presentation of diptheria
TRANSCRIPT
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Andrew James EscolanoAndrew James Escolano
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DefinitionDefinition
Is an infectious diseases cause by corynebacteruimIs an infectious diseases cause by corynebacteruimdiphtheria, characterized by the formation ofdiphtheria, characterized by the formation ofpseudomembrane, commonly in the faucial area and tonsils,pseudomembrane, commonly in the faucial area and tonsils,and the elotoration of powerful exotoxin affecting theand the elotoration of powerful exotoxin affecting theimportant viscera of the heart and kidneys and the peripheralimportant viscera of the heart and kidneys and the peripheralnervous system.nervous system.
Diphtheria causes the progressive deterioration of myelinDiphtheria causes the progressive deterioration of myelinsheaths in the central and peripheral nervous system leadingsheaths in the central and peripheral nervous system leadingto degenerating motor control and loss of sensation.to degenerating motor control and loss of sensation.Diphtheria is a contagious disease spread by direct physicalDiphtheria is a contagious disease spread by direct physicalcontact or breathing the aerosolized secretions of infectedcontact or breathing the aerosolized secretions of infectedindividuals.individuals.
Acute febrile infection of the tonsils, throat, nose, larynx or aAcute febrile infection of the tonsils, throat, nose, larynx or awound marked by a patches of grayish membrane from whichwound marked by a patches of grayish membrane from whichbacilli is readily cultured.bacilli is readily cultured.
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EtiologyEtiology
Corynebacteruim diphtheriaeCorynebacteruim diphtheriae (Klebs-loeffler(Klebs-loefflerbacillus)bacillus)
Is typically a slender, curved and slightly tapered clubbedIs typically a slender, curved and slightly tapered clubbed
organism which gram + to variable, facultatively aerobicorganism which gram + to variable, facultatively aerobic
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Incubation periodIncubation period
2-6 days, occationally longer2-6 days, occationally longer
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Pathognomonic signPathognomonic sign
Sore throatSore throat
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Mode of transmissionMode of transmission
Contact with a patient, carrier,Contact with a patient, carrier,
articles soiled with discharged ofarticles soiled with discharged of
infected personinfected personSource: discharged from noseSource: discharged from nose
pharynx, eyes or lesion on otherpharynx, eyes or lesion on other
parts of body of infected person.parts of body of infected person.
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Period of communicabilityPeriod of communicability
Variable until virulent bacilli hasVariable until virulent bacilli has
disappeared from secretions anddisappeared from secretions and
lesions: usually 2 weeks andlesions: usually 2 weeks andseldom more than 4 weeks.seldom more than 4 weeks.
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Sign and symptomsSign and symptoms
FatigueFatigue DysphagiaDysphagia Nausea/vomitingNausea/vomiting ChillsChills High feverHigh fever
Neck swellingNeck swelling Bull neckBull neckToxaema (except in nasal type): apathy, malaise,Toxaema (except in nasal type): apathy, malaise,
weakness and pulse disproportionately rapid toweakness and pulse disproportionately rapid totemperature.temperature.
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PathogenesisPathogenesis
The typical pseudomembrane is formed by leukocytes, fibrin,The typical pseudomembrane is formed by leukocytes, fibrin,
necrotic tissue and micro organism; which is adherent to thenecrotic tissue and micro organism; which is adherent to the
underlying tissues and leaves a raw bleeding area whenunderlying tissues and leaves a raw bleeding area when
detached.detached.
The toxin elaborated by the organism initiates and contributesThe toxin elaborated by the organism initiates and contributesto the further growth of lesion and formation of more toxinsto the further growth of lesion and formation of more toxins
which attacks the myocardium, kidneys, liver, cranial andwhich attacks the myocardium, kidneys, liver, cranial and
peripheral nerves producing foci of necrosis and degeneration.peripheral nerves producing foci of necrosis and degeneration.
The site of membrane formation influence the clinical features,The site of membrane formation influence the clinical features,
produced more toxins absorbed from the upper respiratoryproduced more toxins absorbed from the upper respiratory
tract than lower respiratory.tract than lower respiratory.
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PathophysiologyPathophysiology
the damage to body is a results ofthe damage to body is a results of
liberation of soluble toxins in the localliberation of soluble toxins in the local
lesion.lesion.
Size of membrane reflects the amountSize of membrane reflects the amount
of toxins being produce.of toxins being produce.
The larger the membrane the moreThe larger the membrane the more
toxins present in blood.toxins present in blood.
