Symptoms and complications of diphtheria

Diphtheria has an incubation period that lasts 2-12 (usually 5-7) days, after which diphtheria symptoms appear.

Diphtheria is classified by localization of the process and the severity of the course of the disease. The most common forms are diphtheria of the oropharynx (pharynx) and respiratory tract. Diphtheria of the nose, eyes, ear, and genitals are also possible. These forms are usually combined with the diphtheria of the oropharynx. Diphtheria of the skin and wounds occurs mainly in tropical countries.

Symptoms of oropharyngeal diphtheria are characterized by the presence on the tonsils of filmy plaque, which can spread beyond the tonsils to the palatine curtain, tongue, soft and hard palate. The plaques have uniform white or gray paint, are located on the surface of the tonsils ("plus tissue"), they are removed with a trowel force, and an eroded bleeding surface is exposed.

Plaque does not rub, do not sink and do not dissolve in water.

[1], [2], [3]

Catarrhal form of diphtheria

The oropharynx diphtheria is diagnosed very rarely on the basis of epidemiological, clinical and bacteriological data, when plaques are absent, there is only slight hyperemia and swelling of the tonsils. Symptoms of the oropharyngeal diphtheria and the nature of the plaques make it possible to divide it into the following forms:

• localized (island, filmy) - plaque does not go beyond the limits of the mandible;
• widespread - the raids pass to the soft and hard palate, the gums.

It is possible to form plaque on the mucous membrane of the cheeks after a chemical burn, on the wound after extraction of the tooth and bite of the tongue. According to the severity of the flow, these forms are referred to as light diphtheria. For a mild form of diphtheria of the oropharynx, an acute onset with an increase in body temperature to 37.5-38.5 ° C, general malaise, and sore throat (minor or moderate) are characteristic. The raids appear in a day, on the second day they acquire a characteristic appearance. On examination, note the pallor of the face, mild hyperemia of the tonsils with a cyanotic shade. Podnizhnelchelstnye lymph nodes, as a rule, are not enlarged, are painless on palpation. The fever lasts up to 3 days. Without treatment, plaque persists up to 6-7 days. With mild forms of diphtheria of the oropharynx (localized and widespread), edema of the tonsils is possible.

[4], [5], [6], [7],

Toxic diphtheria

The presence of edema of the oropharynx gives grounds to diagnose the toxic form of diphtheria, which occurs in a moderate and severe form. The severity of the flow is due to the degree of severity of the main syndromes, primarily the degree of functional changes in various organs and systems during all periods of the disease. Expression of edema of the mucous membrane of the oropharynx and cervical tissue is just one of many signs that characterize the severity of the course of diphtheria, often not the most important.

Subthoxic and toxic diphtheria of the oropharynx of the I degree is more often of medium-heavy course. These forms have more pronounced symptoms of diphtheria: general intoxication, higher (up to 39 ° C) and prolonged fever, severe asthenia, tachycardia, more severe sore throat. Tears on the tonsils are common, sometimes only one amygdala is affected. Tonsils are swollen, brightly hyperemic. Edema of the neck tissue is localized with a sub-toxic variant in the submaxillary region, and in case of toxic diphtheria of the 1st degree it spreads to the middle of the neck.

Toxic diphtheria II, III degree and hypertoxic diphtheria is characterized by the fact that the symptoms of diphtheria develop very rapidly: general intoxication, chills, increased body temperature to 40 ° C and above, severe muscle weakness, headache, severe sore throat. On examination, paleness of the skin, pronounced edema of the cervical tissue, spreading at toxic diphtheria of II degree to the clavicles is revealed. At the third degree - below the clavicles on the thorax. Edematics of a testy consistency, painless. The submandibular lymph nodes are moderately painful, significantly enlarged, their contours due to edema and periadenitis are indistinct. Upon examination of the mucous membrane of the oropharynx, diffuse hyperemia and sharp puffiness of the tonsils are detected, which can close on the middle line, which makes breathing difficult, swallowing, and gives the voice a nasal hue. The raids in the first day can have the appearance of a whitish spider web, on the 2-3rd day of the disease they acquire a characteristic appearance, and in this category of patients the membranes are dense, distributed, extend beyond the boundaries of the tonsils, form folds.

When hypertoxic diphtheria on the 2-3rd day of the disease develop an infectious-toxic shock and multi-organ failure. For the hemorrhagic variant, impregnation of plaque with blood is characteristic, because of what they acquire a scarlet color.

