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Diphteria

Alan R. Tumbelaka
Division of Infectious Diseases & Tropical Pediatrics, FKUI

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

70

8,6

32

21,9

1992

25

32,0

26

7,7

12

34

5,9

19

26,3

1993

19

26,3

18

12

16

62,5

1994

16

18,8

12

10

10

13

46,2

1995

12

25,0

11,1

14,3

1996

28,6

11

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

Nasal diphtheria (2%)

1.

running nose purulosanguinous secretion

Tonsil and pharynx (faucial diphtheria) 75%

2.
-

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 4 th
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 mg , vit BI100mg 10


subsequent days.

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

Prognosis

5. Antitoxin
1st
2nd
3rd
> 4th

day 0.3% (mortality)


days 4%
days 12%
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
Tahun
Bulan
Vaksin
lhr 1 2 3 4 5 6 9 12 15 18 2 3 5 6 10
lhr

BCG
HepB
Polio
DTP

1
0

3
1

Tifoid
HepA

4
1

Campak

Hib
MMR

12

5
2

4
1

2
Ulangan tiap 3 th
2x interval 6-12 bln