneous tissue over the densified painful regional lymph nodes. Lymphadenitis is often one-sided.
At present, the toxic form of diphtheria of the oropharynx is quite common, often (in 20% of cases) developing in adults. The onset is usually turbulent, the body temperature rises rapidly to high values, an increase in intensive toxicosis, cyanosis of the lips, tachycardia, arterial hypotension.
There is severe pain in the throat and neck, sometimes in the abdomen. Intoxication contributes to the violation of central nervous activity, there may be nausea and vomiting, mood disorders (euphoria, agitation), consciousness, perception (hallucinations, delusions).
Toxic diphtheria II and III degree can promote intensive swelling of the oropharynx, which prevents breathing. The raids appear fairly quickly, spreading through the walls of the oropharynx. Films thicken and coarsen, raids persist for two or more weeks. Early lymphadenitis is noted, the nodes are painful, dense. Usually the process captures one side. Toxic diphtheria is characterized by the existing painless edema of the neck.
The first degree is characterized by edema confined to the middle of the neck, at the second degree it reaches the clavicles and at the third degree it extends further to the chest, the face, the back surface of the neck and back. Patients mark an unpleasant putrefactive smell from the mouth, a change in the timbre of the voice (nasal).
The hypertoxic form is most severe, usually in people with severe chronic diseases (alcoholism, AIDS, diabetes, cirrhosis, etc.). The fever with tremendous chills reaches critical numbers, tachycardia, low filling pulse, falling of arterial pressure, pronounced pallor in combination with acrocyanosis. With this form of diphtheria, hemorrhagic syndrome can develop, an infectious-toxic shock with adrenal insufficiency can progress. Without proper medical assistance, death can occur already in the first-second day of the disease.
Types of Diphtheria
With localized diphtheria, the process is limited to the mucous membrane of the larynx, with the common form – the trachea is involved, and with the descending croup – bronchi. Often the croup accompanies the diphtheria of the oropharynx. More and more recently, this form of infection is observed in adults. The disease is usually not accompanied by significant general infection symptoms. There are three consecutive stages of croup: dysphonic, stenotic and asphyxia stage.
The dysphonic stage is characterized by the appearance of a rough “barking” cough and progressive hoarseness. The duration of this stage ranges from 1-3 days in children to weeks in adults. Then there is aphonia, cough becomes silent – the vocal cords are stenosed. This condition can last from a few hours to three days. Patients are usually restless, they notice the pallor of the skin, and noisy breathing. In view of the difficulty of the passage of air, retraction of the intercostal spaces during inspiration can be noted.
The stenotic stage passes into asphyxia – the difficulty of breathing progresses, becomes frequent, arrhythmic until completely stopped as a result of the obstruction of the airways. Prolonged hypoxia disrupts the brain and leads to death from suffocation.
Diphtheria of the nose
It manifests itself in the form of difficulty breathing through the nose. With the catarrhal version of the flow, it is a serous-purulent (sometimes hemorrhagic) discharge from the nose. Body temperature, as a rule, is normal (sometimes subfebrile), intoxication is not expressed.
The mucous nasal during examination is ulcerated, the fibrinous raids are noted, with a filmy version being removed like scraps. The skin around the nostrils is irritated, maceration, crusts can be noted. Most often, diphtheria of the nose accompanies diphtheria of the oropharynx.
The catarrhal variant is manifested in the form of conjunctivitis (predominantly one-sided) with a moderate serous discharge. The general condition is usually satisfactory, fever is absent.
The film variant differs by the formation of fibrinous plaque on the inflamed conjunctiva, edema of the eyelids and detachable serous-purulent character. Local manifestations are accompanied by a subfebrile condition and mild intoxication. Infection can spread to the second eye.
The toxic form is characterized by a sharp onset, a rapid development of general toxication symptoms and fever, accompanied by pronounced edema of the eyelids, purulent hemorrhagic secretions from the eye, maceration and irritation of the surrounding skin. Inflammation extends to the second eye and surrounding tissue.
Diphtheria of the ear, genital organs (anal-genital), skin
These forms of infection are quite rare and, as a rule, are associated with the peculiarities of the method of infection. Most often they are combined with diphtheria of the oropharynx or nose.
They are characterized by edema and hyperemia of affected tissues, regional lymphadenitis and fibrinous diphtheritic attacks.
In men, diphtheria of the genital organs usually develops on the foreskin and around the head, in women – in the vagina, but can easily spread and affect the small and large labia, perineum and anus. Diphtheria of female genital organs is accompanied by secretions of hemorrhagic nature. With the spread of inflammation to the urethra, urination causes pain.
Diphtheria of the skin develops in places of damage to the integrity of the skin (wounds, abrasions, ulceration, bacterial and fungal lesions) in the event of an infection on them. It appears as a gray coating on the area of hyperemic swelling of the skin.
The general condition is usually satisfactory, but local manifestations can exist for a long time and slowly regress. In some cases, asymptomatic carriage of the diphtheria bacillus is recorded, which is more common in people with chronic inflammation of the nasal cavity and pharynx.
This is based on a brief history of a very sore throat followed by rapid deterioration and collapse. The appearance of the throat membrane is typical, and the neck lymph nodes may be much enlarged. The germ that causes the disease can be grown on culture plates and identified under the microscope, but treatment is never delayed while waiting for a report of this.
Diphtheria is a disease that should be prevented rather than treated, but effective measures exist and can control the damage if the diagnosis is made early.
Antibiotics are available to clear out the organisms, and antitoxin can be given to neutralise circulating toxin. Treatment is always very urgent and should not be delayed.
The complex of therapeutic measures is supplemented with drugs according to indications, with toxic forms prescribe detoxification therapy with the use of glucose, cocarboxylase, the introduction of vitamin C, if necessary – prednisolone, in some cases – plasmapheresis. At threat of asphyxia, intubation is performed, in cases of upper airway obstruction, tracheostomy. When a secondary infection threatens to develop, antibiotic therapy is prescribed.
Complications of Diphtheria
A severe form of bronchopneumonia can occur and can be fatal. The exotoxin easily gains access to the bloodstream and is carried throughout the body, where it may cause serious damage to the heart, the nervous system (causing permanent muscle weakness) or the kidneys. These effects may be severe, and many children have died from severe heart damage within a few weeks of onset.
Secondary damage of this kind is especially likely if there has been delay in treating with antitoxin. Even today, the death rate among those who contract diphtheria in developed countries is about 10%. In underdeveloped areas it is much higher.
Prevention of Diphtheria
Immunisation with diphtheria toxoid, combined with tetanus toxoid and pertussis (whooping cough) toxoid (DTP vaccine), should be given to all children at two, three and four months of age.
Diphtheria epidemics still occur in countries where only some of the population are immunised, and people travelling to these areas may contract the disease. There are more than 120 countries for which travellers are recommended to protect themselves by vaccination against diphtheria.