skin diphtheria
Introduction
Introduction to skin diphtheria The cutaneous diphtheria is a diphtheria bacillus that invades a skin wound or is infected by the diphtheria of the nose, pharynx, and throat. Acute patients often have diphtheria in the throat or other areas, while chronic patients generally have only skin symptoms. The clinical manifestation is the appearance of ulcers with grayish white pseudomembrane on the skin. basic knowledge Sickness ratio: 0.05% Susceptible people: Most occur in children, and occasionally in adults. Mode of infection: contact spread Complications: nausea and vomiting, bronchopneumonia, uremia, acute nephritis
Cause
Skin diphtheria cause
(1) Causes of the disease
Corynebacterium diphtheriae is a Gram-positive bacillus belonging to the genus Corynebacterium. The main source of infection is diphtheria patients and carriers. The droplets are caused by droplets, contaminated germs or food brought into the nose or mouth, but the skin is diphtheria. It is often infected by invasive skin, and some are caused by self-infection caused by the nose, throat, and throat.
(two) pathogenesis
It is mainly caused by droplets, contaminated germs or food brought into the nose or mouth, but the skin diphtheria is often infected by broken skin, and some are caused by self-infection caused by nose, throat and throat.
Prevention
Skin diphtheria prevention
1. Control the source of infection
Isolation and treatment of patients until the symptoms disappeared 2 times Nasopharyngeal culture was negative. If there is no culture condition, in the case of adequate treatment, the isolation can be released at 2 weeks of the disease. For close contacts, nasopharyngeal culture should be performed and observed for 7 days. For children who have not received full immunization, it is best to inject the purified diphtheria toxoid and antitoxin simultaneously. Nursery institutions and primary schools should conduct serious morning inspections during the epidemic. Active treatment of carriers. Penicillin is treated with a common dose for 5 to 7 days.
Patients with diphtheria should be promptly isolated and actively treated, isolated until the systemic and local symptoms disappear, and the culture of the nasopharynx or other lesions is negative for the second time. The isolation should not be earlier than 7 days after treatment. The patient's secretions and utensils must be strictly disinfected. The secretions of the respiratory tract are treated with double the amount of 5% phenolic soap (lais) or carbolic acid for one hour, the contaminated clothes and utensils are boiled for 15 minutes, and the boiled can not be boiled with 5% of the coal. Soak for 1 hour with phenol soap or carbolic acid. After the patient leaves, the room should be disinfected with the above disinfectant spray and then cleaned.
Contacts within the group of children and adults should be inspected for 7 days and tested for nasopharyngeal swabs and diphtheria toxins. These checks should also be made by close contacts of adults. 1 culture and toxin test are positive as diphtheria case treatment, should be isolated and treated with penicillin, once the symptoms appear, use anti-toxin. 2 Positive culture and positive toxin test were treated as diphtheria cases. 3 Those who are negative in culture and toxin test can be released. 4 If the culture is negative and the toxin test is positive, vaccination should be given immediately.
2. Cut off the route of transmission
Items touched by the patient and secreted excretion may be soaked in a double volume of 20% chlorine-containing lime emulsion for 1 hour or soaked for 30 minutes with a chlorine-containing disinfectant 5000×10-6.
3. Improve the body's immunity
Autoimmune: It can be injected with white, hundred, broken mixed vaccine or adsorbed and purified diphtheria poisonous toxoid. 3, 4, 5 months old infants receive one shot of 100, white and broken triple vaccine every month, a total of 3 needles for priming. Strengthen 1 stitch from 1 year and a half to 2 years old. At the age of 7 and 15 years old, they are inoculated with purified diphtheria and tetanus toxins once to enhance the immune persistence of diphtheria and protect large children and adults from diphtheria. Adults should also be boosted if necessary. Vaccination is effective and can significantly reduce morbidity and mortality. Children from 6 months to 3 months should be vaccinated with diphtheria toxoid, tetanus toxoid and pertussis vaccine or albino toxoid toxoid. Those who are older than the age of 4 years old are also required to be vaccinated. For susceptible children who have been in close contact with diphtheria, 1000 to 2000 units of diphtheria antitoxin can be injected intramuscularly for emergency prevention, while diphtheria toxoid is injected to prolong immunity.
