Diphtheria

Diphtheria - Acute

Definition  

An acute, severe infection caused by strains of Corynebacterium diphtheriae that produce diphtheria toxin

 

Medical History  

* Inadequate immune status

* Persistent alcohol abuse

* Travel

 

Findings  

* Altered mental status

* Cardiomegaly

* Cyanosis

* Decreased heart rate

* Focal neurological signs

* Heart murmur

* Dyspnea - Acute

* Faucial diphtheria

* Hoarse

* Increased heart rate

* Laryngeal diphtheria

* Pallor

* Stridor

* Wheezing

* Cervical lymphadenopathy

* Dysphagia

* Muscle weakness

* Nausea and vomiting - Acute

* Neck swelling

* Skin ulcer

* Tachypnea

* Cough

* Fever

* Headache

* Nasal discharge

* Pain in throat

* Vulvovaginitis

 

Tests  

 

Suspected and known diphtheria  

* Corynebacterium diphtheriae culture: The isolation of Corynebacterium diphtheriae from an infected site is suggestive of diphtheria .

 

Suspected diphtheria  

* Gram stain microscopy, Lesion sample: A Gram stain smear consistent with Corynebacterium diphtheriae offers presumptive evidence of diphtheria infection .

 

Toxigenicity testing in patients with suspected diphtheria  

* Toxin detection, Corynebacterium diphtheriae: A positive toxin test can confirm a toxigenic strain of Corynebacterium diphtheriae.

 

Suspected diphtheria  

* Polymerase chain reaction analysis, Corynebacterium diphtheriae: A positive polymerase chain reaction (PCR) test result is presumptive evidence of toxigenic diphtheria but requires toxigenic isolation for definitive diagnosis .

 

Suspected diphtheritic endocarditis  

* Blood culture, Corynebacterium diphtheriae

 

Diphtheria  

* White blood cell count: Leukocytosis may be observed in patients with diphtheria .

 

Suspected or known diphtheritic myocarditis  

* 12 lead ECG: ECG recordings may reveal cardiac damage in patients with diphtheritic myocarditis .

 

Suspected diphtheria  

* Diphtheria antibody assay: A fourfold or greater rise in serum antibody titer between acute and convalescent patient samples meets the laboratory criteria for Corynebacterium diphtheriae infection if the serum sample is obtained before the administration of diphtheria toxoid or antitoxin .

 

Measurement of anti-diphtheria toxin antibody titer for the evaluation of immunity status  

* Diphtheria antibody assay: Diphtheria antitoxin concentrations of at least 0.1 International Units/mL are considered protective for diphtheria .

 

Differential Diagnosis  

* Faucial diphtheria

* Anterior nasal diphtheria

* Cutaneous diphtheria

* Laryngeal diphtheria

* Conjunctival diphtheria

* Epiglottitis - Acute

* Streptococcal pharyngitis - Acute

* Retropharyngeal abscess - Acute

* Infectious mononucleosis - Acute

* Staphylococcal infectious disease

* Croup - Acute

* Candidiasis of mouth and esophagus

* Viral pharyngitis

* Upper respiratory infection, acute

* Foreign body

* Bacterial conjunctivitis - Acute

* Viral conjunctivitis - Acute

* PARAQUAT

* Congenital syphilis

 

Treatment  

 

Drug Therapy  

 

Treatment of diphtheria in patients with pharyngeal or laryngeal disease of less than 48 hours' duration  

 

DIPHTHERIA ANTITOXIN  

Adults: 20,000 to 40,000 units IM or IV

Pediatrics: 20,000 to 40,000 units IM or IV

 

 

Treatment of diphtheria in patients with nasopharyngeal lesions  

 

DIPHTHERIA ANTITOXIN  

Adults: 40,000 to 60,000 units IM or IV

Pediatrics: 40,000 to 60,000 units IM or IV

 

Treatment of diphtheria in patients with extensive disease, disease of greater than 3 days duration, or diffuse neck swelling  

 

DIPHTHERIA ANTITOXIN  

Adults: 80,000 to 120,000 units IM or IV

Pediatrics: 80,000 to 120,000 units IM or IV

 

Suspected or known diphtheria  

 

PENICILLIN G PROCAINE  

Adults: 600,000 units IM every 12 hours (maximum 1.2 million units/day) for 14 days; may switch to penicillin V potassium orally when patient tolerates oral intake

Pediatrics: 50,000 units/kg/day IM in divided doses every 12 hours (maximum 1.2 million units/day) for 14 days; may switch to penicillin V potassium orally when patient tolerates oral intake

 

ERYTHROMYCIN  

Adults: 20 to 25 mg/kg IV every 12 hours for 7 to 14 days

 

 

Cutaneous diphtheria  

 

ERYTHROMYCIN - RIFAMPIN  

Adults: Erythromycin 500 mg orally 4 times daily AND rifampin 600 mg orally daily for 7 days

 

DIPHTHERIA ANTITOXIN  

Adults: Antitoxin use is controversial, but if used, the dose is 20,000 to 40,000 units IM or IV

 

Antimicrobial prophylaxis for close contacts of patients with diphtheria  

 

PENICILLIN G BENZATHINE  

Adults: 1.2 million units IM

Pediatrics (?6 years old): 1.2 million units IM

Pediatrics (<6 years): 600,000 units IM

 

ERYTHROMYCIN  

Adults: 1 g/day orally for 7 to 10 days

Pediatrics: 40 mg/kg/day orally for 7 to 10 days

 

DIPHTHERIA ANTITOXIN  

Adults: 5000 to 10,000 units IM after testing for sensitivity and at a site different from that of the toxoid injection

 

Procedural Therapy  

 

Respiratory distress  

* Airway management: Airway management must assume the first priority in the management of any seriously ill or injured patient .

 

Diphtheria  

* Isolation of infected patient

 

Reportable infectious diseases  

* Infectious disease notification: In the United States, specific infectious diseases must be reported to the state or local public health department .

 

Pharyngeal diphtheria  

* Indirect laryngoscopy: Indirect laryngoscopy is recommended in all cases of pharyngeal diphtheria

 

Diphtheria with atrioventricular block  

* Cardiac pacing

 

Non-Procedural Therapy  

 

Suspected or known diphtheria  

* Work Restrictions