1

Literature Reading
Tonsillitis Diphteri

R. Isma Nurul AIni

Consultant :

dr. Ongka M Saiffudin , SpTHT-KL(K)

Department of Otolaryngology - Head & Neck Surgery

Faculty of Medicine Padjadjaran University
Hasan Sadikin General Hospital
Bandung
2016
 Introduction
2

Greek diphtheria

Recognized by Hippocrates in 5th century

B.C.

Epidemics described in 6th century

C. diphtheriae described by Klebs in 1883

Toxoid developed in 1920s

Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public
Health England; 2015.
 Definition :
3

Diphtheria is an acute infectious

disease that is highly contagious

Corynebacterium diphtheria

Corynebacterium diphtheria germs is

very dangerous because it can
produce a powerful exotoxin
Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public
Brodsky, L Poje, C. Tonsillitis, Tonsillectomy and Adenoidectomy. In Head and Neck Surgery Otolaryngology. 5 th ed.
HealthWilliams
Editor: Bailey B.J. & Johnson T.J. Volume one. Lippincot England; 2015. Philadelphia, 2006. p. 1184 - 99
& Wilkins.
 Epidemiology
4

United States
Incidence : 100-200 cases per 100,000
population ( Before of vaccine) 0.001
cases per 100,000 population mortality rate
is 5-10% 20% in children younger than 5
years
Indonesia Endemic in east java : 355

cases ( 2011) Death cases : 11

Mortality rate : 15 %
2012 West java : 65 cases
Pulungan A, Hendarto A, Setyanto D, Pusponegoro H, Wulandari H, Satari W, et all. Curret Evidences in Pediatric
Emergencies Management. Pendidikan Kedokteran Berkelanjutan LXVIII; Departemen Ilmu Kesehatan Anak FKUI
Jakarta; 2014.
 Triad Epidemiology :
5

HOST

Disease
ENVIRONMEN
AGENT T
 Corynebacterium
6
diphtheriae
gram-positive rod bacteria,
not moving,
pleomorphic,
not encapsulated,
do not form spores, dead at 600C
heating
With staining, the bacteria can be seen
in palisade arrangement, L or V shape

Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public
Health England; 2015.
 Pathogenesis :
7

Incubation period 2-5 days

(range, 1-10 days)

Phillips SM, Bhopale MK, Hilliard B, Zekavat SA, Ali MA, Rostami.Cell Immunol. 2010;261(2):144-52
 Exotoxin :
8
 Classification of diphtheria
9

RESPIRATORY DIPTHERIA
Diphtheria of the Nose

Diphtheria of the tonsils and pharynx

Diphtheria of the larynx / trachea

NON-RESPIRATORY DIPHTERIA

Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public
Health England; 2015
.Joel H. Blumin and Nikki Johnston,Bailey Byron J.and Jonas T. Johnson. Head and Neck Surgery Otolaryngology,
5th edition. Volume 1. Philadelphia: Lippincot, William and Wilkins, 2014
 Main symptoms
10

Typical membranes especially of the

tonsils and pharyngeal wall with the
membrane properties:
Thick
White
The edge hyperemia
Edema
difficult removed
Easy to Bleeding
Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public Health England;
2015 in England and Wales 2015 Guidelines. Public
Colin Brown. Public health control and management of diphheriae
.Joel H. Blumin and Nikki Johnston,Bailey Byron J.and Jonas T. Johnson. Head and Neck Surgery Otolaryngology, 5th edition.
Health England; 2015.
Volume 1. Philadelphia: Lippincot, William and Wilkins, 2014
 Additional symptoms
11

Diphtheria nose:
Serosanguinous secretions from the
nostrils and signs of infection in the nose
and upper lip

Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public
Health England; 2015
.Joel H. Blumin and Nikki Johnston,Bailey Byron J.and Jonas T. Johnson. Head and Neck Surgery Otolaryngology,
5th edition. Volume 1. Philadelphia: Lippincot, William and Wilkins, 2014
 Tonsillitis diphtheriae
12

anorexia, malaise, mild fever, and

painful swallowing
Membrane attached (white and gray)
close tonsil pharyngeal wall, extending
to the uvula and soft palate or down to
the larynx and trachea release the
membrane will result in bleeding
soft tissue edema in conjunction with a
wide neck bullneck
Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public
Health England; 2015
.Joel H. Blumin and Nikki Johnston,Bailey Byron J.and Jonas T. Johnson. Head and Neck Surgery Otolaryngology,
5th edition. Volume 1. Philadelphia: Lippincot, William and Wilkins, 2014
 Clinical Pictures
13

BULLNECK Pseudomembrane
 Diphtheria of the larynx
14

hoarseness
stridor
There respiratory obstruction: dyspnea,
thoracic wall retractions, cyanosis
Laryngoscopy

Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public
Health England; 2015
.Joel H. Blumin and Nikki Johnston,Bailey Byron J.and Jonas T. Johnson. Head and Neck Surgery Otolaryngology,
5th edition. Volume 1. Philadelphia: Lippincot, William and Wilkins, 2014
 Diagnostic
15

ANAMNESIS 1. Contact with diphtheria

Contact Definition: people at home and
playmates; contact with nasopharyngeal
secretions (ie: mouth-to-mouth resuscitation);
individuals in the same room with the patient in
time 4 hours for 5 consecutive days or> 24
hours a week (among classmates)
2. Hoarseness and dysphagia
3. Fever is not so high

Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public Health
England; 2015
Colin Brown.
Diphtheriae. Publicfor
Centers health control
Disease and and
Control management
PreventionofEpidemiology
diphheriae inand
England and Wales
Prevention 2015 Guidelines. Public
of Vaccine-Preventable Health
Diseases; 13th
England; 2015
Edition ; 2015
Diphtheriae. Centers
Garha H,Melinda H.for DiseaseDiagnostik
Pedoman Control and Prevention
dan Epidemiology
Terapi Ilmu and Prevention
Kesehatan Anak. Departemenof Vaccine-Preventable
Ilmu Kesehatan AnakDiseases;
FK UNPAD. 13th
 Physical Examination
16

Hoarseness and dysphagia

Stridor and other signs of airway obstruction
Generally show signs of tonsillitis and pharyngitis
In nasal diphtheria: foul smell, discharge serosanguinis/
purulent, shallow ulcers in the nose and upper lip
Swelling of the cervical lymph nodes, tissue edema of
the throat and neck bullneck. When expanded to the
corner of the chin, the limit m. sternocleidomastoid with
boundaries disappearing middle clavicle edema
erasure
There is a membrane at the site of infection grayish
white, bleed easily when lifted
Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public Health
England; 2015
Diphtheriae. Centers for Disease Control and Prevention Epidemiology and Prevention of Vaccine-Preventable Diseases; 13th
Edition ; 2015
Garha H,Melinda H. Pedoman Diagnostik dan Terapi Ilmu Kesehatan Anak. Departemen Ilmu Kesehatan Anak FK UNPAD.
 Difference Between
Tonsillitis Diphtheria and Tonsillitis Folikularis
17

Tonsillitis DIPHTHERIA Tonsillitis

FOLIKULARIS
subfebril fever High fever
Mild pain Moderate Pain
Grayish-white yellowish white
membrane, easy membrane, no easily
bleeding, difficult to bleed, easily
be separated, thick, seperated, thin,
not limited to the limited to the tonsils
tonsils
Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public Health England; 2015
Diphtheriae. Centers for Disease Control and Prevention Epidemiology and Prevention of Vaccine-Preventable Diseases; 13th Edition ; 2015
Garha H,Melinda H. Pedoman Diagnostik dan Terapi Ilmu Kesehatan Anak. Departemen Ilmu Kesehatan Anak FK UNPAD. Bandung; 5 Ed;
 Investigations
18