There are also hemorrhages in the edema zone, nosebleeds and other manifestations of hemorrhagic syndrome.

In case of severe disease, the symptoms of diphtheria, fever and intoxication persist up to 7-10 days, the raids are rejected even later, leaving an eroded surface.

Diphtheria of the respiratory tract

Diphtheria of the respiratory tract (diphtheria croup) is a common form of the disease. Diphtheria croup can be localized (diphtheria of the larynx), common (diphtheria of the larynx and trachea) and descending, when the process spreads to the bronchi and bronchioles. The severity of the course of this form of the disease is determined by the degree of stenosis (ie, the severity of respiratory failure).

Diphtheria croup begins with a slight increase in body temperature, the appearance of a dry, "barking" cough, hoarseness of the voice, turning into aphonia. Within 1-3 days the process progresses, typical symptoms of diphtheria appear and signs of stenosis of the larynx: a noisy zoster, accompanied by the retraction of the epigastric region, intercostal spaces, supra- and subclavian pits, the jugular fossa. After a few hours - 2-3 days signs of respiratory insufficiency: motor anxiety, insomnia, cyanosis, skin pallor, tachycardia, increased blood pressure, followed by retardation, seizures, arterial hypotension. When examining the blood, a growing incidence of hypercapnia is revealed. Respiratory acidosis. In adults, because of the wide lumen of the larynx, symptoms such as aphonia and stenotic breathing may be absent, the process develops slowly. Signs of respiratory failure appear on the 5th-6th day of the disease with the development of descending croup: there is a feeling of lack of air, tachycardia, pallor of the skin, cyanosis, auscultatory - weakening of breathing. Localized and common cereals are often detected only with laryngoscopy - they detect diphtheria films on the vocal cords. The films are easily removed and can be removed by an electric pump.

[8], [9], [10],

Diphtheria of the nose

Diphtheria of the nose is the third most frequent form of the disease. Symptoms of diphtheria begin gradually. Body temperature normal or subfebrile. Mark the mucocutaneous or mucopurulent discharge, more often unilateral, there is maceration of the skin at the entrance to the nose, with a rinoscopy reveal erosions, crusts, fibrinous films in the nasal passages, which can spread to the skin, mucous membrane of the maxillary sinuses. In rare cases, there is edema of the face.

[11], [12], [13], [14], [15]

Eye Diphtheria

The process is usually one-sided. Characteristics of edema of the eyelids, narrowing of the eye gap, purulent-sacred discharge. A fibrinous film appears on the transitional fold of the conjunctiva, which can spread to the eyeball. Possible edema of soft tissues in the orbit.

[16], [17], [18]

Diphtheria of reproductive organs

Diphtheria of the genital organs occurs in girls. Symptoms of diphtheria of the genitals are characterized by the swelling of the vulva, secretion. Fibrinous membranes are localized in the region of small lips and the entrance to the vagina.

[19]

Diphtheria of skin and wounds

Diphtheria of the skin and wounds occurs mainly in the tropics; the symptoms of skin and wound diphtheria are characterized by the presence of a superficial, painless ulcer covered with fibrinous film. The general condition is poorly disturbed; the course is sluggish, up to 1 month.

[20]

Combined diphtheria

Most often there is a combination of diphtheria of the oropharynx with diphtheria of the respiratory tract and nose, less often the eye and genital organs.

[21], [22],

Clinical Diphtheria Syndromes

For severe toxic forms of diphtheria, the damage of various organs and systems is characteristic. In clinical practice, it is advisable to allocate several clinical syndromes.

[23], [24],

Syndrome of local manifestations

The syndrome of local manifestations (swelling of the subcutaneous tissue of the neck, oropharynx, widespread fibrinous plaque, etc.). In the vast majority of cases, it is on the basis of this syndrome that a physician can diagnose diphtheria.

Intoxication syndrome

Intoxication syndrome is observed in all patients with toxic forms of diphtheria. Characterized by severe weakness, fever, arterial hypotension, thirst, tachycardia, decreased diuresis, anorexia and insomnia.

The severity of the intoxication syndrome in the acute period of the disease is one of the criteria for the severity of the course.

