Diphteria

Diphtheria
• An acute infection by Corynebacterium
diphtheriae (Klebs-loecffler Bacillus)
• Predominantly in upper respiratory tract
• The patognomonic sign is a
pseudomembran
• grayish-white color, which
contains fibrin and necrotic tissue;
• hard to remove, easily bleeding
1883 : Klebs found the bacteria in
pseudomembran
1884 : Loeffler grew the bacteria
1888 : The bacteria makes toxin
1894 : Von Behring found the antitoxin
1913 : Immunization against the disease
 Epidemiology

• Transmission : by contact with infected

person or ‘carrier’ through droplet infections
• Food contamination are rare (milk)
• Incubation period : 2-6 days
• Endemic or epidemic: Indonesia is endemic
• Infant < 6 month  seldom
• Peak incidents at age : 2-5 years
• Age > 10 years : has lower incidents
 Jumlah Kasus Difteria dan Kematian di Beberapa Rumah Sakit
Propinsi di Indonesia

RSCM RSHS RSWS RSK RSU PMH

Tahun Kasus *m% Kasus *m% Kasus *m% Kasus *m% Kasus *m%

1991 22 50,0 28 10,7 0 0 70 8,6 32 21,9

1992 25 32,0 26 7,7 12 0 34 5,9 19 26,3

1993 19 26,3 18 0 7 0 12 0 16 62,5

1994 16 18,8 12 0 10 10 8 0 13 46,2

1995 12 25,0 6 0 4 0 9 11,1 7 14,3

1996 7 28,6 3 0 1 0 11 0 14 42,9

 Etiology
Corynebacterium diphtheriae

• Positive gram, nonmotile, nonsporulating

• Three colony type: gravis, intermediate,
mitis has low fatality rate
• Direct staining : methyl blue, neisser, toluidine
blue
• Bacilli parallel group / “V”
• Culture : media blood agar contains kalium
telurit
Corynebacteria diphtheriae
G+, club shaped, pleomorphic, aerobic rod
Diphtheria

Figure 24.6
 Pathogenesis of Diphtheria
• Encounter – Corynebacterium diphtheriae
encountered only from other people (carriers)
• Entry – respiratory droplets; organism
colonizes pharynx
• Spread
• Multiplication
• Evasion of host immune response –
adhesins; toxin may kill phagocytes
contributing to pseudomembrane
• Damage – inflammation; circulating toxin
• Transmission – aerosolized droplets; fomites
 Pathogenesis

• The bacilli multiply in upper respiratory tract

• Vulva, skin, conjunctiva, umbilicus, ear, are
rare
• Pseudomembrane and toxin :
local  spread out
 Clinical manifestations

• Generally : moderate – fever; but

conditions are generally weak
 malaise
 headache
• Specific localized manifestation :
- running nose
- dispnoe
- stridor
• Local (caused by inffected tissue by
exotoxin)
 Immunity

• Shick test: does someone has the antitoxin ?

(+) lower antitoxin titers
(-) immunity ; higher anti toxin titers

• Congenital passive immunity

“absolute” in 3 months 15% : (+) shick test
“parsial” in 6 months 50% : (+)
 Distribution according to spot of the affected tissue

1. Nasal diphtheria (2%)

• running nose  purulosanguinous secretion

2. Tonsil and pharynx (faucial diphtheria) 75%

- likely to attack adenoid, uvula and palatum
mole
- subfebril temperature – pseudomembran
- sore throat, odinophagia
- might change the voice, disphagia
- regional lymph node
3. Laryngo – trocheal (25%)
• wide spread of pharynx infection
• severe  upper respiratory tract
obstruction  tracheotomy

4. Cutaneous diphtheria
• the area of auricular, conjunctiva,
• umbilicus, vagina
 Toxin

• Exotoxin could cause general or local symptom

• Lymphogenic and hematogenic spread to the regional
lymph node, heart, kidney and nerve tissue
• Pathology :
• enlargement and edematous of regional lymph node (“bull
neck”)
• heart  myocardium inflammation and degeneration
• kidney and liver  local necrotic, interstitial nephritis
(seldom)
• nerves  myelin sheet destruction and degeneration ,
edematous of the axon
 Laboratory