Direct smear and culture of lesions of the nose

and/or throat using staining Neisser, Albert
routine blood
Peripheral blood leukocyte count: usually normal;
common hemolytic anemia and thrombocytopenia
complete urine
Ureum and creatinine (when there are suspicious
complications to kidney)
ECG arrhythmias may occur, changes in the ST
segment and T wave in case of myocarditis

Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public Health
England; 2015
Colin Brown.
Diphtheriae. Publicfor
Centers health control
Disease and and
Control management
PreventionofEpidemiology
diphheriae inand
England and Wales
Prevention 2015 Guidelines. Public
of Vaccine-Preventable Health
Diseases; 13th
England; 2015
Edition ; 2015
Diphtheriae. Centers
Garha H,Melinda H.for DiseaseDiagnostik
Pedoman Control and Prevention
dan Epidemiology
Terapi Ilmu and Prevention
Kesehatan Anak. Departemenof Vaccine-Preventable
Ilmu Kesehatan AnakDiseases;
FK UNPAD. 13th
 TREATMENT
19

ADS

Antibiotik

Cortikosteroid
 ADS (Anti Diphteri Serum)
20

40.000 IU mild
60.000 IU sd 80.000 IU moderate
diphtheria
100.000 IU SD 120.000 IU severe
diphtheria

WHO Recommended Surveilance Standars. World Health Organization, Geneva; Second Ed ; 2003
 WHO : Recommended Surveillance
Standards of Diphtheria
21

If the test sensitivity ( + ) if found induration > 3

mm at 20 min after injection tmpat or raised
conjunctivitis . When test sensitivity ( + ) provide
desensitization ADS , each with a 20 minute
interval
0.05 mL of 1:20 s.k.
0.10 mL of 1:20 s.k.
0.10 mL without dilution s.k .
0.30 mL without dilution i.m .
0.50 mL without dilution i.m .
0.10 mL without dilution i.v .
WHO Recommended Surveilance Standars. World Health Organization, Geneva; Second Ed ; 2003
Garha H,Melinda H. Pedoman Diagnostik dan Terapi Ilmu Kesehatan Anak. Departemen Ilmu
Kesehatan Anak FK UNPAD. Bandung; 5 Ed; 2014.
 Antibiotics
22

Penisillin Prokain 100.000 IU / kg Body

Weight/ for 10 days
Erythromycin 40 - 50 mg/kg body
weight/day P.o (max. 2g/day ), divided
into 3-4 doses,for 10days

WHO Recommended Surveilance Standars. World Health Organization, Geneva; Second Ed ; 2003
 23
Corticosteroid
23

Prednisone 2mg/kg body weight/day for

3 weeks.
Deksametasone 0.5-1 mg/kg body
weight/day by IV

WHO Recommended Surveilance Standars. World Health Organization, Geneva; Second Ed ; 2003
24
 Diphtheria Complications
25

Most attributable to toxin

Severity of generally related to extent

of local disease

Most common complications are

myocarditis and neuritis

Death occurs in 5%-10% for respiratory

disease
Colin Brown. Public health control and management of diphheriae in England and Wales 2015 Guidelines. Public
Health England; 2015.
 HIGHLIGHTS
26

Diphtheria is an acute infectious disease

that is highly contagious, caused by
Corynebacterium diphtheria
pseudomembrane formation with
marked on the skin and / or mukosa
Corynebacterium diphtheria germs is
very dangerous because it can produce a
powerful exotoxin that can cause a
disease that is difteria
27

Diphtheria has clinical symptoms of sore

throat and form a membrane that can
cover the tonsils, pharynx and laring
Diagnosis Tonsilitis Diphteheria from the
history and physical examination
Treatment for Tonsilitis Diphtheria giving
ADS, Antibiotics and Corticosteroid
 28

THANK YOU