The syndrome of toxic-metabolic shock

In extremely severe diphtheria (fulminant form) and severe intoxication, toxic-metabolic shock develops in 3-7% of patients. It is characterized by severe DVS-syndrome (manifested not only in laboratory changes, but also clinical symptoms), pronounced hypovolemia, acute respiratory failure and renal insufficiency, impaired myocardial function (impaired contractility and conduction) and cranial nerve damage. In the syndrome of toxic-metabolic shock, a rapid and pronounced lesion of target cells occurs, and in the following, the functions of many organs and systems are decompensated. With the development of the syndrome of toxic-metabolic shock, lethal outcome is observed in almost 100% of cases.

Syndrome of respiratory failure

Syndrome of respiratory failure in severe diphtheria may be due to the following main causes: infectious-toxic shock, stenosis of the larynx, partial obstruction of the upper respiratory tract (edema of the epiglottis, pronounced edema of the oropharynx with dysfunction of the soft palate, rooting of the tongue, mainly in alcoholics, aspiration of the film into the trachea ), descending croup, rapid intravenous injection of large doses of antidiphtheria serum with the development of respiratory distress syndrome, obstructive bronchitis and t zholoy pneumonia polyneuropathy with the defeat of the diaphragm and auxiliary respiratory muscles.

Syndrome of respiratory failure during its manifestation almost always determines the severity of the course of the disease, with severe diphtheria is observed in 20% of cases.

The most frequent signs of respiratory failure are shortness of breath, cyanosis (acrocyanosis), depression of consciousness of varying degrees, unstable hemodynamics (arterial hypertension, tachy- and bradyarrhythmias), decreased diuresis, hypoxemia, hyper- or hypocapnia.

Stenosis of the larynx and descending croup are the most frequent causes of death in diphtheria (especially in the first 10 days of the disease). In the long term of the disease (after the 40th day), the respiratory failure syndrome also often leads to the death of patients: it develops primarily due to a violation of the innervation of the respiratory muscles and the attachment of pneumonia.

The syndrome of disseminated intravascular coagulation

The syndrome of disseminated intravascular coagulation (DVS-syndrome) is observed in all forms of toxic diphtheria. Clinical signs of DIC syndrome in severe forms are recorded in 15% of cases. The development of serum sickness aggravates the course of DIC syndrome.

Myocardial damage syndrome

The heart suffers as a result of the direct action of exotoxin. In severe forms of diphtheria, there are additional damaging factors: hypoxic states of different genesis (DVS-syndrome, respiratory insufficiency, anemia), volumetric overload in acute renal failure, electrolyte disturbances. The defeat of the heart in most cases determines the severity of the patient's condition, especially on the 10th and on the 40th day of the disease.

Symptoms of diphtheria in this syndrome consist of cardiac complaints, heart failure syndrome and physical data. Cardiac complaints for diphtheria are fickle and do not reflect the severity of heart damage. At the examination, the most important is the detection of arrhythmia and a pulse deficit. Pallor or cyanosis. For more accurate and early assessment of the state of the myocardium, ECG data, EchoCG studies, as well as results of the activity of cardiospecific enzymes are needed.

Criteria determining severe myocardial damage with an unfavorable prognosis:

• progressive heart failure mainly in the right ventricular type (according to clinical data);
• pronounced conduction disorders, such as atrioventricular dissociation with idioventricular rhythm, AV block of the 2nd degree of the 2nd type according to Mobitsu, combined with di- and tri-percular blockages of the bundle branch (according to ECG data);
• decrease in contractility, i.e. Reduction of left ventricular ejection fraction by less than 40% (according to EchoCG data);
• a marked increase or, conversely, a relatively low activity of cardiospecific enzymes in combination with the features listed above;
• the development in later terms of the disease of electrical instability of the myocardium in the form of frequent tachyarrhythmias and ventricular fibrillation.

The syndrome of myocardial damage in severe diphtheria is detected constantly, in combination with other syndromes this is the most frequent cause of death in severe forms of diphtheria of the oropharynx.

Peripheral Nervous System Syndrome

The syndrome of affection of the peripheral nervous system is associated with the direct action of exotoxin on nerve fibers and autoimmune processes, manifested in the form of bulbar paresis (paralysis) and polyneuropathy.

Bulbar paresis (paralysis) in toxic forms of diphtheria is detected in 50% of the observations. There are nasal voices and choking at the reception of liquid food. These changes are recorded both in the initial period (3-16 days), and in later periods (after the 30th day) of the disease. The defeat of other pairs of cranial nerves (III, VII, X, XII) is less common, paresis (muscle paralysis) of the pharyngeal muscles, language, mimic muscles, skin sensitivity is impaired.

