Tonsillitis syndrome in children. Diphtheria

2.  Acute tonsillitis (angina) is very
frequent disease in childhood. In
practice, the doctor must
distinguish tonsillitis, as an
independent disease, and
tonsillitis occurring on the
background of other infectious
diseases.
 Diphtheria is one of the most
dangerous infectious diseases.
Urgency of the problem can be
shown by the fact that low
immunization coverage of
population (less than 95%) may
increase the incidence of
diphtheria, even epidemics with
serious consequences, up to
lethal.
The word "angina" comes from
the Latin "angere" meaning "to
choke or throttle."
The word "angina" comes from
the Latin "angere" meaning "to
choke or throttle."

3.  1. Characterize tonsillitis, their etiological structure and
clinical forms .
 2. Epidemiological features of diphtheria nowadays.
 3.To characterize the features of diphtheria
(morphology , pathogenic properties).
 4. Characterize clinical forms of diphtheria (paying
particular attention to the diphtheria of oropharynx).
 5. Discuss clinical and laboratory diagnosis methods of
diphtheria.
 6. Make differential diagnosis of tonsils diphtheria.
 7.To learn the principles of treatment of diphtheria.
 8.To learn the basics of diphtheria prevention.
 9.To learn the tactics of the physician in case of
identifying tonsillitis, diphtheria, and in cases of
suspected diphtheria .

5. Medical Lecture Notes – All Subjects
USMLE Exam (America) – Practice

7. Hypertrophic tonsils - can be caused by recurrent pharyngitis and local
inflammation, especially in children and young adults.
Inspection of the oral cavity reveals hypertrophy of the palatine tonsils, so called
“kissing tonsils” when they meet in the midline or overlap. Tonsilloliths may be
lodged in the crypts. May be asymptomatic, massive tonsils sometimes fall back and
occlude the oropharynx, particularly when the patient is recumbent. Most cases of
obstructive sleep apnea in children are associated with hypertrophic tonsils.

9. Catarrhal tonsillitis
Lacunar tonsillitis
Folicular tonsillitis

10.  acute bacterial anthroponosis infection, caused by Corynebacterium
diphtheria and characterized by inflammation with the formation of
fibrinous exudates on the place of pathogen invasion (diphtheritic or
croupous inflammation), symptoms of intoxication and toxic lesions of
the cardiovascular, nervous system, adrenal glands and kidneys.

11.  The ability to toxin
formation of different
strains of the pathogen
varies, perhaps its loss
can even happen. Under
the influence of
bacteriophages
nontoxigenic strains can
become toxigenic.
 The most important toxin
– is exotoxin (histotoxin),
which determines the
pathogenicity of
corynebacterium
diphtheria.
 The pathogens produce
other biologically active
substances to, including
hyaluronidase, due to
which they penetrate into
the surrounding tissues
from areas of specific
local process and
facilitates the absorption
of toxin into lymph and
blood; neuraminidase –
decreases pain because of
nerves endings damaging
Stained Corynebacterium cells. The "barred"
appearance is due to the presence of
polyphosphate inclusions called metachromatic
granules. Note also the characteristic "Chinese-
letter" arrangement of cells.
Stained Corynebacterium cells. The "barred"
appearance is due to the presence of
polyphosphate inclusions called metachromatic
granules. Note also the characteristic "Chinese-
letter" arrangement of cells.

12.  Diphtheria takes its name from the Greek word
‘dipthera’ meaning leather and was named in
1826 by French physician Pierre Bretonneau.
This is because it refers to the leathery, sheath-
like membrane that grows on the tonsils, throat
and in the nose.
 In the (early) 1900s it was the most common
cause of death from an infectious disease with
rates as high as 400 cases per 100,000 people.
In 1932 vaccination against the infection began
and by the late 1950s rates had plummeted
 There's a risk that an outbreak could occur if
the number of people who are vaccinated falls
below a certain level. This risk was
demonstrated by the diphtheria epidemic that
struck the countries of the former Soviet Union
between 1990 and 1998. It resulted in 157,000
cases and 5,000 deaths. The epidemic was
caused by an increase in the number of children
who were not vaccinated against the disease.
 Diphtheria takes its name from the Greek word
‘dipthera’ meaning leather and was named in
1826 by French physician Pierre Bretonneau.
This is because it refers to the leathery, sheath-
like membrane that grows on the tonsils, throat
and in the nose.
 In the (early) 1900s it was the most common
cause of death from an infectious disease with
rates as high as 400 cases per 100,000 people.
In 1932 vaccination against the infection began
and by the late 1950s rates had plummeted
 There's a risk that an outbreak could occur if
the number of people who are vaccinated falls
below a certain level. This risk was
demonstrated by the diphtheria epidemic that
struck the countries of the former Soviet Union
between 1990 and 1998. It resulted in 157,000
cases and 5,000 deaths. The epidemic was
caused by an increase in the number of children
who were not vaccinated against the disease.
Number of
reported cases
2010 2011
Ukraine 17 8
Russian
Federation
9 5
Germany 8 4
India 3123 3485
Ghana 47 -
Turkey 0 1
Nigeria - 0
http://www.who.int/countries/enhttp://www.who.int/countries/en/

