Doughty pharynx

Diphtheria is an acute infectious disease that occurs during intoxication, inflammation in the throat, pharynx, less often in the larynx, trachea, nose and other organs with the formation of raids merging with the necrotic tissue of the affected mucous membranes.

In toxic forms, the heart and the peripheral nervous system are affected.

For the first time described the clinical signs of diphtheria Syrian physician Aretei Kanpadokisky in the I century. N. And, for several centuries, diphtheria was called "Syrian disease" or "Syriac ulcers." In the XVII century. Diphtheria was called "garatillo" (loop of the executioner), since the disease often ended in death from suffocation. In Italy, since 1618, diphtheria was known as "respiratory tube disease," or "suffocating disease." To save patients, tracheotomy was already used. "Croup" diphtheria of the larynx began to be called in the XVIII century. In 1826, the French doctor Brötneneau gave a full description of the clinical manifestations of diphtheria, which he called "diphtheria," noting the identity of the diphtheritic and croupous film and proving that strangulation in diphtheria is associated with the narrowness of the larynx of the child. He also developed a tracheotomy. His pupil A.Trousseau, on the basis of observations made during a diphtheria epidemic in Paris in 1846, called this disease "diphtheria", which emphasized the importance of the common phenomena of this acute infectious disease. In 1883, E. Klebs (E.Klebs) discovered the causative agent of diphtheria in sections of the diphtheria film, and in 1884 F.Leffler (F.Loffler) singled it out in pure culture. In 1888 P.Roux and N.Jersen received a specific toxin, and in 1890 I.I. Orlovsky discovered an antitoxin in the blood of a sick person and, finally, in 1892, I B. Bardakh and E. Bering, independently of each other, obtained antitoxic antidiphtheria serum, which played a huge role in the prevention of this disease.

[1], [2], [3], [4], [5], [6]

Epidemiology of diphtheria of the pharynx

The source of the causative agent of infection is a human diphtheria or bacteriocarrier of the toxigenic corynebacterium diphtheria. Infection is transmitted by airborne droplets: when coughing, sneezing, talking along with droplets of saliva, phlegm, mucus, the causative agent enters the environment. The causative agent is very stable in the external environment, so infection can occur through various objects infected with the patient (underwear, dishes, toys, etc.). The patient becomes infectious in the last days of the incubation period and continues to be during the entire period of the disease until being released from the pathogen.

Over the past 3-4 decades, due to the massive preventive vaccinations, the incidence of diphtheria and the frequency of toxigenic bacterial transport in the territory of the former USSR and in Russia have dramatically decreased, but individual outbreaks of this disease still occur.

[7], [8], [9],

The cause of pharyngeal diphtheria

The causative agent of diphtheria is the corynebacterium diphtheria (Corynebacterium diphtheriae), which produces a toxin that has a pronounced neurotropic effect, which also affects the mucous membrane and the submucosal layer of various hollow organs. There are also nontoxigenic diphtheria bacilli, which are not dangerous to humans.

Pathogenesis and pathological anatomy

The entrance gates for infectious agents are usually the upper respiratory tract, but it is possible that they penetrate through the skin, genitalia, eyes, etc. At the site of the introduction of the corynebacterium diphtheria, a foci of fibrinous inflammation arises, from which the toxin released by the pathogen enters the body. The process involves nearby lymph nodes, which increase. With a toxic form, swelling of the subcutaneous tissue appears. After the transferred diphtheria, specific immunity develops.

Symptoms of diphtheria of the pharynx

The incubation period is from 2 to 10 days, more often 5 days. Depending on the localization of the process, a wide variety of clinical forms of the disease is observed. It is accepted to distinguish diphtheria of throat, nose, larynx, trachea, bronchi, eyes, external genital organs, etc.

Diphtheria of throat is the most common form of the disease. It can be localized, spread and toxic.

Localized diphtheria of throat is characterized by mild symptoms of intoxication. According to different authors, the frequency of this type of diphtheria in the first half of the XX century. Was 70-80%. The disease begins with general malaise, weakness, poor appetite, fever up to 38 ° C. According to the severity of the local process, the localized diphtheria of the pharynx is divided into pleural, islet and catarrhal forms.

When the film form shows a slight increase in tonsillar (upper cervical) lymph nodes, moderately painful in palpation. The mucous membrane of the throat is easily or moderately hyperemic, mainly in the tonsils. The latter are enlarged, also slightly hyperemic, there is a slight soreness in swallowing or lack of it. On tonsils appears plaque, which in the first hours of the disease resembles a dense arachnoid network. By the end of the first or on the second day, the raid takes on characteristics characteristic of diphtheria: it becomes grayish-white or dirty-gray, less often yellow with a smooth shiny surface and sharply outlined edges, located mainly on the convex surfaces of the tonsils, protrudes over the surface of the mucous membrane, tightly soldered with the underlying tissue, is removed with difficulty, in its place there are small-dot bleedings (a symptom of bloody dew), always has a fibrinous character.