Polyneuropathy occurs in 18% of cases, manifested by impaired function (paresis or paralysis) of the limbs, diaphragm, intercostal nerves. Polyneuropathy occurs, as a rule, after the 30th day of the disease. Identify peripheral paresis (or paralysis) with oppression or lack of tendon reflexes, a decrease in muscle strength, impaired sensitivity, restriction of the mobility of the diaphragm (determined radiographically or by excursion of the lower edge of the lungs). Patients complain of muscle weakness, impaired sensation, numbness of fingers, gait disturbance or inability to walk, feeling short of air, shortness of breath. The defeat of the limbs always occurs before respiratory disorders, and the function of the respiratory muscles is restored earlier.

The degree of severity of polyneuropathy is assessed on the basis of patient complaints and the results of conventional clinical examination methods (definition of reflexes, skin sensitivity, respiratory movement frequency, etc.). By the method of electroneuromyography, a significant dissociation between the rate of development and the severity of clinical signs and the degree of electrophysiological disorders can be detected. ENMG studies reveal a reduced rate of impulse conduction along the nerves and a decrease in the amplitude of the M-response, not only with obvious clinical signs, but also in their absence. Changes in electroneuromyography occur 2-3 weeks before clinical manifestations. The most frequent and difficult polyneuropathy occurs in people who abuse alcohol.

Kidney damage syndrome

Defeat of kidneys in diphtheria is usually characterized by the term "toxic nephrosis". In severe disease, kidney damage is manifested by macrogemuria, leukocyturia, cylindruria, and proteinuria.

Direct damaging effect of exotoxin on the renal parenchyma is minimal, does not lead to clinical manifestations of renal failure and does not affect the severity of the flow. The development of acute renal failure in diphtheria is determined only by secondary factors of influence:

• development of severe DVS-syndrome and hypovolemia on the 5-20th day of the disease;
• development of multi-organ (septic) insufficiency after 40 days;
• iatrogenic causes (an overdose of antidiphtheria serum, the appointment of aminogliccosides).

With the development of acute renal failure in patients observed oligoanuria, increased levels of urea, to a lesser extent, creatinine and potassium in blood plasma. A greater increase in the level of urea in comparison with the level of creatinine is associated with a high activity of catabolic processes. With an increase in the concentration of potassium in the plasma, asystole and a lethal outcome are possible.

Syndrome of nonspecific infectious complications

The severity of this syndrome depends on the severity of the course of diphtheria and the damage to the immune system. The syndrome of nonspecific infectious complications can occur both in the first week of the disease, and in the more distant periods (after the 30th day of the disease). Most often, they register pneumonia, bronchitis, urinary tract infection; possibly the development of an abscess of tonsils, a peritonsillar abscess.

These complications are much more frequent in people who abuse alcohol. Their occurrence is facilitated by inadequate sanitation of the tracheobronchial tree with prolonged ventilation, catheterization of the bladder and central veins. The development of sepsis is possible even in late terms of the disease.

Complications of diphtheria

All of the above syndromes and symptoms of diphtheria are associated with the action of toxin, a local process. They determine the severity, course and outcome of the disease, therefore they are considered as characteristic manifestations, not complications. In severe diphtheria, complications of nonspecific character are possible that can prevail in the clinical picture and even be the direct cause of the lethal outcome.

[25], [26], [27], [28], [29], [30],

Iatrogenic complications of diphtheria

The following types of iatrogenic complications are possible.

• Complications associated with the development of serum sickness due to the introduction of antidiphtheria serum: exanthema, myocarditis, polyarthritis, "exacerbation" of DVS-syndrome, kidney damage, respiratory failure; possible anaphylactic shock.
• Complications caused by long-term administration of glucocorticosteroids, which leads to suppression of immunity, hypokalemia (with the development of muscle weakness, extrasystole, sluggish peristalsis of the intestine, with bloating), erosive gastritis, trophic disorders.
• Renal damage due to taking aminoglycosides.

Mortality and causes of death in diphtheria

Severe symptoms of diphtheria lead to a fairly large lethality, which is 10-70%. The main causes of death are heart damage, respiratory muscle paralysis, asphyxia in respiratory tract diphtheria, infectious-toxic shock, and secondary bacterial complications.