พ. ญ. จริยา แสงสัจจา สถาบันบำราศนราดูร ๘ ตุลาคม ๒๕๕๕

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

Corynebacterium diphtheriae

 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

 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 

 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

 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

 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 U of antitoxin  Skin lesions only:20,00-40,000U

 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

 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

 Care of close contact :Surveillance 7 days for evidence of disease : Culture 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.)

 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