tropical disease

1. Diphtheria & Pertussis
Hafiz Muhammad Irfan RN, BSN, MSPH

2. Diphtheria

3. Diphtheria
• Serious bacterial infection usually
affecting the mucous membranes of
your nose and throat
• Diphtheria typically causes a sore
throat, fever, swollen glands and
weakness.
• Hallmark sign is a sheet of thick, gray
material covering the back of your
throat, which can block your airway,
causing you to struggle for breath.

5. Pathogen
• Gram positive
• Aerobic
• Produce exo-toxin
• Non motile, non
capsulated, non spore
forming.
• Readily killed by heat
& chemicals
Corynebacterium
Diphtheriae
(Bacillus)

6. Susceptible persons may acquire toxigenic
diphtheria bacilli in the nasopharynx. The
organism produces a toxin that inhibits
cellular protein synthesis and is responsible
for local tissue destruction and
pseudomembrane formation. The toxin
produced at the site of the membrane is
absorbed into the bloodstream and then
distributed to the tissues of the body. The
toxin is responsible for the major
complications of myocarditis and neuritis
and can also cause low platelet counts
(thrombocytopenia)

7. Diphtheria Epidemiology
• Reservoir
– human carriers, usually asymptomatic
• Transmission
– respiratory
– skin and fomites rarely
• Temporal pattern
– winter and spring
• Communicability
– without antibiotics, seldom more than 4
weeks. Effective antibiotic therapy
promptly terminates shedding

8. Temporal Pattern
Chest Pain

9. Incubation period:
• 2-5 days
Risk factors:
• Children
• Immuno-compromised
• Environmental factors

10. Mode of Transmission
• Respiratory droplets
• Direct contact with respiratory
secretions
• Direct contact with exudates of skin
• Human carry organism for weeks-
months
• Cuts & wounds

11. Classification Of
Diphtheria

12. Classification Of Diphtheria
• Nasal
• Facial
• Tracheo-laryngeal
• Malignant
• Cutaneous
• Other

13. Nasal Diphtheria
• Common in infancy
• Milder form
S/S
Characterized by unilateral nasal discharge (100%).
• Thin at first
• Purulent & bloody
• Excoriation of nostril & skin
• A white membrane usually forms on the nasal
septum.
• It can be terminated rapidly by diphtheria antitoxin
and antibiotic therapy.

14. Facial Diphtheria (Pharyngeal and
Tonsillar Diphtheria)
• The most common form
• Effect tonsils & pharynx
• Slow onset
S/S
• Moderate fever <102 F
• Malaise
• Sore throat
• Painful dysphagia

15. S/S….
• Within 2-3 days, Grayish-yellow
membrane formation
• At start it dx looks like tonsillitis ------then
extend to uvula, soft palate, naso/ oro-
pharynx & larynx
• Bull’s neck (Lymph adenitis)
• If enough toxin is absorbed, the patient
may even die within 6 to 10 days.

16. Tracheo-laryngeal Diphtheria
• 85% secondary to facial diphtheria.
S/S
• No membrane on pharynx
• Fever
• Hoarseness
• Unproductive barking cough
• Obstruction of breathing (over 24 hrs)
• Use of accessory muscles
• Agitation & sweating
• Cyanosis
Note: Without tracheostomy the child will die

18. Malignant Diphtheria
• Most severe form of facial diphtheria
• Fatal
• Onset is more acute
S/S
• High grade Fever
• Rapid pulse
• Low B.P
• Cyanosis
• Classic bull’s neck appearance
• Bleeding (nose, mouth, skin)
Note: Heart block occurs

19. Bull’s Neck

20. Other forms of Diphtheria
• Ears
• Conjunctiva
• Vagina

21. Complications
Breathing problem
• Diphtheria causing bacteria may produce a toxin.
This toxin damage tissue in immediate area of
infection-usually the nose and throat.
• At that site infection produce a tough, grey
colored membrane composed of dead cells and
bacteria
• This membrane can obstruct breathing

22. Complications
Heart damage
• The diphtheria toxin may spread through
blood stream and damage other tissues of
body, such as Heart muscles causing
inflammation (myocarditis)
• It may be slight, showing minor
abnormalities on ECG, or severe
leading sudden death.

