Pharyngeal diphtheria
Introduction
Pharyngeal diphtheria Pharyngeal diphtheria is an acute infectious disease caused by diphtheria bacilli, with a short incubation period and rapid spread. Most of the patients are children aged 1-7 years. The disease is characterized by the formation of grayish white pseudomembrane in the pharyngeal mucosa and systemic toxemia caused by diphtheria exotoxin. The mild type has a slow onset, general malaise, body temperature around 38 °C, mild sore throat; severe cases are more acute. Severe sore throat, may have high fever, irritability, shortness of breath, cyanosis and circulatory failure. In the pharyngeal examination, the tonsil is swollen, and the surface is covered with a gray-white pseudomembrane. The range is beyond the tonsils. The pseudomembrane is thicker and not easy to be peeled off. If it is forcibly peeled off, the bleeding wound remains. basic knowledge The proportion of illness: 0.004%-0.008% Susceptible population: Most patients with this disease are children aged 1-7. Mode of infection: contagious Complications: myocarditis, nephritis, abdominal pain
Cause
Pharyngeal diphtheria
Cause of the disease (60%):
Diphtheria bacilli have obvious pleomorphism, which is rod-shaped or slightly curved, and one or both ends are slightly enlarged, and the opposite staining particles are common at both ends. According to the morphology and biochemical characteristics of bacteria, colonies and virulence, it can be divided into heavy intermediate type and light type, and the frequency of occurrence varies in different regions and at different periods. Diphtheria bacilli invasiveness is weak, but it can produce strong exotoxin, which is the main cause of pathogenesis.
Prevention
Pharyngeal diphtheria prevention
1, 3 to 5 months old infants, receive one hundred, white, broken triple vaccine every month, a total of 3 needles for priming, 1 year and a half to 2 years old, then strengthen 1 needle, 7 years old and 15 years old each infusion refined Diphtheria and tetanus doxoids once to strengthen the immune persistence of diphtheria, protect large children and adults from diphtheria, and if necessary, adults should also strengthen immunity.
2, patients with diphtheria should be promptly isolated and actively treated, isolated to the systemic and local symptoms disappeared, the nasopharynx or other lesions culture continued to be negative for the second time, the isolation should not be earlier than 7 days after treatment, the patient's secretions and utensils must be strict Disinfection, secretions of the respiratory tract are treated with double the amount of 5% phenol soap (lais) or carbolic acid for 1 hour, contaminated clothes and utensils are boiled for 15 minutes, and those who cannot be boiled are soaked with 5% phenol soap or carbolic acid for 1 hour. After the patient leaves, the room should be disinfected with the above disinfectant spray and then cleaned.
3. Contact persons in collective children and adult institutions should be inspected for 7 days, and nasopharyngeal swab culture and diphtheria toxin test should be performed. Those who are in close contact with adults should also perform these tests.
Complication
Pharyngeal diphtheria complications Complications, myocarditis, nephritis, abdominal pain
Although diphtheria toxin can affect whole body cells, the heart, nervous system and kidney are most prominent. Severe diphtheria can be complicated by myocarditis or peripheral nerve palsy, and occasionally toxic nephritis can occur.
(a) cardiovascular system
1. Peripheral circulatory failure: manifested as nausea, vomiting, pale, cold limbs, weak pulse, decreased blood pressure, etc. If myocardial damage occurs at the same time, the symptoms of circulatory failure may be aggravated.
2. Myocarditis: generally appears in the second week of the disease, manifested as fatigue, pale, difficulty breathing, heart enlargement, low heart sound, tachycardia or slow, arrhythmia, liver enlargement, etc., ECG often shows low voltage , ST segment and T wave changes, bundle branch and atrioventricular block or other heart rhythm disorders, patients may die due to heart failure, must be closely observed, timely treatment.
Diphtheria myocarditis is divided into early (3rd to 5th day) and late (5th to 14th) types. The early stage is caused by severe toxemia and can suddenly die within minutes to hours. It is caused by myocardial lesions and then affects the surrounding circulation. The patient has purpura after each extreme paleness, abdominal pain, more common pulse, slower pulse rate, the first heart sound is unclear or even disappeared, the heart rhythm can be completely irregular, blood pressure drops, etc. which performed.
(B) peripheral nerve paralysis
It is characterized by relaxation, which occurs in the 3 to 4 weeks of the disease. The most common soft palate is the slight nasal sound. When the fluid is swallowed, it is removed from the nostrils. The uvula reflex disappears, followed by the eye muscle spasm and strabismus. The drooping of the eyelids, the enlargement of the pupils, etc., can also occur facial paralysis, which is characterized by a skewed mouth. Although the voluntary muscles of the extremities can also occur, it is rare, and the cerebrospinal fluid is generally not found abnormally.
