Diphtheria. Indications for hospitalization

The main source of diphtheria infection is a person - a patient with diphtheria or a bacteriocarrier of toxigenic diphtheria microbes. In the body of a patient with diphtheria, the pathogen is found already in incubation period, is present throughout acute stage disease and in most individuals continues to stand out some time after it. So, in 98% of cases, diphtheria bacilli are isolated in the first week of convalescence, in 75% - after 2 weeks, in 20% - more than 4, in 6% - more than 5 and in 1% - 6 weeks. and more.

Epidemiologically, the most dangerous are persons who are in the incubation period of the disease, patients with erased, atypical forms diphtheria, especially rare localizations (for example, diphtheria of the skin in the form of eczema, diaper rash, pustules, etc.), which differ in a longer course compared to diphtheria of normal localization and a typical course, and are diagnosed late. Coorman, Campbell (1975) note the particular contagiousness of patients with skin form diphtheria, proceeding as impetigo, due to the tendency of these forms to significant environmental contamination.

Bacteriocarrier develops after diphtheria and in healthy individuals, while there may be a carriage of toxigenic, atoxigenic, and simultaneously both types of corynebacteria.

With diphtheria, healthy carriage is widespread, it significantly exceeds the incidence, it occurs everywhere and even in places (Philippines, India, Malaya) where this infection has never been recorded.

Carriers of toxigenic diphtheria bacteria are of epidemiological importance. Carriers are convalescents, as are patients in acute period diseases, many times more intensively emit the pathogen compared to healthy bacteria carriers. But, despite this, during the period of sporadic morbidity, when manifest forms of diphtheria are rare and in these patients contacts with healthy individuals are very limited due to low mobility due to poor health, they acquire special epidemiological significance, except for patients with erased, atypical forms of diphtheria, healthy bacteria carriers of toxigenic corynebacteria. Currently, the latter are the most massive and mobile sources of diphtheria.

Healthy carriage is seen as infectious process without clinical manifestations. This is confirmed by the indicators of antitoxic and antibacterial (specific and nonspecific) immunity, electrocardiogram data, produced in the dynamics of carriage. Histopathologically, in the tissues of the tonsils of rabbits carrying corynebacteria, changes in the multilayer squamous epithelium, submucosal layer, lymphoid apparatus of the tonsils, inherent in acute inflammation.

The frequency of carriage of toxigenic corynebacteria reflects the epidemiological situation of diphtheria. It is minimal or reduced to zero in the absence of morbidity and significant in case of unfavorable diphtheria - 4-40. According to the data in the foci of diphtheria, the carriage is 6-20 times higher than among healthy individuals.

In contrast to the carriage of toxigenic cultures, the carriage of non-toxigenic strains of corynebacteria does not depend on the incidence of diphtheria, it remains more or less constant or even increases.

The level of carriage in groups also depends on the state of the nasopharynx. In diphtheria foci, carriage among children with normal state the mucous membrane of the pharynx and nasopharynx is detected 2 times less often than the environment of children suffering from chronic tonsillitis. The role of chronic tonsillitis in the pathogenesis of long-term diphtheria bacteriocarrier is also evidenced by the studies of A. N. Sizemov, T. I. Myasnikova (1974). In addition, in the formation of long-term carriage great importance give concomitant staphylo-, streptococcal microflora, especially in children with chronic pathological changes from the nasopharynx. V. A. Bochkova et al. (1978) believe that the presence of a chronic focus of infection in the nasopharynx and concomitant infectious diseases reduce the immunological reactivity of the body and are the cause of weakly strained antibacterial immunity, leading to the formation of a bacteriocarrier.

The degree of danger of carriers of toxigenic corynebacteria is determined by the level of antitoxic immunity in the team, which indirectly affects the process of carriage, reducing the incidence of diphtheria and thereby sharply reducing the possibility of contact with the pathogen. With a high level of antitoxic immunity and the presence of a significant number of carriers of toxigenic bacteria, diphtheria may not occur. The carriage becomes dangerous if non-immune persons appear in the team.

Many authors (V. A. Yavrumov, 1956; T. G. Filosofova, D. K. Zavoiskaya, 1966, etc.) note (after extensive immunization of the child population against diphtheria) a decrease in the number of carriers among children simultaneously with an increase in their number among adults . The reason for this is a significant percentage (23) of adults who are not immune to diphtheria, which corresponds to the number of the entire child population that is immunized. This is the reason for the increased role of adults in the epidemic process of diphtheria.