4. The schick's test is used to determine whether the body has immunity to diphtheria and to determine if vaccination is required. The method was to intradermally inject 0.1 ml of diphtheria toxin (minimum lethal dose of 1/50 guinea pig) in the left forearm flexion side, and also inject the control toxin into the right forearm flexor side (heating 80 ° C for 5 minutes to destroy its toxicity) 0.1 ml ,as comparison. Negative reaction, no blush or infiltration on both sides of the injection, showing that the body is immune to diphtheria. Positive reaction, after 24 to 36 hours on the left injection site, a circular micro-lifting blush appeared, gradually forming red and swollen hard blocks, reaching the highest peak on the fourth day, the diameter reached 1-2 cm, and the reaction gradually subsided after 7 to 14 days, while the control side No response, indicating no immunity to diphtheria. A false positive reaction indicates both immunity and allergies. The mixed reaction indicates that the body has no anti-virulence immunity to diphtheria toxin, but it has an allergic reaction to the toxin protein, and attention should be paid to the difference.
5. Passive immunization : Patients with diphtheria susceptibility who are unable to receive diphtheria toxoid injection due to infirmity or illness and who are exposed to diphtheria may give antitoxin. Diphtheria antitoxin is a special treatment preparation, and a sufficient amount of diphtheria antitoxin should be injected early in the onset. Adults 1000 ~ 20000U intramuscular injection, children 1000U, valid for only 2 to 3 weeks. A skin test is performed prior to the use of antitoxin serum to prevent xenogeneic serum allergic reactions. Antibiotics should be given at the same time as antibacterial therapy, such as intramuscular injection with procaine penicillin until the symptoms disappear and the culture of diphtheria is negative. The body's immunity to diphtheria. Determined by the level of anti-toxin in the blood. Containing 10 U/L in serum is protective. The diphtheria toxin (Silk) test, or indirect hemagglutination test and ELISA can be used to detect the anti-toxin level in the serum of the population, to understand the anti-toxin level of the population, to help predict the possibility and extent of the diphtheria epidemic, and to detect the effect of the vaccination. . The level of immunization in the population is negatively correlated with the incidence. The antitoxin level in some areas of China has reached 85% to 95%. There is no diphtheria epidemic in these areas in the near future.
Complication
Diphtheria complications Complications nausea and vomiting bronchial pneumonia uremia acute nephritis
Toxic myocarditis
The most common and most common complication of this disease. It occurs mostly in the second to third weeks of the course of the disease, but it also occurs in the first week and the sixth week. In general, the heavier the toxemia, the earlier and the more severe the myocarditis occurs. Some severely ill patients have improved symptoms after treatment, and the pseudomembrane falls off, but myocarditis can still occur. It is often weak and weak, pale, irritated, arrhythmia, atrioventricular block, first heart sound is low and blunt, severe heart enlarges, liver enlarges, urine volume decreases and edema. The ECG is abnormal.
Diphtheria myocarditis is divided into two types: early (3rd to 5th day) and late (5th to 14th). The early stage is caused by severe toxemia, which can suddenly die within a few minutes to several hours; the late stage is caused by myocardial lesions and then affects the surrounding circulation. The patient has cyanosis and abdominal pain after each extreme paleness, and the pulse is weak. The pulse rate is slowed down, the first heart sound is unclear or even disappears, the heart rhythm can be completely irregular, and the blood pressure is lowered.
2 peripheral circulatory failure
It is characterized by nausea, vomiting, pale complexion, cold limbs, weak pulse, and decreased blood pressure. If myocardial damage occurs at the same time, the symptoms of circulatory failure can be aggravated.
