Diphtheria Pertussis and Tetanus Dr Kalyan Diphtheria Epidemiology

Diphtheria, Pertussis and Tetanus Dr Kalyan

Diphtheria • Epidemiology : • Organism: Gram Positive bacillus, Corynebacterium diphtheriae. • Source of infection: Secretions and discharge from infected person or carrier. • Portal of entry: RT, Skin, Conjunctiva

Pathology • Exotoxin : A and B. • Local lesions: Pseudo-membrane formation. • Systemi Effects: CVS CNS Renal system.

Clinical features • Incubation period: 2 -5 days. • Constitutional symptoms: • Local manifestations: 1. Nasal diphtheria; 2. Faucial diphtheria: 3. Laryngotracheal diphtheria: 4. Unusual sites;

Complications • Myocarditis: End of 1 st week, abdominal pain, vomiting, dyspnea, systemic venous congestion, tachycardia, extrasystoles, thready pulse, soft mufled 1 st heart sound. • Neurological complications; palatal palsy, loss of accommodation, polyneuritis. • Renal: oliguria, proteinuria

Diagnosis • Clinical examination, • Demonstration of organism by Albert”s stain From the lesions • Isolation of organism by culture from the lesions. • Rapid diagnosis by Fluoresent antibody technique

Differential diagnosis • Nasal diphtheria – FB Nose, Congenital syphilis • Faucial diphtheria- Acute membranous tonsilitis. Moniliasis, IMN. • Laryngeal diphtheria—Croup, Acute epiglottis Retropharyngeal abscess

Treatment • Principles: • Antitoxin • Antibiotics • Supportive • Symptomatic • Management of complications

Antitoxin • • • Pharyngeal / laryngeal 20, 000 - 40, 000 U Nasopharyngeal 40, 000 – 60, 000 U Extensive disease 80, 000 - 1, 20, 000 U

Antibiotics • • Procaine penicillin: 3 - 6 lakhs IM 12 th Hrly 14 days (or) Erythromycin 25 – 30 mg/kg /day

Management of complications • Myocarditis; Restriction of fluids and salts Bed rest Diuretics. Digoxin • Respiratory obstruction : Huminified oxygen Tracheostomy • Neurological complications NG feeds Ventilator support

• Prevention: Isolation of the case Disinfection of articles Chemoprophylaxis of close contacts Erythromycin 40 -50 mg/kg /day for 7 days Benzathene penicillin 6 – 12 lakhs IM Single dose • Active Immunization

Whooping cough Pertussis • Epidemiology: Age incidence : < 4 yr Mode of infection- Droplet infection Organism: Non motile Gm Negative bacilllus- Bordetella pertussis

Clinical features • Incubation period: 7 -14 days • Clinical stage 1: Catarrhal stage: Lasts for 7 – 10 days Most infectuous period Clinical features : Cough Which become paroxysmal in the later part of this phase Coryza With little naso pharyngeal secretions

• Clinical stage 2 : Paroxysmal Phase: • Laasts for 2 - 4 weeks • Severe cough in explossive manner ending with whoop, paroxysms of cough are precipitated by cold air, food , cold liquids • Child appear choked, unable to breathe • Anxious with suffused face

• Clinical Stage 3: Convalesent phase: Lasts for 2 - 4 weeks Frequency and severity of paroxysms decreases gradually

Complications • Respiratory: Atelectasis, pneumonia, Bronchiectasis, Pneumothorax, Subcutaneous emphysema, Accentuation of dormant TB focus *Neurological: Convulsions Encephalopathy Focal intracranial Hemorrhages

• GIT; Hernia Rectal Prolapse • Hemorrhagic: Subconjuctival hemorrhage • Malnutrition

Diagnosis • TLC Elevated • Rapid diagnosis by fluoresent antibody staining • Isolation of organism in cultures

Differential diagnosis • • FB in air passages TB hilar lynphadenitis Bronchiolitis Adenovirus infection of RT

Traetment • Erythromycin 40 - 50 mg/kg/day for 14 days • Bronchodilator therapy by nebulisation • Betamethasone in life thretening states O. 75 mg/kg/day

Prevention • Active immunisation: Primary at 6. 10, 14 weeks • booster after 1 year of age.

Tetanus • Some 60% of tetanus deaths occur in neonates and children under the age of 5. • The World Health Organization has repeatedly failed to meet its deadlines for tetanus elimination and the disease remains an important global health concern. • The causative agent of tetanus, Clostridium tetani is a ubiquitous organism, present in the soil and in human and animal faeces.

• Neonatal tetanus usually arises from contamination of the umbilical stump. • Even after maternal immunization, the infant is still at risk in many countries, as malaria and HIV reduce placental transfer of protective antibody.

Clinical manifestation • Tetanus is most often generalized but may also be localized. • Incubation period -2 to 14 days • In generalized tetanus the presenting symptom in about half of cases is trismus (masseter muscle spasm, or lockjaw) • Tetanus toxin does not affect sensory nerves or cortical function, the patient unfortunately remains conscious, in extreme pain, and in fearful anticipation of the next tetanic seizure.

• Neonatal tetanus, the infantile form of generalized tetanus, typically manifests within 3 -12 days of birth. • Localized tetanus results in painful spasms of the muscles adjacent to the wound site and may precede generalized tetanus. • Results of routine laboratory studies are usually normal.

Treatment • Surgical wound excision and debridement. • Surgery should be performed promptly after administration of human tetanus immunoglobulin (TIG) and antibiotics. • Single intramuscular injection of 500 units of TIG to neutralize systemic tetanus toxin, but total doses as high as 3, 000 -6, 000 U are also recommended. • Oral (or intravenous) metronidazole (30 mg/kg/day, given at 6 hr intervals; maximum dose, 4 g/day) decreases the number of vegetative forms of C. tetani and is currently considered the antibiotic of choice. • Diazepam provides both relaxation and seizure control. • The initial dose of 0. 1 -0. 2 mg/kg every 3 -6 hr intravenously.

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