Diphtheria of the pharynx

Diphtheria is an acute infectious disease that occurs with symptoms of intoxication, an inflammatory process in the pharynx, throat, less often in the larynx, trachea, nose and other organs with the formation of plaque that merges with the necrotic tissue of the affected mucous membranes.

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

The first to describe the clinical signs of diphtheria was the Syrian physician Aretaeus of Canpadocia in the 1st century AD, and for several centuries diphtheria was called the "Syrian disease" or "Syrian ulcers." In the 17th century, diphtheria was called "garatillo" (hangman's noose), since the disease often ended in death from suffocation. In Italy, beginning in 1618, diphtheria was known as the "disease of the respiratory tube" or "suffocating disease." Tracheotomy was already used to save patients. Diphtheria of the larynx began to be called "croup" in the 18th century. In 1826, the French physician Bretonneau gave a complete description of the clinical manifestations of diphtheria, which he called "diphtheritis," noting the identity of the diphtheritic and croupous film and proving that suffocation in diphtheria is associated with the narrowness of the child's larynx. He also developed tracheotomy. His student A. Trousseau, based on observations made during the diphtheria epidemic in Paris in 1846, called this disease "diphtheria", which emphasized the importance of the general phenomena of this acute infectious disease. In 1883, E. Klebs discovered the diphtheria pathogen in sections of diphtheria film, and in 1884, F. Loffler isolated it in pure culture. In 1888, P. Roux and N. Jersen obtained a specific toxin, and in 1890, I. I. Orlovsky discovered an antitoxin in the blood of a sick person, and finally, in 1892, Ya. Yu. Bardakh and E. Bering independently obtained an antitoxic anti-diphtheria serum, which played a huge role in the prevention of this disease.

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Epidemiology of pharyngeal diphtheria

The source of the infectious agent is a person sick with diphtheria or a carrier of the toxigenic Corynebacterium diphtheriae. The infection is transmitted by airborne droplets: when coughing, sneezing, talking, the pathogen enters the environment along with droplets of saliva, sputum, mucus. The pathogen is very resistant in the external environment, so infection can occur through various objects contaminated by the patient (linen, dishes, toys, etc.). The patient becomes contagious in the last days of the incubation period and continues to be so throughout the entire period of the disease until liberation from the pathogen.

Over the past 3-4 decades, due to the implementation of mass preventive vaccinations, the incidence of diphtheria and the frequency of toxigenic bacterial carriage in the territory of the former USSR and in Russia have sharply decreased, but isolated outbreaks of this disease still occur.

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Cause of diphtheria of the pharynx

The causative agent of diphtheria is Corynebacterium diphtheriae, which produces a toxin that has a pronounced neurotropic effect, also affecting the mucous membrane and submucous layer of various hollow organs. There are also non-toxigenic diphtheria bacilli that are not dangerous to humans.

Pathogenesis and pathological anatomy

The entry point for pathogens is usually the upper respiratory tract, but they can penetrate through the skin, genitals, eyes, etc. At the site of the introduction of the diphtheria corynebacterium, a fibrinous inflammation center appears, from which the toxin released by the pathogen enters the body. The process involves nearby lymph nodes, which increase in size. In the toxic form, edema of the subcutaneous tissue appears. After suffering 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 customary to distinguish diphtheria of the pharynx, nose, larynx, trachea, bronchi, eyes, external genitalia, etc.

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

Localized diphtheria of the pharynx is characterized by mild symptoms of intoxication. According to various authors, the frequency of this type of diphtheria in the first half of the 20th century was 70-80%. The disease begins with general malaise, weakness, poor appetite, and an increase in body temperature to 38°C. According to the severity of the local process, localized diphtheria of the pharynx is divided into membranous, insular, and catarrhal forms.

In the membranous form, a slight increase in the tonsillar (upper cervical) lymph nodes is detected, moderately painful on palpation. The mucous membrane of the pharynx is slightly or moderately hyperemic, mainly in the area of the tonsils. The latter are enlarged, also slightly hyperemic, there is little or no pain when swallowing. A coating appears on the tonsils, which in the first hours of the disease resembles a thick spider web. By the end of the first or on the second day, the coating takes on the properties characteristic of diphtheria: it becomes grayish-white or dirty-gray, less often yellow with a smooth shiny surface and clearly defined edges, is located mainly on the convex surfaces of the tonsils, protrudes above the surface of the mucous membrane, is tightly fused with the underlying tissue, is removed with difficulty, in its place small-point bleeding appears (bloody dew symptom), always has a fibrinous character.

In the insular form, plaque tightly fused with the underlying tissue is found on slightly hyperemic tonsils.