Healthy carriage most often lasts 2-3 weeks, relatively rarely lasts more than a month, and sometimes up to 6-18 months. According to M. D. Krylova (1969), one of the reasons for long-term carriage may be the reinfection of the carrier with a new phagovariant of the pathogen. Using the phage typing method, it is possible to more accurately determine the duration of the bacteriocarrier. This method is also promising in identifying the source of a diphtheria outbreak in the outbreak.

In different communities, both toxigenic and non-toxigenic corynebacteria can simultaneously circulate. According to G. P. Salnikova (1970), more than half of patients and carriers simultaneously vegetate toxigenic and non-toxigenic corynebacteria.

In 1974, a classification of bacterial carriage was adopted, taking into account the type of pathogen, the state of the nasopharynx and the duration of carriage (Order No. 580 of the USSR Ministry of Health of June 26, 1974):

1. Bacterial carriers of toxigenic diphtheria microbes:
- a) with a sharp inflammatory process in the nasopharynx when the diagnosis of diphtheria is excluded on the basis of comprehensive examination(including quantitative determination of antitoxin in the blood);
- c) with a healthy nasopharynx.
2. Bacteriocarriers of atoxigenic diphtheria microbes:
- a) with an acute inflammatory process in the nasopharynx;
- b) with a chronic inflammatory process in the nasopharynx;
- c) with a healthy nasopharynx.

According to the duration of microbial isolation:

a) transient bacteriocarrier (single detection of diphtheria bacilli);
b) short-term carriage (microbes are isolated within 2 weeks);
c) carriage medium duration(microbes are excreted within 1 month);
d) prolonged and recurrent carriage (microbes are excreted for more than 1 month).

In addition to humans, domestic animals (cows, horses, sheep, etc.) can also be a source of diphtheria infection in nature, in which corynebacteria are found on the mucous membranes of the mouth, nose, and vagina. A great epidemiological danger is the presence on the udder of cows of pustules and chronic ulcers that cannot be treated, in the contents of which diphtheria bacilli are determined. The carriage and incidence of diphtheria among animals depends on its incidence among humans. During the period of sporadic incidence of diphtheria among humans, the incidence of diphtheria also decreases among animals.

The mechanism of transmission of infection:

Infection is transmitted mainly by airborne droplets. The infection is spread by the sick person or carrier through talking, coughing and sneezing. Depending on the specific gravity droplets of discharge can remain in the air for several hours (aerosol mechanism). Infection can occur immediately upon contact or through contaminated air after some time. The possibility of indirect infection with diphtheria through infected objects is not ruled out: toys, clothes, underwear, dishes, etc. There are known "milk" outbreaks of diphtheria associated with infection through infected dairy products.

Susceptibility and Immunity:

Susceptibility to diphtheria is low, the contagiousness index ranges from 10-20%. So, infants up to 6 months are immune to this disease due to their passive immunity transmitted from the mother through the placenta. The most susceptible to diphtheria are children aged 1 to 5-6 years. By the age of 18-20 and older, immunity reaches 85%, which is due to the acquisition of active immunity.

But in Lately The age composition of patients with diphtheria has changed dramatically. The majority of patients are adolescents and adults, the incidence among preschool children has sharply decreased.

The incidence of diphtheria is affected whole line factors, including the state of natural and artificial, i.e. vaccination, immunity. The infection is defeated if 90% of children under 2 years of age and 70% of adults are vaccinated. A certain place is occupied by social and environmental factors.

Periodicity and seasonality:

Within a given territory, the incidence of diphtheria periodically increases, which depends on age composition, immunity and accumulation of population groups susceptible to diphtheria, especially children.

The incidence of diphtheria is also characterized by seasonality. During the entire analyzed period, the autumn-winter seasonality characteristic of this infection was noted. This period accounts for 60-70% of the annual incidence.

With bad organization preventive measures the incidence of diphtheria in the season increases by 3-4 times.

In 1980, S. D. Nosov, characterizing the epidemiological features of the current course of diphtheria in our country, notes the disappearance of the periodicity in the incidence, the smoothing or disappearance of its seasonal fluctuations; increase in morbidity in older age groups, equalization of morbidity rates for children attending and not attending children's institutions; increase in the share of morbidity among rural population compared to urban a decrease in the frequency of carriage of toxigenic diphtheria bacteria, but less significant compared to a decrease in the incidence.

Diphtheria is an acute infectious disease characterized by toxic damage to the cardiovascular and nervous systems, a local inflammatory process with the appearance of typical fibrinous films.

Etiology

Pathogen - diphtheria bacillus, belongs to the genus Corynebacteria, is characterized by serological heterogeneity, is divided into three cultural and biochemical types, into two varieties - toxigenic and non-toxigenic. Rods can be stored for a long time in dried pathological material at temperatures below 0 °C. In disinfectant solutions, they die quickly.

