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A 6 years old boy with swallowing pain HELVI…
A 6 years old boy with swallowing pain
HELVI RAMADHANI 1908260083
differential diagnosis of painful swallowing
odinofagia
Odynophagia is a sharp pain in the substernal area on swallowing and on reflex
from severe erosive disease
Esofagitis
Tonsilitis
Faringitis
dysphagia
Dysphagia is related to difficulty eating due to disturbances in the swallowing process.
Achalasia
: primary esophageal motility disorder. Functional obstruction of the distal esophagus with dilatation of its proximal portion, caused by incomplete relaxation of the lower esophageal sphincter
Scleroderma
: occurs as a result of progressive smooth muscle atrophy and replacement with tissue fibrosis
diphtheria definition
Diphtheria is a toxin-mediated infection caused by Corynebacterium species, primarily Corynebacterium diphtheria. It causes skin and mucosal infection and can rarely cause focal infection after bacteremia
differential diagnosis of dphytheria
Retropharyngeal Abscess
Oral Candidiasis: Grayish pseudomembrane, in the case of diphtheria, must be differentiated from oral candidiasis.
Epiglottitis: It is an acute inflammation involving the supraglottic region of the oropharynx with inflammation of the epiglottis and surrounding structures
difference between endotoxin and exotoxin
Exotoxins are toxins produced and excreted from the bodies of Gram-positive and Gram-negative bacteria (Clostridium tetani Cornybacterium diphtheria).
Endotoxin is a lipopolysaccharide (LPS) component of the cell walls of Gram-negative bacteria (cocci and bacilli) that is stored and not actively excreted by bacteria (Escherichia coli, Pseudomonas, Shigella, Haemophilus influenza, Vibrio cholerae, and Bordetella pertussis).
diphtheria classification
Difteri tracheolaryngeal
Difteri maligna
Difteri faucial
Difteri Kutan/Kulit
anterior nasal diphteria
diphtheria pathophysiology
Exotoxin is a single polypeptide consisting of two subunits; A and B
B subunit mediates the binding of the toxin to the receptor on the cell membrane. A subunit has an enzymatic property that cleaves nicotinamide from nicotinamide adenine dinucleotide (NAD), thus inhibiting protein synthesis by ADP-ribosylation of elongation factor 2 (EF-2).
Exotoxin production is the primary mechanism by which the organism shows its typical clinical characteristics
The host response to the bacteria results in the local inflammation in the throat and pharynx, forming a tough, gray pseudomembrane, which is the characteristic physical finding of the diseases.
diphtheria etiology
C. diphtheria is a nonencapsulated, nonmotile, gram-positive bacillus that appears club-shaped and is arranged in palisades or V- or L-shaped formation. These are non-spore-forming gram-positive rods. Besides C. diphtheria, Corynebacterium ulcerans causes cutaneous diphtheria and, in rare cases, is the cause of respiratory diphtheria
how to make a diagnosis of diphtheria
physical examination
Have an infection of the pharynx, larynx, trachea, or a combination thereof;
A grayish-white membrane (pseudomembrane) appears
Swollen lymph glands in the neck (bullneck);
Not high fever (< 38.5˚C)
Makes a sound when inhaling (stidor)
pemeriksaan penunjang
A smear of the throat sample is stained with Gram stain and methylene blue
The Gram stain shows club-shaped, nonencapsulated, nonmotile bacilli found in clusters. The methylene blue stain reveals the typical metachromatic granules.
culture
A black colony with halos on Tindale media, metachromatic granules seen on a Loffler medium, the typical gray-black color of tellurium shows the presence of the organism in these media.
toxin testing
This can be achieved via the Elek test, PCR testing, and enzyme immunoassay (EIA) test.
Complete blood count: It may show moderate leukocytosis.
Chest and neck x-ray may reveal swelling of the soft tissue structure in and around the pharynx, epiglottis, and chest.
anamnesis
Incomplete immunization history
diphtheria risk factors
Incomplete immunization status or no immunization at all
humidity
room, lighting, ventilation,
availability of health care facilities
education and prevention
active vaccine
Active immunization is the administration of weakened or killed germs or poisons with the aim of stimulating the body to produce its own antibodies, for example polio or measles.
passive vaccine
Active immunization is carried out with vaccines containing:
c) Live attenuated viruses (eg smallpox germs,
poliomyelitis vaccine)
d) Toxoid (= toxin = poison rather than neutralized germs:
diphtheria toxoid, tetanus toxoid)
b) Kuman-kuman hidup yang diperlemah (misalnya vaksin BCG
terhadap tuberkulosis).
a) Dead germs (eg cholera-typhoid/typhus vaccine
abdominalis-paratyphus ABC, whooping cough pertussis vaccine).
diphtheria complications
Cardiac Complications
It presents with myocarditis accompanied by cardiac arrhythmias with either first, second, or third-degree heart block
Neurological complications in diphtheria include nerve weakness or paralysis, especially involving the cranial nerves and also affecting the nerves in the extremity leading to weakness of the muscle of the extremity
initial management of diphtheria
Antibiotics in the form of erythromycin or penicillin are given for therapy and prophylaxis.
Antibiotics in the form of erythromycin or penicillin are given for therapy
and prophylaxis.
ADS (Antidiphteria Serum)
prognosis
Cardiac Involvement: It is associated with a very poor prognosis, particularly AV and left bundle-branch blocks
Systemic Disease: High mortality rate is seen in cases of systemic involvement.
Age of Onset: High mortality rates are seen in individuals younger than five years and those older than 40 years.
Duration of Onset of Symptoms: High mortality is seen in cases with onset of duration greater than four days.
diphtheria pathogenesis
Multiply in the mucosa of the upper respiratory tract
• Producing exotoxins
Toxin >> necrosis increases to form fibrous
exudate/pseudomembrane
Direct contact with C.diphtheriae germs
or indirectly --> mouth and nasal cavity
The toxin crosses the mucous cell membrane • Inflammation and destruction of epithelial cells, followed by necrosis along with fibrin and infiltration of leukocyte cells --> membrane (patchy exudate)