Toxin-tissue union in many body portsToxin-tissue union in many body ports
but special affinity appears to exist inbut special affinity appears to exist in
certain parts, heart and peripheralcertain parts, heart and peripheral
nerves.nerves.
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Diagnostic testDiagnostic test
Nose and throat swabNose and throat swab
Virulence testVirulence test
Shick testShick testMoloney testMoloney test
Differential diagnosisDifferential diagnosis
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Nose and throat swabNose and throat swab
Culture of both nose andCulture of both nose and
throat in all types ( swabthroat in all types ( swab
are streak on fresh paisare streak on fresh pais
loeefler serum apgar, bloodloeefler serum apgar, bloodtellurite or tisdale mediatellurite or tisdale media
and examine 8- 24 hours ofand examine 8- 24 hours of
incubation.incubation.
Negative results do not ruleNegative results do not ruleout diphtheria.out diphtheria.
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Virulence testVirulence test
Direct smear property stained willDirect smear property stained will
appear typical gram (+) organismappear typical gram (+) organism
but although having an advantagebut although having an advantageof being simple delay is notof being simple delay is not
entirely reliable.entirely reliable.
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Schick testSchick test
Intradermal injection of diluteIntradermal injection of dilute
diphtheria toxins ( 0.1cc)diphtheria toxins ( 0.1cc)
(+) to individual w/o immunity,(+) to individual w/o immunity,
hence susceptible to diphtheriahence susceptible to diphtheria After 48-72 hours (+) reactionAfter 48-72 hours (+) reaction
reveals itself as localreveals itself as local
circumscribed area of redness 1-circumscribed area of redness 1-
3 cm in diameter, but3 cm in diameter, butoccasionally larger.occasionally larger.
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Moloney testMoloney test
Test to determined hypersensitivity toTest to determined hypersensitivity to
diphtheria toxoiddiphtheria toxoid
Performed by injecting 1.0cc fluidPerformed by injecting 1.0cc fluid
toxoid intradermally.toxoid intradermally.
If (+) an area erythema will developedIf (+) an area erythema will developed
in 24 hours.in 24 hours.
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MedicationMedication
Serum therapySerum therapy
antibioticantibiotic
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Serum therapy ( diphtheriaSerum therapy ( diphtheria
antitoxin)antitoxin)
Early administration aim toEarly administration aim to
neutralizing the toxins present inneutralizing the toxins present in
general circulation before it absorbedgeneral circulation before it absorbed
by the tissues.by the tissues.
Skin testing is required beforeSkin testing is required before
administration of antitoxin for allergicadministration of antitoxin for allergic
reaction.reaction.
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One must be guided with some severalOne must be guided with some several
factor:factor:
a.a. The day of disease which patient isThe day of disease which patient is
first observedfirst observed
b.b. Apparent severity of the lesion,Apparent severity of the lesion,
namely the extent of membrane.namely the extent of membrane.
c.c. Evidence of toxemia.Evidence of toxemia.
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Dosage and route inDosage and route in
administration of antitoxinadministration of antitoxin
TypeType DoseDose RouteRoute
Anterior nasalAnterior nasal 10,000-20,00010,000-20,000
unitsunits
IntramuscularIntramuscular
FaucialFaucial 15,000-25,00015,000-25,000unitsunits
IM/IVIM/IV
Pharyngeal/laryPharyngeal/laryngealngeal
20,000-40,00020,000-40,000unitsunits
IVIV
Combined, lateCombined, latecasescases
40,000-80,00040,000-80,000unitsunits
IVIV
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AntibioticsAntibiotics
Effective for sensitive strainEffective for sensitive strain
a.a. Penicillin G potassium,Penicillin G potassium,
100,000 mg/kg/day in 4100,000 mg/kg/day in 4
doses, IM or IV.doses, IM or IV.
b.b. Erythromycin, 40mg/kg inErythromycin, 40mg/kg in
4 doses, oral, for 7-104 doses, oral, for 7-10
daysdays
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ProphylaxisProphylaxis
Active immunizationActive immunization
Passive immunizationPassive immunization
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Active immunizationActive immunization
Based on principle that the smallBased on principle that the small
doses of toxins stimulates thedoses of toxins stimulates the
production of antitoxin in the body.production of antitoxin in the body.
Most desirable period is between 6-12Most desirable period is between 6-12
months of age, preferably 9 months.months of age, preferably 9 months.