Pathogenesis

Main operating principle is a diphtheria exotoxin that affects tissues at the site of implantation of bacteria on the mucous membrane or in the wound. The toxin causes the death of mucosal cells that secrete thrombokinase. Penetrating deep into the tissues, it affects the vessels, increases their permeability with the release of blood serum into the surrounding tissues. The toxin affects the autonomic nervous system, including the apparatus that regulates the work of the heart. This can lead to early death of the patient as a result of sympathicoparesis and cardiac arrest, especially when physical activity. On the 2-4th week of the disease, the development of paralysis of the limbs and soft palate (nasal) is possible. Profound degenerative changes (fatty degeneration) occur in the heart muscle, with possible sudden death at 3-4 weeks of illness stressful situation, abruptly getting out of bed. The kidneys, liver, adrenal glands can be affected. With diphtheria of the larynx, there is an accumulation of films on the vocal cords, swelling of the mucous membranes and submucosa, which, with muscle spasm, is accompanied by complete asphyxia.

Epidemiology

Morbidity in Russia under the influence of mass preventive vaccination children is low, in a number of areas for many years diphtheria has not been recorded. On the background high level immunity in children, there is a shift in diseases to older age groups. Diphtheria occurs as sporadic cases in unvaccinated or incompletely vaccinated people. The disease belongs to the group drip infections

Clinic

The diphtheria clinic is distinguished by a variety of forms depending on the location of the lesion - the pharynx, larynx, nose, mucous membranes of the eyes, skin, wounds, limited process (localized and widespread), the presence of intoxication (toxic and non-toxic forms). IN modern conditions in 85-95% of cases, diphtheria of the pharynx occurs. According to the modern classification, localized (islet, membranous), widespread, toxic diphtheria of the pharynx I, II and III degree, hypertoxic, hemorrhagic and gangrenous forms.

The existence of an atypical catarrhal form is recognized. The disease develops with a rise in temperature, moderate redness of the mucous membrane of the pharynx, the appearance of typical grayish-whitish, smooth, fibrinous deposits that cannot be removed with a spatula in the form of islands or completely covering the tonsils.

Sore throat when swallowing is mild. The toxic form of diphtheria of the pharynx is accompanied by edema of the paratonsillar and cervical tissue, severe intoxication, lesions internal organs- heart, kidneys, adrenal glands, liver.

Zev is narrowed due to sharp edema paratonsillar fiber, tonsils almost close to each other, covered with typical plaque. The mucous membrane of the pharynx and arches is cyanotic, hyperemic.

Heart sounds are muffled, arrhythmias are often detected, arterial pressure, the liver is enlarged. In the blood, neutrophilic leukocytosis, aneosinophilia are noted.

ESR increased, proteinuria in the urine, pathological elements. Diphtheria of the larynx (laryngitis) is accompanied by barking cough, in a hoarse voice.

Against this background, croup can develop - stenosing laryngitis (laryngotracheobronchitis) with a significant narrowing of the lumen of the larynx. Clinical symptoms of diphtheria croup develop gradually.

With absence specific therapy the process is progressing. There are three degrees of severity of croup: I - dysphonic - catarrhal degree lasts 2-4 days, accompanied by difficulty in breathing on inspiration, retractions of the intercostal spaces appear, epigastric region, whistling respiratory noise and tension of the auxiliary respiratory muscles.

The transition of the process to the II - stenotic - stage, lasting from 2-4 hours to 2-3 days, is accompanied by constant difficulty in breathing and noisy breathing. III - asphyxic stage of croup is accompanied by a sharp anxiety of the patient.

There are cyanosis of the lips, then the extremities, face, paradoxical pulse, convulsions. With increasing oxygen deficiency the patient may die.

Differential Diagnosis

Diphtheria of the pharynx must be differentiated from diseases of another etiology, accompanied by angina: infectious mononucleosis, tonsillitis of strepto-, staphylococcal and fusospirillosis nature, fungal infection of the tonsils; toxic form of diphtheria of the pharynx - with paratonsillitis. In the catarrhal form of diphtheria of the pharynx, in contrast to angina, there is a slight rise in temperature, there is no pain in the throat when swallowing. The tonsils are slightly enlarged. Hyperemia of the mucous membranes of the pharynx and tonsils is mild. Changes in the blood are insignificant or absent.

