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Tetanus neonatorum

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					                 Diphtheria
• Is an acute infectious disease of the childhood
  characterized by local inflammation of the
  epithelial surface , formation of a membrane ,
  and severe toxemia

Epidemiology : -
• Age groups : Pre – school age children
• Occurs in the autumn and winter months.

Caused by ---- Gram positive bacilli,
 Corynebacterium diphtheria
                    Cont ..
Source : -
 - secretions and discharge from an infected
   person or carrier
 – Human are chief reservoirs
Mode of transmission : -
 – Contact or through droplets of secretion
Portal of entry :
 – Respiratory tract
 – May enter through the conjuntiva or skin
   wound
                 Risk factors
1. Poor nutrition.
2. Outbreak in the community.
3. Crowded or unsanitary living conditions.
4. Low vaccine coverage among infants and
   children.
5. Lack of mass immunization programmes
   amongst children and adults at high risk.
6. Insufficient information for the general public on
   dangers of the disease and the benefits of
   immunization.
7. Lack of vaccines in many areas.
                  Pathogenesis
• Entry ------ the bacilli multiply locally in the throat and
  elaborate a powerful exotoxin ----- produce local and
  systemic symptoms.
  Local lesions :
• Exotoxin causes necrosis of the epithelial cells and
  liberates serous and fibrinous material which forms a
  grayish white pseudomembrane

• The membrane bleeds on being dislodged

• Surrounding tissue is inflamed and edematous
                   Cont …
  Systemic lesions :
• Exotoxin affects the heart , kidney and CNS

  Heart :
  – Myocardial fibers are degenerated and the
    heart is dilated
  – Conduction disturbance

  CNS : polyneuritis

  Kidney : renal tubular necrosis
             Clinical features
• Incubation period : 2 – 5 days
Constitutional symptoms:

• Onset : acute with fever ( 39 C ) , malaise ,
  headache and loss of appetite

• Child looks very sick and toxic

• Delirium

• Circulatory collapse ( myocarditis )
                Local manifestation
 Depend on the site of             Faucial diphtheria :
  lesion:                         • Redness and swelling over
  Nasal diphtheria :                fauces
• Unilateral or bilateral         • Exudates on the tonsils
  serosanguineous ( blood and       coalesces to form grayish
  serous fluid ) discharge from     white pseudo membrane
  the nose                        • Regional lymph nodes are
• Excoriation of upper lip          inflamed
• Toxemia is minimal              • Sore throat and
                                  • dysphagia
                    Fauces ( throat )




Fauces : - two pillars of mucous membrane.
Anterior : known as the palatoglossal arch and
Posterior : the palatopharyngeal arch
Between these two arches is the palatine tonsil.
                         Cont …
Laryngotracheal diphtheria :
 – Membrane over the larynx results in
   brassy ( hardness ) cough and
   hoarse voice
 – Respiration ------- noisy               Unusual sites :
 – Suprasternal and subcostal
   recession
                                         • Conjunctiva and
 – Restlessness
                                           skin
 – Increasing respiratory effort          In the skin :
 – Use of accessory muscles              • Ulcers ( tender )
                      Diagnosis

• clinical history , examination and identification of
  diphtheria bacilli from the site of lesion.

• Culture

• Albert`s staining

• Fluorescent antibody technique
           Schick Test
–Schick test: It is an intradermal test,
 the test is carried out by injecting
 intradermally into the skin of
 forearm 0.2 ml of diphtheria toxin,
 while into the opposite arm is
 injected as a control, the same
 amount of toxin which has been
 inactivated by heat.
                    Interpretation
• Negative reaction: If a person had immunity to diphtheria,
  no reaction will be observed on either arm.

• Positive reaction: An area of in duration 10-15 mm in
  diameter generally appears within 24-36 hours reaching
  its maximum development by 4-7 days, the control arm
  shows no change. The person is susceptible to diphtheria.

• False positive reaction: A red flush develops in both arms,
  the reaction fades very quickly, and disappears by 4th day.
  This is an allergic type of reaction found in certain
  individuals
• Combined reaction: the control arm shows pseudo
  positive reaction and the test arm is true +ve reaction,
  susceptible and need vaccination
             Differential diagnosis
  Nasal diphtheria :
• Foreign body in nose ,
• Rhinorrhea


    Laryngeal diphtheria :
•   Croup
•   Acute epiglottitis
•   Laryngotracheobronchitis
•   Peritonsillar abscess
•   Retropharyngeal abscess
                     Cont ….
Faucial diphtheria :
 Acute streptococcal membranous tonsillitis (
  high grade fever , child less toxic )

 Viral membranous tonsillitis :
• high grade fever ,
• WBC : normal or low ,
• Antibiotic : no effects

Herpetic tonsillitis ( Gingivitis and stomatitis )

Infectious mononeucleosis :
• Generalised rash and lymphadenopathy besides
  oral mucosal lesions
                  Treatment
  Principles :
• Neutralization of free circulating toxin by
  administration of antitoxin

• Antibiotic to eradicate bacteria

• Supportive and symptomatic therapy

• Management of complication
                    Antitoxin
    Diphtheria antitoxin :
•   Pharyngeal or laryngeal diphtheria of 48 hours
    duration : 20,000 to 40,000 units.
•   Nasopharyngeal lesions : 40,000 – 60,000 units
•   Extensive disease of 3 or more days duration or
    patient with swelling of neck : 80,000 – 120,000
    units
•   Antitoxin may be repeated if the clinical
    improvementis slower
                   Antibiotics
 Penicillin :
• Procaine penicilline ( 3 – 6 lac units IM at 12
  hourly intervals till the patient is able to swallow )
• Oral penicillin ( 125 – 250 mg qid )

• Erythromycin ( 25 – 30 mg / kg / day ) for 14
  days

• Three negative cultures at 24 hours intervals
  should be obtained before the patient is
  declared free of the organism
    Supportive and symptomatic therapy

• Bed rest for 2 – 3 weeks ( to reduce cardiac
  complications )

• Antipyretics and sedative ( if required )

• Monitor rate and rhythm of the heart
   Management of complication
 Respiratory obstruction :
• Humidified oxygen
• Tracheostomy

 Myocarditis :
• Fluids and salt restriction
• Sedation and oxygen supply
• Diuretics and digoxin

Neurological complications :
• Palatal paralysis ( NG feeding )
• Generalised weakness ( as polio )
               Complications
   Myocarditis :
• Occurs towards the end of the first or beginning
  of second week
• Abdominal pain , vomiting , dyspnea ,
  tachycardia
  Neurological complications : ( Traid )
  – Palatal paralysis ( 2 weeks )
  – General polyneuritis ( 3 – 6 weeks )
  – Loss of accommodation ( 3 weeks )
  Renal complications :
• Oliguria and proteinuria indicate kidney
  complications
                  Prevention

Vaccination: Immunisation with diphtheria toxoid,
combined with tetanus and pertussis toxoid (DTP
vaccine), should be given to all children at two,
three and four months of age. Booster doses are
given between the ages of 3 and 5 .


The child is given a further booster vaccine
before leaving school and is then considered to
be protected for a further 10 years (16 – 18
years).
                  Prognosis
• Death may occur due to : -

  – Respiratory obstruction

  – Myocarditis

  – Respiratory paralysis

				
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