13. 4'489 reported cases in 2012
25'00 estimated deaths (in 2011)
83% estimated DTP3 coverage
32% of countries reached >=80%
DTP3 coverage in all districts
4'489 reported cases in 2012
25'00 estimated deaths (in 2011)
83% estimated DTP3 coverage
32% of countries reached >=80%
DTP3 coverage in all districts

15. The period of circulation of toxins in the
blood is not longer than 12-24 hours
because of their intense fixation on the
cells (primarily the nervous system).
The period of circulation of toxins in the
blood is not longer than 12-24 hours
because of their intense fixation on the
cells (primarily the nervous system).

19.  low or moderate intoxication
 local inflammation is limited by area of the tonsils, mild pain when
swallowing, moderate enlargement of lymph nodes, which are not very
painful
 low or moderate intoxication
 local inflammation is limited by area of the tonsils, mild pain when
swallowing, moderate enlargement of lymph nodes, which are not very
painful

21.  expressed intoxication: temperature is
380
C and higher, pallor, malaise,
anorexia, mild sore throat, especially
when swallowing.
 Thick greyish-white or dirty gray
deposits with wavy surface extending to
the anterior palatine arches, uvula,
nasopharynx. Deposits can not be
removed with a spatula, after their
rejection surface under them bleeds,
they are fibrinous (elastic, not grinded,
keep their shape)
 The mucosa is slightly hyperemic with
cyanotic shade, there is a clear-cut
swelling of the mucous membrane
around the site with deposits (perifocal
edema). Swelling may involve
neartonsillar tissue.
 Regional lymph nodes are enlarged,
moderately painful
 There are symptoms of the
cardiovascular system injury from the
first days of illness .
 expressed intoxication: temperature is
380
C and higher, pallor, malaise,
anorexia, mild sore throat, especially
when swallowing.
 Thick greyish-white or dirty gray
deposits with wavy surface extending to
the anterior palatine arches, uvula,
nasopharynx. Deposits can not be
removed with a spatula, after their
rejection surface under them bleeds,
they are fibrinous (elastic, not grinded,
keep their shape)
 The mucosa is slightly hyperemic with
cyanotic shade, there is a clear-cut
swelling of the mucous membrane
around the site with deposits (perifocal
edema). Swelling may involve
neartonsillar tissue.
 Regional lymph nodes are enlarged,
moderately painful
 There are symptoms of the
cardiovascular system injury from the
first days of illness .
Pharyngeal diphtheria with membranes
covering the tonsils and uvula in a 15-year-
old girl.

22.  begins acutely
 temperature is 400
C, there is severe headache, vomiting,
anorexia, pallor, growing malaise
 mucosa is edematous, hyperemic with cyanotic shade.
 tonsils are enlarged expressively, their surface is covered
with thick whitish-gray, dirty-gray, gray deposits with the
rough surface.
 The deposits extend to the anterior palatine arches, uvula,
soft and hard palate, the back wall of the pharynx.
 The voice has nasal tone. Breathing becomes noisy.
 Face is pale, lips are dry, cracked. The mouth is half-
opened, there is rotten sweet sugary smell from the mouth.
During examination of oropharynx intense perifocal edema
is observed, swelling extends to the neck subcutaneous
adipose tissue.
 begins acutely
 temperature is 400
C, there is severe headache, vomiting,
anorexia, pallor, growing malaise
 mucosa is edematous, hyperemic with cyanotic shade.
 tonsils are enlarged expressively, their surface is covered
with thick whitish-gray, dirty-gray, gray deposits with the
rough surface.
 The deposits extend to the anterior palatine arches, uvula,
soft and hard palate, the back wall of the pharynx.
 The voice has nasal tone. Breathing becomes noisy.
 Face is pale, lips are dry, cracked. The mouth is half-
opened, there is rotten sweet sugary smell from the mouth.
During examination of oropharynx intense perifocal edema
is observed, swelling extends to the neck subcutaneous
adipose tissue.