• Decrease of Hb and erythrocyte

• Leucocytosis, PMN
• Urine:
• mild albuminuria
• founded as thorax-hialyn sediment ,

• erythrocyte, leukocyte
 Diagnosis

1. Clinical manifestations.
2. Direct preparation / positive culture of
throat swab.
3. Immunization history
 Differentials diagnosis

• Nasal diphtheria
• Corpus alienium
• Syphilis congenital

• Faucial diphtheria
• Tonsillitis follicularis (lacunaris)
• Fever
• general conditions
• regional lymph node
• direct preparation / culture
• Angina Plaut Vincent
• fragile membrane, thick, smelly, not easy
bleeding
• direct preparation Bacillus fusciformis
(+ gram)
• Laryngitis diphtheria
• laryngitis acute / laryngo tracheitis
• corpus alienum
 Complications
• Cardiovascular system  Occurred at the end
of the first week or early of the 2nd week . ECG
abnormality 20%.
• ST-segment mild depression; frequently T-wave
inversion at lead 2 or more.
• Disturbances of conductions (bad prognosis)
• BBB (complete heart block)
• Cardiac Sign
• tachycardia in the beginning.
• myocardium acute inflammation  bradycardia
• Myocarditis
• weakness of the 1st heart sound
• heart hypertrophy
• gallop rhythm.
• systolic murmur

• Cardiac shock (usually in the 2nd week)

• extensive myocardium damage  decrease of
cardiac output  shock
• Cardiac decompensation
• Urogenital system : nephritis.
• Nerves system : 10% of patients
– Palate paralysis : voice changes/disphagia
(1st/2nd week)
– Ophthalmologic muscles  especially
accommodation muscles
• Strabismus
• pupil dilatation
• ptosis (3rd week and following
weeks)
• General paralysis affected the face ,
neck and extremities (after the 4th
week).
• N. Phrenicus paralysis (4th-7th week) :
cough, dyspnoe, thoracal breathing,
cyanosis .

• Respiratory systems
– Airway obstruction
– Bronchopneumonia
– Atelektasis
Airway obstruction  Tracheotomy
• Dyspnea, cyanosis
• Irritability
• Stridor inspiratory
• Retraction
- epigastrium
- intercostals
- suprasternal
 Treatment

1. General
- isolation , good nursing
- observation of the complications
- bed rest total

2. Specific
- A.D.S 100.000 UI
- Antibiotic : PP 50.000 UI/KgBW.
 Treatment

- Corticosteroid = anti infection, anti allergy, anti

edema,
- Prednisone 2mg/KgBW, stop by tapp off.

• Paralysis = Strychnine ¼ mg , vit BI100mg  10

subsequent days.
 Prognosis

Depends on :
1. Age
2. Stadium
3. Localization
4. Bacteria pathogenicity (mitis has lower-
virulency)
 Prognosis

5. Antitoxin

1st day 0.3% (mortality)

2nd days 4%
3rd days 12%
> 4th days 25%
 Attention

1. Totally bed rest (luminal 5 mg/KgBw,

largactil 2mg/KgBw)
2. Throat swab
3. ECG each week
4. Urinary and hematological examination
weekly
5. Pulse, respiratory, defecation
6. Airway obstruction
 Jadwal Imunisasi Rekomendasi IDAI 2004
Umur Pemberian Vaksinasi
Jenis
Bulan Tahun
Vaksin lhr 1 2 3 4 5 6 9 12 15 18 2 3 5 6 10 12

BCG 1

HepB 1 2 3

Polio 0 1 2 3

DTP 1 2 3 4 5

Campak 1 2

Hib 1 2 3 4

MMR 1 2

Tifoid Ulangan tiap 3 th

HepA 2x interval 6-12 bln

Varisela >10