The catarrhal form of localized diphtheria of the pharynx is manifested by moderate enlargement of the tonsils and mild hyperemia of the mucous membrane covering them. In this case, symptoms of general intoxication are expressed insignificantly or are absent, the body temperature is low. Often, this form of diphtheria is mistaken for vulgar catarrhal tonsillitis and is recognized only on the basis of a bacteriological examination 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 for localized diphtheria of the pharynx, a rapid improvement in the general condition of the patient occurs within 24 hours, the body temperature returns to normal, the plaque becomes looser, and the pharynx is cleared in 2-3 days. Without the use of serum, localized diphtheria of the pharynx can progress: plaque increases, and this clinical form may transition to the following - widespread or toxic. Spontaneous healing may occur with the mildest forms of diphtheria of the pharynx (catarrhal and insular). With the membranous form, complications often develop in untreated cases (mild cardiovascular disorders, isolated paresis of a toxic nature, such as paresis of the soft palate, sometimes mild polyradiculoneuritis.

Generalized diphtheria of the pharynx accounted for 3-5% of all pharyngeal lesions in the last century. Symptoms of general intoxication are more pronounced than in localized diphtheria of the pharynx: general weakness increases with the appearance of signs of apathy, appetite is lost, spontaneous pain and pain when swallowing are moderate, the mucous membrane of the pharynx is more hyperemic than in localized diphtheria of the pharynx, its edema is more significant. Characteristic filmy plaques spread to other parts of the pharynx, pharynx and uvula.

In untreated cases or with late administration of serum, complications characteristic of diphtheria are more often observed. Currently, widespread diphtheria of the pharynx is rare.

Toxic diphtheria of the pharynx sometimes develops from localized diphtheria of the pharynx, but more often it occurs from the very beginning, acquiring pronounced signs of general intoxication. It most often affects children aged 3 to 7 years. The most severe forms of it occur at this age. Diphtheritic croup in toxic diphtheria of the pharynx occurs mainly in children aged 1-3 years, but its appearance is not excluded at an older age and even in adults.

Clinical course of diphtheria of the pharynx

Toxic diphtheria of the pharynx usually reaches full development on the 2nd-3rd day, and the symptoms may progress for another 1-2 days, despite the introduction of large doses of antidiphtheria serum, after which its symptoms begin to subside. It begins violently with a high body temperature (39-40 ° C), repeated vomiting may be observed. The pulse is rapid, threadlike, breathing is rapid, shallow, the face is pale. General weakness, lethargy, apathy, less often agitation and delirium are noted. Tonsillar lymph nodes are significantly enlarged, painful; edema of the subcutaneous tissue appears around them, which sometimes spreads over a significant distance (down to the nipples, back - to the upper back, up - to the cheek area). The edema is soft, doughy, painless, forms 2-3 or more thick folds on the neck. The skin above the edema is unchanged.

One of the earliest and most characteristic signs of toxic diphtheria of the pharynx is swelling of the soft tissues of the pharynx, which never occurs to such a pronounced degree in vulgar pharyngitis and tonsillitis. Sometimes with such swelling, the tissues of the tonsils and soft palate close, leaving almost no clearance; breathing becomes noisy, reminiscent of snoring during sleep, the voice is nasal, of a changed timbre, eating is sharply difficult. Hyperemia of the mucous membrane of the pharynx is often of a congestive nature with a sharply expressed bluish tint, but can also be brighter. The plaque in the first hours is thin, cobweb-like, then denser, dirty gray, quickly spreading beyond the tonsil to the soft and hard palate, the lateral walls of the pharynx. Often the process spreads to the nasopharynx; in this case, the mouth is open, breathing becomes snoring, and abundant serous glassy discharge from the nose appears, irritating the skin in the area of the nasal vestibule and upper lip.

Toxic diphtheria of the pharynx, depending on the extent of subcutaneous edema (which serves as a classification criterion), which correlates in 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 collarbone and III - below the collarbone. The most severe signs of general intoxication, reaching a soporous state, are observed in grade III toxic diphtheria of the pharynx.

Depending on the severity of the intoxication syndrome and the degree of expression of pathomorphological changes, toxic diphtheria of the pharynx is divided into subtoxic, hypertoxic and hemorrhagic forms.

In the subtoxic form, the above-described symptoms appear in a reduced form. Hypertoxic diphtheria begins violently with high body temperature, repeated vomiting, delirium, and convulsions. At the same time, local manifestations of diphtheria may be moderate. In this form, the phenomena of general intoxication prevail over morphological changes; adynamia, clouded consciousness, pronounced weakness of cardiac activity with hemodynamic disturbances, stupor, turning into a coma are observed. Death occurs within the first 2-3 days.

The hemorrhagic form is characterized by the addition of hemorrhagic phenomena to the clinical picture of toxic diphtheria (usually stage III). The plaques acquire a hemorrhagic hue, are soaked with lysed blood, hemorrhages under the skin, nasal, pharyngeal, esophageal, gastric, intestinal, uterine and other bleedings appear. As a rule, with this form, the disease ends in death, even despite timely and correct treatment.