(three) toxic nephropathy
Rarely, the main manifestation is reduced urine output, white blood cells and casts in the urine, and generally no hematuria.
Diphtheria can be secondary to bacterial infections such as cervical lymphadenitis, inflammation around the lymph nodes, otitis media, pneumonia, etc. Occasionally, an abscess around the tonsils occurs, and it is necessary to cut the drainage after giving a sufficient amount of antitoxin.
Symptom
Pharyngeal diphtheria symptoms common symptoms throat enlargement nausea airway obstruction fatigue irritability shortness of breath shortness secondary infection cyanosis
Early myocardial edema, edema and steatosis, followed by multiple, focal necrosis, cell infiltration and muscle fiber rupture, cardiac conduction beam can also have lesions, peripheral nerves are toxic neuritis, neuromyelin is fatty degeneration, nerve axis Subsequent rupture, the most common damage to the nerves such as eyes, sputum, pharynx, larynx and heart, kidney edema, renal tubular epithelial shedding, liver fat infiltration and hepatocyte necrosis, renal gland congestion, turbidity, even visible Small bleeding points.
Diphtheria can be divided into four types, the order of which is pharyngeal diphtheria, throat diphtheria, nasal diphtheria and other parts of diphtheria. Adults and older children are mostly pharyngeal white throat. Other types of diphtheria are more common in young children.
(a) pharyngeal diphtheria
Light weight
Fever and systemic symptoms are mild, the tonsils are slightly red and swollen, and there is a little or small piece of pseudomembrane. After a few days, the symptoms can disappear naturally. It is easy to be misdiagnosed as acute tonsillitis, and should be paid attention to when the diphtheria is popular.
2. General type
Gradually onset, fatigue, poor appetite, nausea, vomiting, headache, mild to moderate fever and sore throat, tonsil moderate redness, milky white or gray-white large pseudomembrane, but the range is still not beyond the tonsils, sometimes fake The film has a yellow color. If it is mixed with blood, it is dark black. The fake film begins to be thin, the edges are neat, and it is not easy to peel off. If it is wiped off hard, it can cause a small amount of bleeding and form a new pseudo-film within 24 hours. .
3. Severe type
Tonsils and pharyngeal edema, congestion is obvious, the pseudomembrane spreads into large pieces within 12 to 24 hours, except for the tonsils, and affects the zygomatic arch, upper jaw, uvula, pharyngeal wall and nasopharynx, and even extends to the oral mucosa The mouth has rancid smell, neck lymph nodes, and even lymph nodes around the inflammation, neck swelling such as "cattle neck", pharyngeal pain in pharyngeal diphtheria is mostly not significant, systemic poisoning symptoms may have high fever or body temperature Li, irritability, shortness of breath, pale, vomiting, rapid pulse, blood pressure, or heart enlargement, arrhythmia, bleeding, thrombocytopenia and other critical symptoms.
(2) Throat and tracheobronchial diphtheria
Most of them are caused by the spread of pharyngeal diphtheria to the throat. They can also be primary. They are more common in children aged 1 to 5 years. The onset is slower, accompanied by fever. The cough is "empty", hoarse, and even aphasia. There are pseudomembranes, edema and sputum which cause respiratory obstruction. When inhaling, there may be snoring sounds. In severe cases, the "three concave signs" can be seen when inhaling. The patient presents with convulsions and purpura. Laryngoscopy reveals redness and swelling of the throat. Pseudomembrane, the pseudomembrane can sometimes extend to the trachea and bronchi, and in severe cases, there is also a pseudomembrane formation in the bronchioles.
(c) nasal diphtheria
Rarely, refers to the anterior nasal diphtheria, the posterior nasal diphtheria is part of the pharyngeal diphtheria, the nasal diphtheria can exist alone, or with the throat diphtheria, pharyngeal diphtheria, more common in infants and young children, the original origin in the nose, more The lesions are small, the systemic symptoms are mild, mainly manifested as serous bloody nasal discharge, later converted to thick purulent sputum, sometimes mixed with nasal discharge, often unilateral, redness around the nostrils, erosion and scarring, nasal vestibule or septum White pseudomembrane can be seen on the top, and untreated patients often do not heal.
(4) cutaneous and wound diphtheria
It is rare to be infected directly or indirectly by skin or mucous membranes. Although this type of symptom is not heavy, the course of disease is prolonged and it is easy to spread diphtheria.