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Method of activeMethod of active
immunizationimmunizationa.a. toxin-antitoxintoxin-antitoxin is a preparation in w/c the is a preparation in w/c the
active immunizing substance, the toxinactive immunizing substance, the toxinhas been buffered or attenuated, withhas been buffered or attenuated, withsuitable amount of antitoxins.suitable amount of antitoxins.
-has been replace by toxoid w/c is prepared-has been replace by toxoid w/c is preparedby addition of 1.4% formalin, thusby addition of 1.4% formalin, thusattenuating the toxin.attenuating the toxin.
The dose is 0.5cc subQ for 3 doses interval ofThe dose is 0.5cc subQ for 3 doses interval of3 months3 months
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ToxoidToxoid
As in routine of DPT immunization program of infancyAs in routine of DPT immunization program of infancyand childhood and provide protection about 10 years.and childhood and provide protection about 10 years.
Booster doses is given at suitable interval untilBooster doses is given at suitable interval until
adulthood.adulthood. Protection may not absolute, but disease becomeProtection may not absolute, but disease become
milder and minimum of complication.milder and minimum of complication.
Given subQ or IM by large gauge needle coz danger ofGiven subQ or IM by large gauge needle coz danger ofblockage by particles of precipitate.blockage by particles of precipitate.
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Passive immunizationPassive immunization
For susceptible person who has beenFor susceptible person who has been
directly exposed to an unquestioneddirectly exposed to an unquestioned
case of the disease.case of the disease.
Advisable to protect them at once byAdvisable to protect them at once by
injection of 10,000 units of antitoxins,injection of 10,000 units of antitoxins,
IM and last about 3-4 weeks.IM and last about 3-4 weeks.
Antitoxin prevent development of theAntitoxin prevent development of the
disease.disease.
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Nursing managementNursing management
RestRest
Care of nose andCare of nose and
throatthroat
Ice collarIce collarDietDiet
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RestRest
Patient should be confined to bedPatient should be confined to bed
at least 2 weeks, not permittedat least 2 weeks, not permitted
to feed himself, bathe, or toto feed himself, bathe, or to
make exertion.make exertion.
Patient is restless, especiallyPatient is restless, especiallywhen dyspneic of laryngealwhen dyspneic of laryngeal
diphtheria, therefore warm, freshdiphtheria, therefore warm, fresh
air must be ensured.air must be ensured.
In severe cases even making bedIn severe cases even making bedis omitted to conserved energy.is omitted to conserved energy.
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Vomiting is exhausting, therefore noVomiting is exhausting, therefore no
procedure that might nauseate theprocedure that might nauseate the
patient should be used.patient should be used.
This means small, frequent feeding,This means small, frequent feeding,
rather than larger ones at longerrather than larger ones at longer
intervals.intervals.
Another important point in rest is toAnother important point in rest is to
prevent straining at defecationprevent straining at defecation
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Care of nose and throatCare of nose and throat
Nose, throat, mouth should be kept clean.Nose, throat, mouth should be kept clean.
Gentle swabbing must be done to preventGentle swabbing must be done to prevent
bleeding.bleeding.
Liquid albolene is soothing to mucousLiquid albolene is soothing to mucousmembrane after cleansing and it preventmembrane after cleansing and it prevent
dryness and excoriation caused by thedryness and excoriation caused by the
discharges from the lesions.discharges from the lesions.
The whole room must be moist atmosphere,The whole room must be moist atmosphere,with humidity carefully regulated, in order towith humidity carefully regulated, in order to
lessen irritability to nose and throat.lessen irritability to nose and throat.
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Ice collarIce collar
Sometimes ice collar is moreSometimes ice collar is more
effective than warmeffective than warm
application in relieving pain ofapplication in relieving pain of
the sore throat.the sore throat. Kept aroud the neck asKept aroud the neck as
intended.intended.
Rubber collar must be placedRubber collar must be placed
in cloth or gauge to protectin cloth or gauge to protect
patient skin and preventpatient skin and prevent
wetting patient clothing.wetting patient clothing.
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DietDiet
When throat is very sore, softWhen throat is very sore, soft
foods.foods.
Small amounts given frequently.Small amounts given frequently.
Fruit juices help to maintainFruit juices help to maintain
alkalinity of blood, citrus mayalkalinity of blood, citrus may
comfort when in sore throat.comfort when in sore throat.
Creamed soups, purees, soft eggs,Creamed soups, purees, soft eggs,
jellies, custards, broth andjellies, custards, broth and
buttermilk should provide abuttermilk should provide a
balanced ration if a sufficientbalanced ration if a sufficient
amount can be swallowed.amount can be swallowed.