In most cases catarrhal form diphtheria pharynx is an early stage pathological process, which further progresses in the absence of specific therapy, plaques (films) appear on the tonsils. Such a course of the process in the pharynx should always arouse suspicion of diphtheria. The island form of diphtheria of the pharynx largely resembles follicular tonsillitis. In contrast, the island form of diphtheria of the pharynx is accompanied by a moderate rise in temperature, slight sensations in the pharynx (“something interferes with swallowing”).

Zev slightly hyperemic. On the tonsils, gray-white raids in the form of islands are visible. They are tightly soldered to the underlying tissues, are not removed with a spatula, but they can be removed with tweezers, after which bleeding appears in their place. In the absence of specific therapy, raids extend to the entire amygdala and beyond.

With membranous diphtheria of the pharynx, against the background of more often moderately elevated temperature, slight discomfort when swallowing, smooth, shiny grayish-white fibrinous films with well-defined edges are visible on the mucous membrane of the tonsils, covering partially or completely the entire surface. The raids are not removed; when they are removed with tweezers, the surface under them bleeds. Blood changes are little expressed. With this form, changes in the heart can already be determined.

The presence of raids on the tonsils in infectious mononucleosis is a common cause of a false diagnosis of diphtheria of the pharynx. Infectious mononucleosis begins acutely, often with a significant rise in temperature, pain when swallowing, enlargement of the tonsils with the appearance of whitish plaques or necrotic changes on them. The patches are easily removed. In recognition infectious mononucleosis significant peripheral lymphadenitis lymph nodes, especially cervical and occipital, the presence of hepatolienal syndrome, an increase in the number of mononuclear cells in peripheral blood.

Fusospirillous angina (Simanovsky-Vincent's angina) begins with a moderate fever and slightly pain when swallowing. Light hyperemia of the mucous membrane of the pharynx and dirty grayish-yellow plaques on the tonsils are revealed, which are easily removed. As with diphtheria of the pharynx, changes in the blood are not very pronounced. Fusospirillous angina often affects one tonsil.

With diphtheria, the films are located on both tonsils, they have a shiny surface, they are not removed. A smear on the bacterial flora in fusospirillosis angina reveals a fusiform bacillus in association with oral spirilla. The disease proceeds favorably, with treatment, changes in the pharynx quickly disappear. At fungal infection tonsils there is no pronounced hyperemia of the mucous membrane, raids white color, are difficult to remove.

The patient complains of mild pain when swallowing. Raids can also be on the mucous membrane of the tongue, cheeks, temples. In a smear from a plaque, fungi of the genus Candida are found. The toxic form of diphtheria of the pharynx has to be differentiated from paratonsillitis, which is characterized by high fever, severe pain when swallowing, and the mouth opens with difficulty.

On the side of the lesion, there may be swelling of the cervical tissue, but intoxication is mild. When examining the pharynx - unilateral edema of the paratonsillar tissue, the tonsil is, as it were, immersed in the edematous tissue, merges with it (without clear boundaries), the mucous membrane is hyperemic. In the blood, leukocytosis with a shift leukocyte formula to the left to stab neutrophilic granulocytes, ESR is sharply increased. At toxic diphtheria edema often occupies symmetrical areas of the tissues of the submandibular region and neck or falls below.

Pain in the throat when swallowing is not sharp. In the pharynx, symmetrical swelling of both Tonsils, raids. At mumps flattened ear fossa. This place is painful on palpation, swelling of the salivary parotid or submandibular lymph nodes, a positive Murson's symptom (hyperemia and swelling of the nipple of the parotid duct outlet) are often detected.

Angina, raids on the tonsils, swelling of paratonsillar tissue are absent. Epidemiological data, blood test results (leukopenia, lymphocytosis, normal ESR) and urine (possibly increased activity of diastase) can finally confirm the diagnosis of parotitis and exclude diphtheria. In the establishment final diagnosis diphtheria of the pharynx, the clarification of the anamnesis, positive results of bacteriological studies of a smear from the pharynx, a low titer of anti-diphtheria antibodies in the blood serum at the onset of the disease are of great importance. Diphtheria of the larynx (diphtheria croup) should be differentiated from croup of a different etiology (with measles, influenza, other acute respiratory infections and staphylococcal infections, whooping cough and other bacterial infections), which were previously combined by the term " false croup».

Croup in these diseases develops against the background of clinical symptoms The main infectious disease in the vast majority of patients is acute (usually in the middle of the night): symptoms of laryngitis appear, and then signs of difficulty breathing join. Often, the process progresses rapidly and can go into the asphyxic stage for a short time. When examining a patient, they find the symptoms of the infection against which the croup developed. Rational therapy usually leads to an improvement in the patient's condition.

