• Diphtheria is a life-threatening  is a life-threatening disorder caused by a highly disorder caused by a highly contagious bacterial infection, the contagious bacterial infection, the Corynebacterium diphtheriaeCorynebacterium diphtheriae, an , an anerobic gram + bacterium. It anerobic gram + bacterium. It primarily affects the upper primarily affects the upper respiratory tract and even spread respiratory tract and even spread to the heart and the peripheries to the heart and the peripheries when the disease progress. when the disease progress.

» Diphtheria is a contagious disease Diphtheria is a contagious disease spread by direct physical contact or spread by direct physical contact or breathing the breathing the aerosolized secretions of  secretions of infected individuals.infected individuals.

• Corynebacteria are Corynebacteria are Gram-positive, Gram-positive, aerobic, nonmotile, aerobic, nonmotile, rod-shaped bacteria rod-shaped bacteria classified classified as Actinobacteria.as Actinobacteria.

• related related phylogenetically to phylogenetically to mycobacteria and mycobacteria and actinomycetes.actinomycetes.

• They undergo They undergo snapping movements snapping movements just after cell division, just after cell division, which brings them into which brings them into characteristic forms characteristic forms resembling Chinese resembling Chinese letters or palisades. letters or palisades.

• Etiologicagent = Cornebacterium diphtheriae

• Reservoir = Human carriers are the reservoir for C. diphtheriae, and are usually asymptomatic

• Portal of Exit = Respiratory droplets; aerosolized secretions of infected individuals

• Mode of Transmission = person-to-person spread.

• Portal of Entry = mucus membranes in the respiratory tract

• Susceptible Host = immunocompromised individuals

• PREDISPOSING PREDISPOSING FXFX

– RACE– AGE– GENDER

• PRECIPITATING FX

– Known exposure, current epidemic, and travel to endemic areas increases risk.

– Compromised host, individuals

– Cornebacterium Diphtheria

INVASION OF THE BACTERIA(CORNEBACTERIUM

DIPHTHERIAE w/ ave. incubation period of 2-7 days)

SECRETIONS OF THE EXOTOXINS

INHIBITION OF THE PROTEIN

SYNTHESIS

INACTIVATION/ MODIFICATION OF

KEY CELLULAR CONSTITUENTS

CELL DEATH

• infects the epithelium of the skin and infects the epithelium of the skin and the mucosa of the upper respiratory the mucosa of the upper respiratory tract, leading to inflammation of tract, leading to inflammation of those tissues those tissues

• Diphtheria classically involves the Diphtheria classically involves the tonsils and pharynx, although the tonsils and pharynx, although the nose and larynx are also common foci nose and larynx are also common foci of infection of infection

• The local inflammation in the upper The local inflammation in the upper respiratory tract leads to an respiratory tract leads to an accumulation of inflammatory cells, accumulation of inflammatory cells, necrotic epithelial cells, and organism necrotic epithelial cells, and organism debris, which form the characteristic debris, which form the characteristic adherent grey pseudomembrane. adherent grey pseudomembrane.

• Attempts to removeAttempts to remove the the pseudomembrane pseudomembrane result in bleeding result in bleeding and expose an inflamed and expose an inflamed erythematous mucosa.erythematous mucosa. Due to local Due to local neurological effects of the exotoxin, neurological effects of the exotoxin, paralysis of the palate and paralysis of the palate and hypopharynx can also occurhypopharynx can also occur. This . This paralysis, in combination with paralysis, in combination with inflammation and oedema of the inflammation and oedema of the upper respiratory tract, upper respiratory tract, can lead to can lead to airway obstructionairway obstruction. In addition, . In addition, systemic spread of the toxin systemic spread of the toxin can can cause injury to the kidneys, heart, cause injury to the kidneys, heart, and neural tissue and neural tissue

• MUSCULOSKELETALMUSCULOSKELETAL– fatiguefatigue– edemaedema

• HEENTHEENT– Sore throatSore throat– Swelling throat orSwelling throat or– ““bull neck”bull neck”– HeadacheHeadache– Double visionDouble vision

• CARDIOVASCULAR CARDIOVASCULAR SYSTEMSYSTEM– low blood pressurelow blood pressure– cardiomyopathycardiomyopathy– peripheral neuropathyperipheral neuropathy

• RESPIRATORY RESPIRATORY SYSTEMSYSTEM– dyspneadyspnea

•

• GASTROINTESTINAL GASTROINTESTINAL SYSTEMSYSTEM– paralysis of the paralysis of the

palatepalate– hypopharynxhypopharynx– dysphagiadysphagia– nausea and vomitingnausea and vomiting

• INTEGUMENTARY INTEGUMENTARY SYSTEMSYSTEM– chills and feverchills and fever– exposed exposed

erythematous erythematous mucosa or lesionsmucosa or lesions

•

• Erythromycin (orally or by injection) for 14 days (40 mg/kg per day with a maximum of 2 g/d), or

• Procaine penicillin G given intramuscularly for 14 days (300,000 U/d for patients weighing <10 kg and 600,000 U/d for those weighing >10 kg). Patients with allergies to penicillin G or erythromycin can use rifampin or clindamycin.

• diphtheria anti-toxin - The patient must be tested for sensitivity before antitoxin is given. 

• A A throat culturethroat culture is is a technique for a technique for identifying disease identifying disease bacteria in bacteria in material taken material taken from the throat. from the throat. – RESULT: A gram + RESULT: A gram +

bacteria, bacteria, Cornebacterium Cornebacterium diphtheriaediphtheriae

NURSING NURSING INTERVENTIONSINTERVENTIONS

• Administer OxygenAdminister Oxygen– (as obstruction in the throat may (as obstruction in the throat may

require intubation and require intubation and tracheostomy)tracheostomy)

• Encourage bed restEncourage bed rest• Provide safetyProvide safety• Monitor vital signs ( esp. HR)Monitor vital signs ( esp. HR)• Administer medications as Administer medications as

indicatedindicated

ISOLATION!!!ISOLATION!!!

• The diphtheria vaccine is an inactivated toxin called a toxoid. It is made by growing the bacteria in a liquid medium and purifying and inactivating the toxin.

• In the 1940s, diphtheria toxoid was combined with pertussis vaccine and tetanus toxoid to make the combination DTP vaccine.

• The DTaP, DT, Td, and Tdap preparations are all given as an injection in the anterolateral thigh muscle (for infants and young toddlers) or in the deltoid muscle (for older children and adults).

• The usual schedule for infants is a series of four doses given at two, four, six, and 15-18 months of age. A fifth shot, or booster dose, is recommended at 4-6 years of age, unless the fourth dose was given late (after the fourth birthday).

• An immunochromatographic strip (ICS) test was developed for the detection of diphtheria toxin by using an equine polyclonal antibody as the capture antibody and colloidal gold-labeled monoclonal antibodies specific for fragment A of the diphtheria toxin molecule as the detection antibody. The ICS test has been fully optimized for the detection of toxin from bacterial cultures

Immunochromatographic Strip Test for Rapid Detection of Diphtheria Toxin: Description and

Multicenter Evaluation in Areas of Low and High Prevalence of Diphtheria