When the islet form on weakly hyperemic tonsils are found tightly welded to the underlying tissue.

The catarrhal form of the localized diphtheria of throat is manifested by a moderate increase in the tonsils and a slight hyperemia of the mucosa covering them. In this case, the symptoms of general intoxication are slightly or absent, the body temperature is low. Often such a form of diphtheria is taken as vulgar catarrhal tonsillitis and is recognized only on the basis of a bacteriological study of a smear taken from the surface of the tonsils or with the progression of clinical manifestations of diphtheria.

After the introduction of antidiphtheria serum with localized diphtheria, a rapid improvement in the general condition of the patient occurs in 24 hours, the body temperature is normalized, the raids become more friable, and after 2-3 days the pharynx is cleared. Without the use of serum, the localized diphtheria of the throat can progress: the plaques increase, it is possible to switch this clinical form to the following - common or toxic. Spontaneous cure can occur with the most mild forms of diphtheria (catarrhal and islet). When the film form in untreated cases, complications often develop (not pronounced cardiovascular disorders, isolated paresis of a toxigenic nature, for example, the paresis of the soft palate, sometimes light polyradiculoneuritis.

The common diphtheria of the throat was 3-5% of all throat lesions in the last century. Symptoms. General intoxication with it more pronounced than with localized diphtheria of throat: general weakness increases with the appearance of signs of apathy, loss of appetite, spontaneous pain and pain when swallowing are mild, the mucous membrane of the throat is more hyperemic than with localized diphtheria, the swelling is more significant. Characteristic filmy raids spread to other parts of the pharynx, pharynx and tongue.

In untreated cases or with late introduction of serum, the complications typical of diphtheria are more often observed. At present, the common diphtheria of throat is rare.

Toxic pharyngeal diphtheria sometimes develops from localized diphtheria of throat, but more often occurs from the very beginning, acquiring pronounced signs of general intoxication. More often affects children aged 3 to 7 years. At this age, its most severe forms occur. Diphtheria croup with toxic diphtheria of throat is found mainly in children 1-3 years old, however, its appearance is not excluded even in older age and even in adults.

Clinical course of diphtheria of the pharynx

Toxic diphtheria of throat usually reaches its full development on the 2nd-3rd day, and the phenomena can progress for another 1-2 days, despite the introduction of large doses of antidiphtheria serum, after which its signs go to decline. It begins violently with a high body temperature (39-40 ° C), there may be repeated vomiting. Pulse is frequent, threadlike, breathing fast, superficial, face pale. There is general weakness, lethargy, apathy, less often arousal and delirium. Tonsillar lymph nodes are significantly enlarged, painful; around them there is swelling of the subcutaneous tissue, which sometimes spreads over a considerable distance (down to the nipples, back to the upper back, upward - to the area of the cheeks). Swelling soft, dough-like, painless, on the neck forming 2-3 or more thick folds. Skin over the swelling is not changed.

One of the earliest and most characteristic signs of toxic diphtheria of throat is edema of soft tissues of throat that never occurs in such an expressed degree with vulgar pharyngitis and tonsillitis. Sometimes with such edema, the tissues of the tonsils and the soft palate are closed, leaving almost no lumen; the breathing becomes noisy, resembling snoring during sleep, the voice of a nasal, altered timbre, eating is hampered. Hyperemia of the mucous membrane of the throat is often stagnant with a pronounced bluish tinge, but it can be brighter. The raid in the first hours is thin cobwebike, then more dense, dirty gray, rapidly spreading beyond the tonsils to the soft and hard palate, the side walls of the pharynx. Often the process extends to the nasopharynx; in this case, the mouth is open, breathing becomes snoring, abundant serous vitreous discharge from the nose appears, irritating the skin in the area of the anterior nose and upper lip.

Toxic diphtheria of the throat, depending on the prevalence of the hypodermic edema (which serves as a classification criterion), correlating with its magnitude with the severity of the disease, is divided into three degrees depending on the spread of the edema: I - to the second cervical fold, II - to the clavicle and III - below the clavicle . The most severe signs of general intoxication, reaching the co-morbidity state, are observed at the third degree of toxic diphtheria of throat.

Depending on the severity of the intoxication syndrome and the degree of severity of pathomorphological changes, the toxic diphtheria of the throat is divided into sub-toxic, hypertoxic and hemorrhagic forms.

In the case of a sub-toxic form, the characteristics described above are manifested in a reduced form. Hypertensive diphtheria begins violently with high body temperature, repeated vomiting, delirium, convulsions. In this case, local manifestations of diphtheria can be moderate. The phenomena of general intoxication with this form predominate over morphological changes; observed adynamia, darkened consciousness, marked weakness of cardiac activity with hemodynamic disturbances, sopor, passing into a coma. Death occurs within the first 2-3 days.

The hemorrhagic form is characterized by the adherence to the clinical picture of toxic diphtheria (more often III degree) of hemorrhagic phenomena. The raids acquire a hemorrhagic tinge, are saturated with lysed blood, hemorrhages under the skin, nasal, pharyngeal, esophageal, gastric, intestinal, uterine and other bleeding. As a rule, with this form of the disease ends with death, even despite timely and correct treatment.