Croup in diphtheria is characterized by a slowly progressive respiratory disorder, often combined with membranous angina or rhinitis, a positive result of a smear (or films) from the pharynx and tonsils for diphtheria bacillus, the absence of effect from conventional methods treatment. The introduction of antidiphtheria serum leads to a clear improvement in the condition.

Prevention

Prevention of diphtheria is carried out with diphtheria toxoid, which is part of combined drugs- DPT, ADS, ADS-m. Vaccination of children of the first 4 years is carried out three times with DTP, 4-6-year-olds use ADS with a double injection for this, patients older than 6 years are usually vaccinated with ADS-m. Revaccination is carried out 9-12 months after the completed vaccination course. Repeated injections ADS-m is performed at 6, 11, 16 years and then every 10 years. If the disease occurs in children's team children who have been in contact with the patient are examined bacteriologically and separated for 7 days. The discharge of convalescents is carried out after a double negative result bacteriological examination.

Treatment

Emergency hospitalization for suspected diphtheria. Antidiphtheria serum is administered as early as possible, without waiting for laboratory confirmation of the diagnosis, intramuscularly or intravenously at a dosage corresponding to the clinical form of the disease. Before the introduction of a full dose, a skin or conjunctival test for hypersensitivity is performed.

Intradermal test: diphtheria antitoxin at a dilution of 1:100 is administered intradermally, the reaction is considered positive if an infiltrate forms within 20 minutes after injection. Conjunctival test: antidiphtheria serum at a dilution of 1:10 is instilled into the conjunctival cavity of one eye, 0.1 ml of 0.9% sodium chloride solution is instilled into the other eye.

The reaction is considered positive when local reaction(itching, redness). In all cases (incl.

hours and for the carrier) antibiotics are prescribed, for example, erythromycin 40-50 mg / kg / day (maximum 2 g / day) for 14 days or benzylpenicillin 100,000-150,000 IU / kg / day in 4 injections / m .

Attention! The described treatment does not guarantee positive result. For more reliable information, ALWAYS consult a specialist.

DIPHTHERIA- acute infectious disease with airborne transmission mechanism; characterized by croupous or diphtheritic inflammation of the mucous membrane at the gates of infection - in the call, nose, larynx, trachea, less often in other organs and general intoxication.

Etiology and pathogenesis of diphtheria

Etiology, pathogenesis. The causative agent is a toxigenic diphtheria bacillus, gram-positive, resistant to external environment. Pathogenic action associated with exotoxins. Non-toxigenic corynebacteria are non-pathogenic. Diphtheria bacillus vegetates on the mucous membranes of the pharynx and other organs, where croupous or diphtheria inflammation develops with the formation of films. The exotoxin produced by the pathogen is absorbed into the blood and causes general intoxication with damage to the myocardium, peripheral and autonomic nervous system, kidneys, and adrenal glands.

Symptoms of diphtheria

Symptoms, course. The incubation period is from 2 to 10 days. Depending on the localization of the process, diphtheria of the pharynx, nose, larynx, eyes, etc.

Diphtheria of the pharynx. There are localized, widespread and toxic diphtheria of the pharynx. With a localized form, fibrinous membranous raids are formed on the tonsils. Zev is moderately hyperemic, pain during swallowing is expressed moderately or weakly, regional lymph nodes are slightly enlarged. General intoxication is not expressed, temperature response moderate. A variation of this form is islet diphtheria of the pharynx, in which raids on the tonsils look like small plaques, often located in lacunae. With a common form of diphtheria of the pharynx, fibrinous deposits pass to the mucous membrane palatine arches and tongue; intoxication is pronounced, body temperature is high, and the reaction of regional lymph nodes is more significant. Toxic diphtheria is characterized by a sharp increase in the tonsils, a significant swelling of the mucous membrane of the pharynx and the formation of thick, off-white plaques, passing from the tonsils to soft and even solid sky. Regional lymph nodes are significantly enlarged, the subcutaneous tissue surrounding them is edematous. cervical edema subcutaneous tissue reflects the degree of intoxication. With toxic diphtheria of the 1st degree, the edema extends to the middle of the neck, with the 2nd degree - up to the collarbone, with the 3rd degree - below the collarbone. The general condition of the patient is severe, high temperature (39-40 degrees C), weakness, anorexia, sometimes vomiting and abdominal pain are noted. Severe disturbances are seen of cardio-vascular system. A variation of this form is subtoxic diphtheria of the pharynx, in which the symptoms are less pronounced than in toxic diphtheria of the 1st degree.