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complicationcomplication
ToxemiaToxemia
NeuritisNeuritis
Difficulty swallowing and breathingDifficulty swallowing and breathingPneumoniaPneumonia
Kidney failureKidney failure
DeathDeath
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ToxemiaToxemia
Due to toxemiaDue to toxemia
a.a. Toxic myocarditis- Myocarditis is inflammation of theToxic myocarditis- Myocarditis is inflammation of the
heart muscle that can cause an irregular heartbeatheart muscle that can cause an irregular heartbeat
and lead to heart failure. It often is fatal.and lead to heart failure. It often is fatal.
b.b. Due to action of toxins in the heart muscles.Due to action of toxins in the heart muscles.
c.c. Usually during the first 10-14 days.Usually during the first 10-14 days.d.d. Diminution in intensity of first heart sound.Diminution in intensity of first heart sound.
e.e. ArrhythmiaArrhythmia
f.f. E.C.G elevation of S-T segment prolongation of P-RE.C.G elevation of S-T segment prolongation of P-R
interval evidence of heart block.interval evidence of heart block.
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Abdominal pain due to enlargement ofAbdominal pain due to enlargement of
the liver caused by cardiac failure, sothe liver caused by cardiac failure, so
called chronic passive congestion.called chronic passive congestion.
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NeuritisNeuritis
Caused by absorption of toxin in the nerves.Caused by absorption of toxin in the nerves.
May appear early o late may affect the:May appear early o late may affect the:
a. Palate (paralysis of soft palate); nasal twanga. Palate (paralysis of soft palate); nasal twang
and regurgitation occurring the 3and regurgitation occurring the 3rdrd
week na lastweek na last1-2 weeks.1-2 weeks.
b. Extra ocular muscles (ocular palsy) bilateralb. Extra ocular muscles (ocular palsy) bilateral
paralysis of ocular muscles of accommodationparalysis of ocular muscles of accommodation
causing blurring of vision during 5causing blurring of vision during 5thth week,week,strabismus.strabismus.
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c. Diaphragm (paralysis) occurs 6c. Diaphragm (paralysis) occurs 6 thth-10-10thth week;week;
simulating guillain-barresimulating guillain-barre
d. Motor and skeletal muscle (motor and sensoryd. Motor and skeletal muscle (motor and sensory
paralysis)) respiratory difficulty limb or trunkparalysis)) respiratory difficulty limb or trunkweakness.weakness.
e. Toxic nephritis with albuminuria, cast ane. Toxic nephritis with albuminuria, cast an
edema may also occuredema may also occur
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Difficulty swallowing andDifficulty swallowing and
breathingbreathing
Soft-palate paralysis prevents normalSoft-palate paralysis prevents normal
swallowing and can lead to choking orswallowing and can lead to choking or
aspiration of food into the lungs, causingaspiration of food into the lungs, causing
aspiration pneumonia.aspiration pneumonia.
Paralysis of the diaphragm can lead to difficultyParalysis of the diaphragm can lead to difficulty
breathing, pneumonia, and even respiratorybreathing, pneumonia, and even respiratory
failure and death. In addition, the membrane atfailure and death. In addition, the membrane at
the back of the throat or in the voice box canthe back of the throat or in the voice box canpartially or completely block the airway,partially or completely block the airway,
resulting in suffocation.resulting in suffocation.
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PneumoniaPneumonia
Pneumonia can result from thePneumonia can result from the
infection itself, or it can be secondaryinfection itself, or it can be secondary
to the swallowing and breathingto the swallowing and breathing
difficultiesdifficulties
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Kidney failureKidney failure
The toxin produced byThe toxin produced by
Corynebacteruim diphtheriae canCorynebacteruim diphtheriae can
cause kidney failure directly, or kidneycause kidney failure directly, or kidney
failure can develop secondarily as afailure can develop secondarily as acomplication of heart failure.complication of heart failure.
h
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DeathDeath
The mortality rate is about 5 to 10The mortality rate is about 5 to 10
percent, although it can climb as highpercent, although it can climb as high
as 20 percent in children under theas 20 percent in children under the
age of five years. In recent years, theage of five years. In recent years, themortality rate in diphtheria epidemicsmortality rate in diphtheria epidemics
in the independent states of thein the independent states of the
former Soviet Union has ranged from 3former Soviet Union has ranged from 3to 23 percent.to 23 percent.
