Cerebrospinal Fluid (CSF) Rhinorrhea causes, symptoms, treatment, complications

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.

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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