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ญ . จริยา แสงสัจจา สถาบันบ าราศนราดูร ๘ ตุลาคม ๒๕๕๕

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Acute toxicoinfection

by Corynebacterium caused diphtheria  Exclusively inhabitant of human mucous membrane and skin

Corynebacterium diphtheriae

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Pathogenesis& pathology

local inflammation, exotoxin , tissue necrosis, grey-brown adherent pseudo-membrane, toxic myocardiopathy, peripheral neuropathy

Transmission

: Droplet and contact: intimate contact with a patient or carrier :Discharge from respiratory tract, eyes and skin lesions :2-6 weeks transmissible without treatment, communicable <4days after appropriate antibiotics

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Incubation period :

2-7 days or longer

  Low-grade fever: <39  c  Serosanguinous, purulent erosive rhinitis  Sore throat  Upper airway obstruction  Dysphagia,  Tonsillar membrane formation, extends to uvular, soft palate, pharynx, larynx

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Bull-neck

: soft tissue edema and enlarged lymph nodes 

Cutaneous diphtheria

: indolent, non progressive  Purulent and ulcerative conjunctivitis, vulvovaginitis

Nasal Diphtheria Cutaneous Diphtheria

Streptococcus Sore Throat

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Toxic myocardiopathy

:

10-25% of cases, : occurs in the 2nd-3 rd week :Responsible for 50-60% of death :Correlates directly with the extent and severity of exudative local oropharyngeal disease : Tachycardia, prolong PR interval, ST-T change, V-tach, congestive heart failure

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Toxic neuropathy :

Acutely or 2-3 weeks after onset :local paralysis of soft palate :Weakness of posterior and facial nerve :Dysphagia, aspiration :

Cranial neuropathy

occur in the 5 th week :

Symmetric polyneuropathy

occur in 10 days to 3 months

 Antitoxin  Antimicrobial therapy  Immunization

Antitoxin

:  DAT IV after sensitivity test for reaction, desensitization 

Pharyngeal or laryngeal lesions

,48 hr. duration or less, 20,000-40,000 U 

Nasopharyngeal lesions

, 40,000-60,000 U 

Extensive disease of 3 or more days

duration or diffuse swelling of the neck,80,000-120,000 U of antitoxin  Skin lesions only:20,00-40,000U

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Antimicrobial therapy

:14 days of erythromycin or penicillin G IV or IM or procaine pen. G IM 

Immunization

: 3 doses of diphtheria toxoid,1 st dose at the end of 1 st week of illness

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Standard and droplet precautions

for patients and carriers with pharyngeal diphtheria until 2 cultures from both the nose and the throat are negative 

Contact precautions

for patient with cutaneous diphtheria until 2 cultures of skin lesions are negative

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Care of close contact

:

Surveillance

disease :

Culture

7 days for evidence of for C. diphtheriae :

Antimicrobial prophylaxis

: erythromycin40-50 mg/kg 7days or single dose benzathine pen. G (1.2mU for patient BW>=30kg.,0.6mU for patient BW <30kg.)

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Care of close contact

:

Follow up pharyngeal culture

from carrier at 2 weeks after completion of therapy, if culture is positive 10 days course of erythromycin should be given, and follow up culture :

Immunization

of carriers