24.  clinical symptoms are the
manifestations of infectious-toxic shock
with ultra-rapid rate of progression of
the pathological process
 the rapid development of DIC syndrome
(hemorrhagic form): hemorrhage in the
injection site, bleeding.
 Manifestations of ITSH can sometimes
ahead the development of local
inflammation. In some cases typical
fibrinous deposits have no time to be
formed
 Local changes are limited to expressed
swelling of soft tissues of oropharynx
and neck subcutaneous tissue.
 The prognosis is unfavorable
 clinical symptoms are the
manifestations of infectious-toxic shock
with ultra-rapid rate of progression of
the pathological process
 the rapid development of DIC syndrome
(hemorrhagic form): hemorrhage in the
injection site, bleeding.
 Manifestations of ITSH can sometimes
ahead the development of local
inflammation. In some cases typical
fibrinous deposits have no time to be
formed
 Local changes are limited to expressed
swelling of soft tissues of oropharynx
and neck subcutaneous tissue.
 The prognosis is unfavorable
 At the toxic and hypertoxic forms
of diphtheria there is danger of
infectious-toxic shock (ITSH).
 Shock may also occur after gradual
complicating of the form (from
subtoxic to toxic of the III degree),
especially in combination with
other localizations (nasopharynx,
nose, throat) without treatment in
time.
 At the toxic and hypertoxic forms
of diphtheria there is danger of
infectious-toxic shock (ITSH).
 Shock may also occur after gradual
complicating of the form (from
subtoxic to toxic of the III degree),
especially in combination with
other localizations (nasopharynx,
nose, throat) without treatment in
time.

25.  As an independent form is rare, often in combination with tonsillar
and/or nasopharyngeal diphtheria.
 Occurs in
 localized (only larynx) form
 spread (besides the larynx – trachea) form
 descending (if larynx, trachea and bronchi are involved) form
 The severity of hypoxia is caused by the airway occlusion by the films.
The toxin is absorbed poorly, so intoxication is not expressed.

27. On 27 March 2012, a 68-year-old woman
presented to the Ear, Nose and Throat (ENT)
department in a hospital in Västra Götaland
Region, western Sweden, with a five-day
history of fever, coughing, hoarseness and
increasing pain in the throat.
Six days prior to the onset of fever and
throat symptoms she had returned from a
two-week holiday in western Africa
A laryngoscopy was performed on the
same day and revealed greyish
membranes on and surrounding the
vocal cords and the base of the tongue,
and swollen larynx. These changes could
not be seen by ordinary throat
examination.

30.  The first Nobel prize for medicine or physiology was awarded in 1901 to
German researcher Emil von Behring, for his work on serum therapy, a method
of treating disease by the injecting the blood serum of immune animals.
 In particular, the award committee honored von Behring's use of serum
therapy to treat the respiratory illness diphtheria and the nervous system
infection tetanus. "He has opened a new road in the domain of medical science
and thereby placed in the hands of the physician a victorious weapon against
illness and deaths," the committee said at the time.

31.  specific antitoxic antidiphtherical serum (ADS)
 Before the introduction of therapeutic doses intracutaneous
test for sensitivity (Bezredko method) is done according to
the following scheme: 0.1 ml of diluted 1:100 ADS is
injected intradermally on the inner surface of the forearm,
in 30 minutes subcutaneously 0.1 ml of undiluted serum is
injected and in the absence of reaction therapeutic dose is
administered intramuscularly.
 ADS is injected intramuscularly (into one location to 8-10
ml of ADS, heated to 36 ° C).
 In the toxic forms intravenous serum (half dose) infusion is
possible.The calculated dose of serum is dissolved in a
solution of 5% glucose or saline in the ratio 1:2, is added to
2 mg / kg body weight prednisolone and put with speed of
40-60 drops per minute.
 The dose of ADS depends on the form and severity - from
30-50 thousand IU at the localized forms up to 100-120
thousand IU at toxic
 specific antitoxic antidiphtherical serum (ADS)
 Before the introduction of therapeutic doses intracutaneous
test for sensitivity (Bezredko method) is done according to
the following scheme: 0.1 ml of diluted 1:100 ADS is
injected intradermally on the inner surface of the forearm,
in 30 minutes subcutaneously 0.1 ml of undiluted serum is
injected and in the absence of reaction therapeutic dose is
administered intramuscularly.
 ADS is injected intramuscularly (into one location to 8-10
ml of ADS, heated to 36 ° C).
 In the toxic forms intravenous serum (half dose) infusion is
possible.The calculated dose of serum is dissolved in a
solution of 5% glucose or saline in the ratio 1:2, is added to
2 mg / kg body weight prednisolone and put with speed of
40-60 drops per minute.
 The dose of ADS depends on the form and severity - from
30-50 thousand IU at the localized forms up to 100-120
thousand IU at toxic