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Types of diphtheria(2)Types of diphtheria(2)
Respiratory diphtheriaRespiratory diphtheria
Non respiratory diphtheriaNon respiratory diphtheria
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Respiratory diphtheriaRespiratory diphtheria
Faucial and pharyngeal (tonsilar, uvular,Faucial and pharyngeal (tonsilar, uvular,
palatar).palatar).
Low grade fever, malaise, H/A, sore throat.Low grade fever, malaise, H/A, sore throat.
w/in 24 hours, small yellowish spot appear inw/in 24 hours, small yellowish spot appear in
tonsils w/c coalesce to form the adherenttonsils w/c coalesce to form the adherentpseudomembrane, w/c extends to the rest ofpseudomembrane, w/c extends to the rest of
fauces and nasopharynx.fauces and nasopharynx.
Cervical nodes enlargedCervical nodes enlarged
Dysphagia and noisy breathing with nasalDysphagia and noisy breathing with nasal
voice, regurgitation of fluids due to palatalvoice, regurgitation of fluids due to palatal
weaknessweakness
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Very toxic infection, the bullneck appearance Very toxic infection, the bullneck appearance
due to massive enlargement of lymph glands.due to massive enlargement of lymph glands.
Death may occur due to bronchopneumonia orDeath may occur due to bronchopneumonia or
toxic myocarditis.toxic myocarditis.
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Laryngotracheal diphtheria (tracheal, bronchial)Laryngotracheal diphtheria (tracheal, bronchial)
More commonly in infantsMore commonly in infants
Hoarseness with barking cough and noisy breathingHoarseness with barking cough and noisy breathing
(croupy cough, braze-metallic cough)(croupy cough, braze-metallic cough)
Inspiratory stridor, aphonia, dyspnea withInspiratory stridor, aphonia, dyspnea with
subclavicular and suprasternal retractions.subclavicular and suprasternal retractions.
In severe cases with progressive obstruction leadsIn severe cases with progressive obstruction leads
to suffocation, cyanosis, cardiac failure and death.to suffocation, cyanosis, cardiac failure and death.
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Nasal (anterior, posterior)Nasal (anterior, posterior)
Occurs mostly at 1Occurs mostly at 1stst three years of life.three years of life.
Persistent serous nasal discharged laterPersistent serous nasal discharged later
become bloody and foul smelling.become bloody and foul smelling. Discharges: serous serosanguinous Discharges: serous serosanguinous
mucopurulent (excoriating anterior nares andmucopurulent (excoriating anterior nares and
upper lips) impetiginous appearance. (Lateralupper lips) impetiginous appearance. (Lateral
or bilateral.)or bilateral.)
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Non respiratory diphtheriaNon respiratory diphtheria
Ocular (conjucntival)Ocular (conjucntival)reddenedreddened
Ears (aural) purulentEars (aural) purulentdischargeddischarged
Wound and ulcer in theWound and ulcer in theskinskin
Genito urinary tract Genito urinary tract external genitalis,external genitalis,ulcerative lesions onulcerative lesions onvulva and vagina.vulva and vagina.
Umbilical of the newborn.Umbilical of the newborn.
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EpidemiologyEpidemiology
IncidenceIncidence
December to February higher prevalenceDecember to February higher prevalence
occurring at cooler months.occurring at cooler months.
Mainly disease of childhood, peak incidenceMainly disease of childhood, peak incidencebetween 2 to 5 years.between 2 to 5 years.
Rare below 6 months due to transplacentalRare below 6 months due to transplacental
transmission of immunity acquired fromtransmission of immunity acquired from
mother who presumably developed activemother who presumably developed active
immunity from inapparent infection.immunity from inapparent infection.
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PrognosisPrognosis
The prognosis depends on the size andThe prognosis depends on the size and
location of the membrane and on earlylocation of the membrane and on early
treatment with antitoxin; the longertreatment with antitoxin; the longer
the delay, the higher the death rate.the delay, the higher the death rate.The most vulnerable patients areThe most vulnerable patients are
children under age 15 and those whochildren under age 15 and those who
develop pneumonia or myocarditis.develop pneumonia or myocarditis.Nasal and cutaneous diphtheria areNasal and cutaneous diphtheria are
rarely fatal.rarely fatal.
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ReferencesReferences
www.wikipedia.comwww.wikipedia.com
www.google.comwww.google.com
compilation of communicable disease incompilation of communicable disease innursing book.nursing book.
http://www.wikipedia.com/http://www.wikipedia.com/http://www.google.com/http://www.google.com/http://www.google.com/http://www.wikipedia.com/ -
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ThanksThanks