Complications of pharyngeal diphtheria arise mainly in the toxic form. These include myocarditis (weakness of cardiac activity, changes in ECG, PCG, etc.), mono- and polyneuritis, manifested by periodic paralysis of the soft palate (open nasal, liquid food in the nose), eye muscles (strabismus, diplopia), limb muscles and trunk, as well as nephrotoxic syndrome (protein in the urine, uremia, renal edema). Often with severe forms of diphtheria, lung inflammation develops, usually streptococcal etiology.

Diphtheria adults often takes an atypical course and resembles lacunar angina, which often misleads the treating doctor and makes diagnosis difficult. In adults, the appearance and toxic form of diphtheria is possible.

[10], [11]

Diagnosis of diphtheria of the pharynx

The diagnosis is made on the basis of the clinical picture (general and local phenomena), while in all cases of vulgar angina the bacteriological examination is carried out for the presence of diphtheria in the swabs and films of the corynebacterium. Its detection, even with the typically flowing banal angina (possibly bacteriocarrier), makes it interpret the latter as a diphtheria of throat with all the antiepidemic and therapeutic measures that follow from it. Material from the pharynx is taken with a sterile cotton swab on the border between the affected area and the healthy mucous membrane, on an empty stomach or 2 hours after eating. When isolating the corynebacterium of diphtheria, its toxigenicity is determined.

Differential diagnosis of diphtheria of the pharynx is of exceptional importance, since the thoroughness of its conduct depends not only on the state of the patient's health, but also on the health of others. In modern conditions of routine immunization of the population, diphtheria, as a rule, does not take place in classical forms, and often "masked" under the banal forms of angina, while being a source of massive distribution of the corynebacterium of diphtheria. Diphtheria is differentiated from false-angina angina, especially diphtheria (diphtheria is a large group of microorganisms belonging to the genus Corynebaclerium, according to the morphological and cultural properties of diphtheria-like bacteria, in humans they are most often excreted with the nasal mucosa on which they together with white staphylococcus are the dominant microbiota) and pneumococcal etiology; from angina Simanovsky - Plaut - Vincent, herpetic angina in the phase of ulceration, lacunar angina, pharyngeal changes in scarlet fever in the first 2-3 days of the disease before the occurrence of exanthematous rashes or with changes in the pharynx with toxic form of scarlet fever, angina with blood diseases, syphilitic changes in pharynx, mycosis of the pharynx, etc.

[12], [13], [14], [15]

Treatment of diphtheria of the pharynx

Treatment of diphtheria of the pharynx is carried out in an infectious hospital. Its main method is the introduction of antidiphtheria antitoxic serum. VP Lebedev (1989) recommends the introduction of serum according to the modified method. Uncommon: first, 0.1 ml is injected into the skin, 0.2 ml after 30 minutes and after 1-1 / h - the remaining dose intramuscularly (into the outer-upper quadrant buttocks or in the front muscles of the thigh). Serum is dosed in antitoxic units (AE). The amount of the drug administered depends on the severity of the disease and the time that elapsed from the onset of the disease (total dose for 2-4 days): 10,000-30,000 AE in a localized form; 100,000 to 350,000 AE in toxic form. In toxic forms prescribe detoxification therapy (intravenous injection of plasma, haemodesis in combination with 10% glucose solution, rheopolyglucin), as well as drugs that improve cardiac activity, cocarboxylase, B vitamins, corticosteroids. With hypopharyngeal edema and larynx threatening with suffocation, it is advisable, without waiting for asphyxia, to conduct a preventive intubation of the trachea or tracheotomy. At present, the need for these interventions is extremely rare, but it is necessary to create conditions for their emergency conduct.

Antibiotics are prescribed for children with croup, complicated by pneumonia, otitis media and other complications caused by another microbiota.

Prevention of diphtheria of the pharynx

Prevention of diphtheria in the developed countries is planned and carried out in accordance with the existing provision on the mandatory implementation of calendar vaccinations for all children. Persons and children (applicants) entering children's institutions (orphanage, boarding school, special children's institutions for children with CNS diseases, sanatoriums for children with tuberculous intoxication) are subject to bacteriological examination to identify the excretory (bacterial carriers) of the corynebacterium of diphtheria. With regard to carriers of corynebacterium diphtheria and persons who had contact with a patient with diphtheria, the measures provided for by the relevant instruction of the Ministry of Health are carried out. In the focus of diphtheria, the final disinfection is carried out.

Prognosis for diphtheria of the pharynx

The outcome of diphtheria depends on the severity of the disease, the age of the patient, the timing of antidiphtheria antitoxic serum and the correctness of the treatment. By the end of XX century. Mortality from diphtheria, due to mass active immunization against diphtheria, has sharply decreased, and the emerging cases of diphtheria, due to specific, antibacterial and general therapeutic modern treatment, occur in mild and sub-toxic forms.