Diphtheria of the larynx (diphtheria, or true, croup) has recently been rare, characterized by croupous inflammation of the mucous membrane of the larynx and trachea. The course of the disease is rapidly progressive. In the first catarrhal (dysphonic) stage, lasting 1-2 days, there is an increase in body temperature, usually moderate, increasing hoarseness, cough, at first "barking", then losing its sonority. In the second (stenotic) stage, symptoms of stenosis of the upper respiratory tract: noisy breathing, tension during inhalation of the auxiliary respiratory muscles, inspiratory retractions compliant places chest. The third (asphyxic) stage is manifested by a pronounced disorder of gas exchange - cyanosis, loss of pulse at the height of inspiration. sweating, restlessness. If timely n0 render medical assistance, the patient dies of asphyxia.

Diphtheria of the nose, conjunctiva of the eyes, and external genital organs has hardly been observed lately.

The complications arising mainly at toxic diphtheria of the II and III degrees are characteristic, especially n ^ and the late begun treatment. IN early period disease may increase symptoms, vascular and cardiac weakness. Myocarditis is detected more often in the 2nd week of the disease and is characterized by a violation contractility myocardium and its conducting system. The reverse development of myocarditis occurs relatively slowly. Myocarditis is one of the causes of death in diphtheria. Mono- and polyradiculoneuritis appear sluggish peripheral paresis and paralysis soft palate, external main muscles, muscles of the limbs, neck, torso. Danger to life are paresis and paralysis of the laryngeal, respiratory intercostal muscles, diaphragm and damage to the innervation devices of the heart. There may be complications due to secondary bacterial infection(pneumonia, otitis, etc.).

Diagnosis of diphtheria

The diagnosis is confirmed by the isolation of toxigenic diphtheria bacilli. It is necessary to differentiate from tonsillitis, infectious mononucleosis, "false croup", membranous adenovirus conjunctivitis(for diphtheria of the eye).

Treatment of diphtheria

Treatment. The main method of therapy is perhaps the earliest intramuscular administration of antidiphtheria serum in appropriate doses (Table 12).

In mild forms of diphtheria, serum is administered once, with severe intoxication (especially in toxic forms) - for a number of days. In order to avoid anaphylactic reactions, an intradermal test is performed with a diluted (1:100) serum, in the absence of a reaction within 20 minutes, 0.1 ml of whole serum is administered and after 30 minutes - the entire therapeutic dose.

In toxic forms with whole detoxification, non-specific pathogenetic therapy: intravenous drip infusions of protein preparations (plasma, albumin), as well as neocompensan, gemodez in combination with 10% glucose solution; introduce predniolone, cocarboxylau, vitamins. Bed rest at toxic form diphtheria, depending on its severity, 3-8 weeks should be observed.

With diphtheria croup, rest, fresh air are necessary. Sedatives are recommended (phenobarbital, bromides, chlorpromazine - do not cause deep dream). The weakening of laryngeal stenosis contributes to the appointment of glucocorticoids. Apply (with good tolerance) steam-oxygen inhalations in tents-chambers. good effect can provide suction of mucus and films from the respiratory tract using an electric suction. Given the frequency of development in croup pneumonia (especially in children early age) prescribe antibiotics. In severe stenosis (during the transition of the second stage of stenosis to the third), they resort to nasotracheal (orotracheal) intubation or lower tracheostomy.

In case of diphtheria bacteriocarrier, oral administration of tetracycline or erythromycin is recommended with simultaneous administration ascorbic acid; the duration of treatment is 7 days.

Prevention of diphtheria

Prevention. Active immunization is the basis for successful diphtheria control. Immunization is carried out for all children (subject to contraindications) with adsorbed pertussis-diphtheria-tetanus vaccine (DPT) and adsorbed diphtheria-tetanus toxoid (ADS). Primary vaccination is carried out starting from the age of 3 months three times, 0.5 ml of vaccine with an interval of 1.5 months; revaccination with the same dose of vaccine - 1.5-2 years after the end of the vaccination course. At the age of 6 and 11 years, children are revaccinated only against diphtheria and tetanus with ADS-M-toxoid (drug with a reduced number of antigens). Patients with diphtheria are subject to mandatory hospitalization. In the apartment of the patient after his isolation, the final disinfection is carried out. Convalescents are discharged from the hospital subject to a negative result of a double bacteriological research on toxigenic diphtheria bacilli; they are allowed to children's institutions after a preliminary double bacteriological examination. Bacteriocarriers of toxigenic diphtheria daddies (children and adults) are allowed to visit children's institutions, where all children are vaccinated against diphtheria, 30 days after the establishment of the bacteriocarrier.