25. Diagnosis
• Clinical picture
• Swab Culture
• Schick test

26. Management
• Emergency tracheotomy
• Anti-toxin administration
• Mortality rate increases with delay anti toxin
administration
• Adrenaline (anaphylactic reactions to anti
toxin)
• Antibiotics (penicillin, cephalosporin,
erythromycin, tetracycline
• Penicillin is recommended tx (50,000 U/kg in
4 divided doses.)

27. Management
• ECG monitoring
• Cortico-steroids

28. Prevention/Control
Detection of cases:
• Via swab cultures
Isolation:
• 14 days ……. Until –ve culture
Treatment:
• Diagnosed cases
Immunization:
• Close contacts

29. Immunization
• DPT
Diphtheria toxoid has been estimated
to have a clinical efficacy of 97%.

30. Schick test
Immunity can be checked by Schick test.
• A small amount (0.1 ml) of diluted (1/50 MLD)
diphtheria toxin is injected intradermally into the
arm of the person.
• If a person does not have enough antibodies to
fight it off, the skin around the injection will
become red and swollen, indicating a positive
result. This swelling disappears after a few days.
If the person has an immunity, then little or no
swelling and redness will occur, indicating a
negative result.
• Positive: when the test results in a wheal of 5–
10 mm diameter

32. Pertussis

33. Pertussis
• Recognized as Whooping cough
• Named after typical whooping sound
• Mainly effects children
Pathogen
• Bordetella Pertussis
• Gram –ve baccillus
• Aerobic

34. Pathogenesis
• Attachment of the organism with the cilia (tiny,
hair-like extensions) that line part of the upper
respiratory system.
• Release of pertussis toxin.
• Local mucosal damage.
• Local cellular invasion
• Necrosis of epithelium
• lymphocytosis
• Obstruction of bronchioles

35. Epidemiology
• Mostly effects infants & young children
• Caused thousands of deaths in 1930s &
1940s
• High alert in October-January
Incubation period:
• Average 7-10 days……. 21 days

36. Mode of transmission
• Spread from person to person
• Droplet infection from nose or mouth.
• Become air borne by sneezing, coughing,
laughing.
• Most contagious in catarrhal stage

37. Stages of Pertussis
3 stages
1. Coryzal stage: (Catarrhal)
• 1- 2 weeks
• Indistinguishable from RTIs
• Runny nose, sneezing, cough & low grade fever.
2. Paroxysmal stage:
• 2- 4 wks
• Paroxysm of coughs (> 1 min)
• High pitched inspiratory whoop
• Cyanosis, apnea, convulsions

38. Paroxysmal stage….
• Vomiting, poor feeding & weight loss
• Rectal prolapse
• Sub conjunctival hemorrhage
• Ulceration of frenulum
3. Convalescent stage:
• Cough & vomiting reduces
• Bradycardia
• Apnea
• Seizures
• Poor feeding

41. Complications
• Convulsions
• Pneumonia (most common)
• Sub-conjunctival hemorrhages
• Atelectesis
• Bronchiectasis
• Encephalopathy
• Prolapsed rectum
• Inguinal hernia
• Retinal detachment

42. Diagnosis
• History of typical signs and symptoms
• Physical examination
• Laboratory test which involves taking a
sample of mucus (with a swab or
syringe filled with saline) from the back
of the throat through the nose
• Blood test

43. Management
• Mainly supportive
• Generally treated with antibiotics and early
treatment is very important
• Erythromycin 50 mg/kg/day for 10-15 days
• Cough suppressants & sedatives (not much
effective)
• Oxygen administration
• Adequate Hydration & nutrition
• Suctioning
• Isolation precautions
• Prevent from irritants

44. Nursing care
• Cool steam
• Small frequent meals
• Protection from irritants
• Maintain hydration status
• Monitor for dehydration
• Oxygen monitoring
• Monitoring for complications

45. Prevention/Control
Detection of cases:
• By per nasal swab
Isolation of cases:
• Until non infectious
• Avoid sharing of fomites & close contacts
Treatment:
• Diagnosed and close contacts
Immunization:
• Close contacts & prior to schooling

46. Immunization
• Primary Vaccination
( DPT & DTaP)
• Additional vaccine
(Tdap) > 7 year old
children

47. Summarization

48. References
• Cook., & Zumla.,(2003). Manson’s tropical
diseases. E.d.21st.