Complications of diphtheria of the pharynx occur mainly in its toxic form. These include myocarditis (weakness of cardiac activity, changes in ECG, PCG, etc.), mono- and polyneuritis, manifested by periodically occurring paralysis of the soft palate (open nasal speech, liquid food getting into the nose), eye muscles (strabismus, diplopia), muscles of the limbs and trunk, as well as nephrotoxic syndrome (protein in the urine, uremia, renal edema). Often, with severe forms of diphtheria, pneumonia develops, usually of streptococcal etiology.

Diphtheria in adults often takes an atypical course and resembles lacunar tonsillitis, which often misleads the attending physician and complicates diagnosis. In adults, a toxic form of diphtheria may also occur.

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Diagnosis of diphtheria of the pharynx

The diagnosis is established on the basis of the clinical picture (general and local phenomena), while in all cases of vulgar angina, a bacteriological examination is carried out for the presence of diphtheria corynebacterium in smears and films. Its detection, even with a typically occurring banal angina (possibly carriage of bacteria) forces us to interpret the latter as diphtheria of the pharynx with all the ensuing anti-epidemic and therapeutic measures. Material from the pharynx is taken with a sterile cotton swab at the border between the affected area and the healthy mucous membrane, on an empty stomach or 2 hours after eating. When diphtheria corynebacterium is isolated, its toxigenicity is determined.

Differential diagnostics of diphtheria of the pharynx is of exceptional importance, since not only the patient's health, but also the health of others depends on its thoroughness. In modern conditions of planned immunization of the population, diphtheria, as a rule, does not occur in classical forms, but often "masks" itself as banal forms of tonsillitis, being meanwhile a source of massive spread of diphtheria corynebacterium. Diphtheria is differentiated from false-membranous tonsillitis, especially diphtheroid (diphtheroids are a large group of microorganisms belonging to the genus Corynebaclerium, similar in morphological and cultural properties to the causative agent of diphtheria; in humans, they are most often isolated from the nasal mucosa, on which they, together with white staphylococcus, are the dominant microbiota) and pneumococcal etiology; from Simanovsky-Plaut-Vincent angina, herpetic angina in the ulceration phase, lacunar angina, pharyngeal changes in scarlet fever in the first 2-3 days of the disease before the appearance of exanthematous rashes or with changes in the pharynx in the toxic form of scarlet fever, angina in blood diseases, syphilitic changes in the pharynx, mycosis of the pharynx, etc.

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Treatment of diphtheria of the pharynx

Treatment of diphtheria of the pharynx is carried out in an infectious diseases hospital. Its main method is the introduction of antidiphtheria antitoxic serum. V.P. Lebedev (1989) recommends administering the serum using a modified Bezredka method: first 0.1 ml is injected subcutaneously, after 30 minutes - 0.2 ml and after 1-1 '/h - the remaining dose intramuscularly (into the outer upper quadrant of the buttock or into the anterior thigh muscles). The serum is dosed in antitoxic units (AU). The amount of the administered drug depends on the severity of the disease and the time elapsed from the onset of the disease (total dose over 2-4 days): 10,000-30,000 AU for the localized form; 100,000-350,000 AU for the toxic form. In toxic forms, detoxification therapy is prescribed (intravenous plasma, hemodesis in combination with 10% glucose solution, rheopolyglucin), as well as drugs that improve cardiac activity, cocarboxylase, B vitamins, and corticosteroids. In case of edema of the laryngopharynx and larynx that threaten suffocation, it is advisable to perform preventive tracheal intubation or tracheotomy without waiting for asphyxia. Currently, the need for these interventions arises extremely rarely, but it is necessary to create conditions for their emergency implementation.

Antibiotics are prescribed to children with croup complicated by pneumonia, otitis and other complications caused by a different microbiota.

Prevention of diphtheria of the pharynx

Prevention of diphtheria in developed countries is planned and is carried out in accordance with the existing regulation on mandatory calendar vaccination of all children. In order to identify excretors (carriers) of the diphtheria corynebacterium, persons and children (applicants) entering children's institutions (orphanages, boarding schools, special children's institutions for children with diseases of the central nervous system, sanatoriums for children with tuberculosis intoxication) are subject to bacteriological examination. In relation to carriers of the diphtheria corynebacterium and persons who have had contact with a patient with diphtheria, measures are taken as provided for by the relevant instructions of the Ministry of Health. Final disinfection is carried out in the diphtheria outbreak.

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 the introduction of anti-diphtheria antitoxic serum and the correctness of the treatment. By the end of the 20th century, the mortality rate from diphtheria, thanks to mass active immunization against diphtheria, has sharply decreased, and the cases of diphtheria that do occur, thanks to specific, antibacterial and general therapeutic modern treatment, occur in mild and subtoxic forms.