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Diphtheria is a dangerous infectious disease that mainly affects children. The causative agent is the Klebs-Leffler wand - Corynebacterium diphtheriae. Toxin secreted by bacteria causes deep intoxication and typical symptom diphtheria - fibrinous inflammations microbial breeding grounds. Due to the characteristic fibrinous film, until the beginning of the 20th century, the disease was called diphtheria, which means “film” in Latin.

Exciter characteristic

Three biotypes of diphtheria bacillus have been studied. Bacteria are polymorphic, anaerobic, Gram stain. Their length varies from 1 to 12 µm. The diameter is 0.3-0.8 microns. Diphtheria bacilli often contain grains of volutin. When staining microorganisms according to Neisser, the bacteria acquire yellow, while volutin granules are dark brown.

Blood-containing media are used to grow cultures of corynebacteria.. The colonies are convex, medium-sized. Bacteria are able to tolerate low temperatures for a long time, but quickly die when boiled, high temperatures, disinfection, exposure to direct sunlight.

Ways of the spread of the disease

Patients and carriers of the disease spread in a latent form. Possibility of transmission through household items food products. The bacterium enters the body through mucous membranes, wound surfaces, conjunctiva of the eye. The most contagious patients in acute phase diseases.

Diphtheria bacilli have fimbriae - organs that provide attachment of the microorganism to the cells of the human body. Most often, bacteria settle on the epithelium of the tonsils and pharynx - 75-90% of all diseases, but there are also lesions of the ear, eye, genital organs, nose, and skin. In the captured areas, microbes actively multiply, releasing a toxin. He plays a leading role in the pathogenesis of the disease.

Course of the disease

The incubation period lasts from 2 to 10 days. Diphtheria begins with acute intoxication- Fever, sore throat, weakness. The patient loses appetite, performance decreases. The temperature rises moderately - up to 38 0 C. Pain in the throat is not strong, which is associated with damage to sensitive nerve endings.

Pathological anatomy distinguishes several forms of diphtheria, depending on the location of the pathogen and the severity of the disease.

The most dangerous toxic and hypertoxic forms of the disease.

They most often develop in people who are weakened, suffering from immunodeficiency or chronic severe illnesses.

Bacterial exotoxin causes necrosis epithelial cells. The permeability of blood vessels increases, the influx of fluid to the affected areas leads to the appearance of edema. After 2-3 days, fibrinous films appear on the tonsils, which have a mother-of-pearl shade typical of diphtheria. After their removal, the mucous membranes bleed. Films disappear after 6-8 days.

There is hyperemia of the lymph nodes. They are enlarged and painful.

Toxic diphtheria is accompanied by severe fever, low blood pressure, severe pain in the neck and throat. The patient's work of the central nervous system is disrupted, periods of weakness are replaced by bouts of excitement, hallucinations and delirium are possible. Breath acquires an unpleasant putrefactive odor.

In the clinic, there are cases when bacteria, along with the lymph flow, spread to other parts of the body. As a result, secondary foci of diphtheria developed.

diphtheria croup

Distinguish between true and false croup. Diseases have different etiology: true croup causes diphtheria bacillus, and false causes measles and influenza.

Diphtheria croup is more common in adults. The disease has three stages:

dysphonic (lasts from several hours to 7 days) - during this period, there is an active reproduction of bacteria, accompanied by intoxication of the body, the mucous membranes of the larynx become inflamed, cough and hoarseness appear;
stenotic (lasts 2-3 days) - swelling of the larynx leads to difficulty breathing, lack of oxygen causes tachycardia, the breath is noisy, the skin and mucous membranes become bluish, the cough becomes silent;
asphyxia - shallow breathing, blood pressure decreases, convulsions and hallucinations begin, without emergency medical care, death from suffocation occurs in a few hours.

Croup develops much faster in children than in adults.

Damage to internal organs in diphtheria

Pathological changes in severe forms diseases affect the cardiovascular, excretory and nervous system, adrenals.

In case of severe intoxication in the first days of the disease, the kidneys are affected.. The death of the renal tubules leads to a decrease in the filtration capacity of the kidneys. As a consequence, in abdominal cavity fluid accumulates, swelling appears.
At 2-3 weeks of illness, acute heart failure occurs, which can lead to lethal outcome. Myocardial tissues partially die. Focal cardiosclerosis develops.
There is a breakdown of myelin fibers of peripheral nerves. Early complications of diphtheria appear after 1-2 weeks, late - after 1.5-3 months. The patient develops paralysis of the heart, diaphragm, soft palate, mimic muscles of the face, eyes, there is a loss of sensitivity. These pathologies are partially reversible due to the ability of neurons to regenerate. It is also common for intact nerves to take on additional functions.
Cause late complications is the body's immune attack on the nerves affected by the bacterial toxin. Paralysis affects mainly the muscles of the limbs. The patient's gait is disturbed, reflexes fade, sensitivity disappears.
In the adrenal glands, dystrophic and necrotic changes take place.