32.  Immediate hospitalization
 Bed regimen (at localized forms - 10 days, at toxic - not less than 35-
45 days)
 Glucocorticoids (in toxic forms and croup)
 Antibiotics (penicilin, tetracyclin, erythromycin)
 In case of croup - inhalations, broncholitics, diuretics,
glucocorticoids, antibiotics, antihistamine, lytic admixture; if there
are indications - intubation, tracheotomy
 Immediate hospitalization
 Bed regimen (at localized forms - 10 days, at toxic - not less than 35-
45 days)
 Glucocorticoids (in toxic forms and croup)
 Antibiotics (penicilin, tetracyclin, erythromycin)
 In case of croup - inhalations, broncholitics, diuretics,
glucocorticoids, antibiotics, antihistamine, lytic admixture; if there
are indications - intubation, tracheotomy
DIPHTHERIA SEVERITY FIRST DOSE OF SERUM (in IU)
Mild form 20 000 – 40 000
Moderate form 50 000 – 80 000
Severe form 90 000 – 120 000
Hypertoxic form. ITSH 120 000 – 150 000

35.  (glandular fever, Filatov –
Pfeyffer’s disease, monocytic
tonsillitis) -is an acute viral
disease with airborne droplets
transmission mechanism,
characterized by:
polyadenitis (especially
cervical),
fever
acute tonsillitis with deposits,
hepatosplenomegaly,
leukocytosis, limfomonocytosis,
the presence of atypical
mononuclear cells - vyrocytes.
 (glandular fever, Filatov –
Pfeyffer’s disease, monocytic
tonsillitis) -is an acute viral
disease with airborne droplets
transmission mechanism,
characterized by:
polyadenitis (especially
cervical),
fever
acute tonsillitis with deposits,
hepatosplenomegaly,
leukocytosis, limfomonocytosis,
the presence of atypical
mononuclear cells - vyrocytes.

37.  Vincent’s tonsillitis (angina) is usually
a mixed infection, caused by
Fusobacterium fusiformis and
spirochetal anaerobic bacteria.
 In most cases it is unilateral, but
described and bilateral lesions.The
disease begins quietly with swallowing
discomfort, passing then to pain.
Expressed changes in the throat are not
consistent with the overall satisfactory
condition of the patient .The body
temperature is subfebrile or normal.
 On the surface of tonsils gray or
yellowish-white films, like a spot of
stearic candles, round, of soft
consistency , sometimes extending to
the front arche.The film is surrounded
by a rim of inflammation, deposits are
relatively easy to remove with a cotton
swab. After removal of the film
bleeding from ulcerated surface occurs
 Vincent’s tonsillitis (angina) is usually
a mixed infection, caused by
Fusobacterium fusiformis and
spirochetal anaerobic bacteria.
 In most cases it is unilateral, but
described and bilateral lesions.The
disease begins quietly with swallowing
discomfort, passing then to pain.
Expressed changes in the throat are not
consistent with the overall satisfactory
condition of the patient .The body
temperature is subfebrile or normal.
 On the surface of tonsils gray or
yellowish-white films, like a spot of
stearic candles, round, of soft
consistency , sometimes extending to
the front arche.The film is surrounded
by a rim of inflammation, deposits are
relatively easy to remove with a cotton
swab. After removal of the film
bleeding from ulcerated surface occurs
First ulcer is superficial. If the
disease goes on for a long time,
ulcerative defect becomes deep,
crater-like shape, then it can
spread beyond the tonsil with
involvement in the process of deep
First ulcer is superficial. If the
disease goes on for a long time,
ulcerative defect becomes deep,
crater-like shape, then it can
spread beyond the tonsil with
involvement in the process of deep

38.  In January 1925, Alaskan doctors feared a deadly diphtheria epidemic would spread
among the children of Nome. doctors needed to travel nearly a thousand miles to
Anchorage to get serum for treatment.With no trains running that far north and the
only available airplane sidelined by a frozen engine, the best chance of transporting the
medicine across the icy tundra was by sled dog.
 More than 20 sled teams coordinated to make the trip through blinding snow and sub-
zero temperatures. On the first of February, the package was handed off to the final team.
Lead by Balto, the team covered 53 treacherous miles back to Nome in 20 hours.
Newspapers and radio around the world followed the trek, fascinated by the brave team
whose efforts eventually helped end the epidemic.
 Balto became a national hero. Just 10 months after the successful mission, this statue by
animal sculptor Frederick G. R. Roth was dedicated in Central Park.
Balto with Gunnar Kaasen