3. Peripheral nerve paralysis
It is more common to have motor nerve damage. It is most common to use soft phlegm, and it is coughing and phlegm reflexes disappearing in the fluid diet. It occurs mostly in the third to fourth weeks of the disease course. Followed by eye muscle paralysis, if the oculomotor nerve is damaged, the eyelids may sag and the near things may not be seen. Spreading nerve paralysis can cause esotropia. There can also be facial nerve palsy. In addition, flaccid paralysis can occur in the whole body muscles, such as the cervical muscles, the chest muscles, the intercostal muscles, and the muscles of the limbs, leading to corresponding movement disorders. In the 7th to 8th week of the disease, symptoms of vagus nerve paralysis may occur, heart rate increases, sweating, secretion increases, and bowel movements decrease. The paralysis caused by diphtheria can basically recover without leaving sequelae. More than a few weeks to months to recover. Some people may have symptoms of sensory nerve damage, such as abnormal feelings, hyperesthesia, etc., but it is rare.
Bronchopneumonia
More common in young children, often secondary infections. Patients with pharyngeal diphtheria, especially when the pseudomembrane extends down to the trachea and bronchus, are more conducive to the occurrence of pneumonia. After the tracheotomy, if the care is not strict, it is easy to happen.
5. Toxic nephropathy
Protein, red blood cells and casts appear in the urine of diphtheria patients, but true acute nephritis is rare. A small number of critically ill patients may develop uremia with a poor prognosis.
Symptom
Skin diphtheria symptoms common symptoms crunic inflammatory cell infiltration rash acne
Skin diphtheria is rare in China, mostly in children, occasionally seen in adults, generally does not cause systemic symptoms, but in the baby may have serious systemic symptoms, if the patient's nose, throat, throat also suffer from diphtheria, the corresponding parts may have adhesion Hemorrhagic scarring, skin infection is infected, gradually forming an edge of the edge of the ulcer, the surface is attached with a gray-white pseudomembrane, forcibly torn, causing surface bleeding; ulcers with black necrotic tissue, early self-conscious pain, skin lesions Eczema-like, dermatitis-like, and a small number of acne-like or purpura-like changes can also occur, but the surface has a gray-white pseudomembrane.
Examine
Examination of skin diphtheria
1. Blood: Both white blood cells and neutrophils are slightly elevated, and urine routines sometimes change, such as proteinuria.
2. Bacteriological examination: Wipe the diphtheria bacilli on the edge of the pseudomembrane, smear microscopy, and bacterial culture, but it needs to be identified with the non-toxigenic diphtheria, and virulence identification is required. The virulence test was carried out in vitro or in vivo. The former inoculated the cultured bacteria subcutaneously into two guinea pigs, one of which was intraperitoneally injected with diphtheria antitoxin 2 hours before inoculation, and one of the unantitoxins died within 1 to 4 days. That is, it is proved to be a toxigenic strain, and an in vitro test can be performed by an immunoagglutination method, that is, an Elek test.
3. Skin lesions After taking the specimen smear, diphtheria bacilli can be found by staining with methylene blue. It can also grow on Loffler medium.
4. Histopathology: The epithelial cells of the ulcer edge are thickened, and there is acute inflammatory cell infiltration in the dermis. There are necrotic cells, fibrin and neutrophils on the surface of the ulcer. There is a large amount of diphtheria in the necrotic layer.
Diagnosis
Diagnosis of skin diphtheria
According to the clinical manifestations, the skin lesions were taken after smear of the specimen, and the diphtheria bacillus was found by staining with methylene blue, and it could grow on Loffler medium. Histopathology: thickening of epithelial cells in the edge of the ulcer, acute inflammatory cell infiltration in the dermis, There are necrotic cells, fibrin and neutrophils on the surface of the ulcer, and there are a large number of diphtheria bacilli in the necrotic layer, which can be diagnosed.