Diagnostics

Currently, the disease is very rare, many doctors have not encountered diphtheria and cannot make a diagnosis on the basis of diphtheria alone. visual inspection sick. The first 2-3 days of diphtheria differs from SARS only in the absence of a runny nose.

The main method for determining the disease is bacteriological examination.

Mucus is taken from the patient from the affected mucous membranes and seeded on culture media. To identify the pathogen, microscopy is carried out, cultural and biochemical properties bacteria.

A complete blood count shows an increase in the level of leukocytes with a predominance of neutrophilic granulocytes. Young forms of cells come out into the blood. ESR increases. There is a progressive decrease in platelet count.

Additionally, the titer of antibodies to diphtheria toxin is determined.

Treatment

Patients with diphtheria are subject to mandatory hospitalization. Antitoxic serum, antibiotics, glucocorticoids are used for treatment. To strengthen the patient's immunity, vitamins and immunomodulators are prescribed. Drugs and dosage are prescribed by the doctor depending on the age of the patient and the severity of the disease.

With the threat of asphyxia, it is shown surgical intervention followed by mechanical ventilation.

Indicated for the prevention of cardiac complications bed rest. Food must be complete. It is recommended to exclude fatty, smoked dishes, mushrooms, rich bakery products from the diet.

Prevention

The main way to prevent the disease is vaccination with a modified bacterial toxin.. When it enters the body, a strong immunity is developed, and upon repeated contact with the pathogen, infection does not occur. Vaccinate children aged 3, 4.5, 6 and 18 months of the combined DTP vaccine. Revaccination is carried out at the age of 7 and 14.

Currently, the epidemiological danger has increased due to unreasonable refusals from vaccinations.

Diphtheria is caused by Klebs-Leffler sticks. The disease is dangerous high probability development of complications. The main method of treatment is the introduction of antitoxic serum. Vaccination against diphtheria is included in the planned vaccination schedule.

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Diphtheria is caused by the Gram-positive bacterium Corynebacterium diphtheriae. The carrier and source of the pathogen is a person. The most dangerous for others are people suffering from diphtheria of the pharynx, especially patients with implicit and atypical course diseases.

During the recovery period, the carrier sheds the bacterium into environment, and this happens for 15-20 days, sometimes up to three months. The most dangerous are carriers of the infection, in which the release of bacteria occurs from the nasopharynx. Prolonged carriage of diphtheria is observed in approximately 13-29% of cases. The spread of the infection is facilitated by the fact that many people are carriers of the bacteria, but do not suspect it and do not go to medical institutions.

The causative agent of diphtheria is transmitted by airborne droplets, in some cases through dirty hands, household items (household utensils, toys, linen, etc.). Diphtheria of the eyes, skin and genital organs can be transmitted through touch. Transmission of diphtheria through food has also been reported, for example when bacteria multiply in dairy products, confectionery and other food environments.

People are generally susceptible to the diphtheria pathogen, the likelihood of infection is associated with the activity of antitoxic immunity. If a person's blood contains 0.03 AU / ml of specific antibodies, the body is sufficiently protected from the disease, but not from the state of carriage. Specific antibodies transmitted from the mother to the fetus through the placenta protect the newborn during the first six months of life. People who have had diphtheria or been vaccinated acquire antitoxic immunity, the degree of which determines how much the body is protected from infection.

Diphtheria pathogenesis

The pathogen enters the human body through oral cavity, nose, sometimes through the eyes, genitals and skin. In the area of \u200b\u200bthe body through which the infection got inside, mass reproduction of pathogens begins. Bacteria produce exotoxins and other substances that contribute to the onset of inflammation. Diphtheria toxin causes necrosis of epithelial tissues, bleeding of blood vessels, makes the walls of blood vessels permeable. The fluid formed in the focus of inflammation and containing thromboplastin appears outside the vessels. In contact with dead cells, thromboplastin acts on fibrinogen - fibrin is formed. The fibrin layer adheres firmly to the surface of the mouth and pharynx, but is easily separated in the larynx, trachea and bronchi. Diphtheria sometimes proceeds in a mild form, and then only the usual catarrh of the respiratory tract is determined, without the formation of a fibrin film and raids.