(5) Others
Vulva, umbilicus, esophagus, middle ear, conjunctiva and other places may occasionally occur diphtheria, local inflammation and pseudomembrane, often accompanied by secondary infection, systemic symptoms are light, chronic diphtheria has been reported in China, the course of disease is 1 to 3 months, Although there are not many such cases, they are of importance in the spread of the disease.
The diagnosis of diphtheria mainly depends on medical history and clinical symptoms. Most of the patients have not received vaccination against diphtheria. There is a history of contact with diphtheria patients. The clinical manifestations are pseudomembranous, and it is not easy to separate from submucosal tissue. Nasal and pharyngeal membranes can be coated. Tablets, if found to have a shape like diphtheria, can be initially diagnosed as diphtheria; if the culture finds diphtheria, the diagnosis is basically certain, if the culture is positive and the clinical diagnosis is suspect, it should be tested for bacterial virulence to help identify Early treatment is extremely important. If the clinical symptoms suggest that the diphtheria is more likely, the anti-toxin treatment can be started without waiting for the culture result. The culture-negative person cannot completely exclude the diphtheria.
Examine
Pharyngeal diphtheria examination
1. Blood picture: Leukocytosis, generally (10 ~ 20) × 109 / L, the proportion of neutrophils increased. In severe cases, poisonous particles may appear.
2. Bacteriological examination: Applying at the junction of the pseudomembrane and the mucosa, performing smear examination and culture (Lu's medium), Gram-positive bacilli or diphtheria bacilli can often be found. It can be used as a virulence test for diphtheria bacilli if necessary. There are many test methods. Intradermal injection of guinea pigs can be used: two guinea pigs are taken, one of which is injected with 250 U antitoxin before the test, and then two guinea pigs are injected intradermally with 0.1 ml of the test solution (cultured in Lu's medium 18~) After 24 hours, the bacterial liquid washed with 5 ml of broth), after 24 to 72 hours, if the injection site of the anti-toxin-injected animal was red and swollen, and the injection did not change, the test strain was proved to be toxic.
3. Serological examination: The fluorescent antibody method is used to detect diphtheria bacilli under a fluorescence microscope, which can be diagnosed early.
4. Rapid diagnosis of potassium citrate.
5. Other examinations: Electrocardiogram helps to detect toxic myocarditis, and changes in urea nitrogen, creatinine, and liver function in liver and kidney damage.
6. Toxic myocarditis ECG shows that the PR interval prolongs ST-T wave changes.
Diagnosis
Diaphragm and diphtheria diagnosis and differentiation
diagnosis
Diagnosis can be made based on medical history, clinical manifestations, and examination.
Differential diagnosis
(1) pharyngeal diphtheria needs to be identified with the following diseases
1. Acute tonsillitis: acute onset, high fever, tonsil redness, obvious sore throat; thinner secretions, lighter color, limited to tonsils, easy to peel off.
2. Thrush: The heat is not high, there are white flaky blocks attached to the oral mucosa, which can spread to the pharynx, white film loose, easy to peel off, although the lesion range can be very wide, but the symptoms of poisoning are not significant.
3. Ulcer membranous pharyngitis: There are necrotizing ulcers and pseudomembranes in the pharynx, often accompanied by gingivitis, bleeding, oral malodor, throat swab smear can find Fusobacterium and spirochetes.
4. Infectious mononucleosis: There is white membrane on the tonsils, slow regression, smear and culture without diphtheria, diphtheria antitoxin treatment is ineffective, abnormal lymphocytes in the surrounding blood, blood heterophilic agglutination test can be positive, specific Anti-all positive.
(2) Throat and diphtheria need to be differentiated from the following diseases
1. Acute laryngitis: acute laryngeal obstruction in childhood is mostly caused by acute laryngitis, measles complicated by laryngitis and throat diphtheria, measles and laryngitis have a history of measles; acute laryngitis is acute, sudden breathing difficulties, due to the original Patients with larynx have no pseudomembrane in the pharynx, so it is difficult to confirm when there is laryngeal obstruction; if there is a white film ejected from the tracheal incision, the diagnosis of diphtheria should be considered.
2. Foreign body in the trachea: There is a history of foreign body inhalation. When the foreign body inhales, there is a severe cough. After the cough is paroxysmal, no pseudomembrane is found. Local emphysema or atelectasis is often seen in the chest.
(3) Nasal diphtheria needs to be differentiated from the following diseases
1. Foreign body in the nasal cavity: often one side, it can be found that there are foreign bodies in the nasal cavity without pseudomembrane.
2. Congenital syphilis: often accompanied by other symptoms of syphilis, there is ulcer in the nasal cavity without white membrane, serum Huakang reaction is positive.
