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Pharyngitis due to Diphtheria | symptoms, complication, dd, treatment

Dr.Tamer Mobarak
(1)
Definition: Acute specific infection of the pharynx (throat).
Etiology: 
Gram positive bacillus (corynebacterium diphtheriae) transmitted by droplets.
Incidence: 
Usually young 2-6 y (bellow 12y), incubation period 2-6 days.
Diphtheria-Pharyngitis
Pathology: 
Site: pharynx, larynx & nose (secondary), conjunctiva (rare). It is a pseudo membranous type of inflammation

Symptoms of Diphtheria Pharyngitis: 

Insidious onset
General: low grade fever, headache, malaise, anorexia & may be vomiting.
Local: severe sore throat & dysphasia.

Signs:

General: low grade fever, severe toxemia, tachycardia disproportionate to fever.
Local: False membrane over the tonsil which is:
  • Unilateral, yellow white or dirty gray.
  • Thick & firm, adherent & leaves a bleeding surface on removal & reforms rapidly
  • Often exceeds limits of the tonsils
- Enlarged tender cervical LN: Bull’s neck
+ Clinical picture of laryngeal & nasal diphtheria

Investigations: 

Throat swab: 
a: Direct smear 
b: Culture on loeffler’s serum

Complications of Diphtheria Pharyngitis

These complications occur due to the effect of toxins on different body systems, as follows:
 Body system/organ Possible complication
 Cardio vascular system
  • Toxic myocarditis.
  • Vagal neuritis.
  • Acute heart failure.
 Neurological (Nerves)
  • Soft palate paralysis
  • Occular paralysis
  • Laryngeal & pharyngeal muscle paralysis
  • Diaphragm & inter costal muscle paralysis
  • Peripheral neuritis
 Respiratory system
  • Laryngeal obstruction
  • Lung collapse 
  • Peumonia and lung abscess
  • Respiratory muscle paralysis & respiratory failure
 Renal system
  • Toxic nephritis 

Differential Diagnosis 

This should be diiferentiated from other causes of membrane over tonsils:
  1. Acute follicular tonsillitis
  2. Vincent’s angina
  3. Infectious mononucleosis
  4. Acute leukaemia & granulocytosis
Comparison between Acute follicular tonsillitis and Diphtheria
  Acute follicular tonsillitis  Diphtheria
Onset Acute Gradual
Fever High (39-40) Low (38)
Toxemia Mild Severe
Face Flushed Pale
Pulse Full, rapid, proportionate to fever Weak,rapid, disproportionate to fever
Vomiting Uncommmon  More common
Exudation Yellow spots, confined to tonsils,
 easily removed and no bleeding		 Dirty gray membrane, exceeds the tonsils, adherent and leaves bleeding surface
Side Bilateral  Unilateral
Swab Negative for Diphtheria  Positive for Diphtheria

Treatment of Pharyngitis due to Diphtheria:

1. Hospitalization, isolation, and complete bed rest.
2. Diphtheria antitoxic serum
  • To: neutralize circulating toxins.
  • Dose: 40000-100000 I.U I.M or I.V repeated after 24-48 h.
  • When: diphtheria is suspected, within 48 h.
  • Precautions: do skin sensitivity before, if positive start desensitization or shift to another serum, be ready with antihistaminics ,and steroids.
3. Antibiotics: penicillin ½ million day IV/ IM for 10 days.
4. Observe airway if stridor…………>> tracheostomy.
5. Treatment of complications.

Prophylaxis of Diphtheria:

1- Active: DPT vaccine. 
2- Passive: 5000-10000 IV antitoxic serum I.M for contacts

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