Diphtheria is a severe infectious disease caused by the diphtheria bacillus. Clinically, it is characterized by the appearance of gray-white pseudomembranes in the throat, tonsils, and other local areas, accompanied by systemic toxic symptoms. It spreads through droplets and contaminated utensils or milk, with a higher incidence rate among children aged 1 to 7. After widespread vaccination with the "DPT" (diphtheria, pertussis, tetanus) vaccine, this disease has been essentially eradicated in China.

bubble_chart Clinical Manifestations

The incubation period is 1 to 10 days.

1. Systemic symptoms: The onset is relatively slow, with fever mostly around 38°C, accompanied by symptoms such as loss of appetite, fatigue, lack of strength, listlessness, and dysphoria.
2. Based on the affected area, it can be classified as:
   1. Pharyngeal diphtheria: Gray pseudomembranes can be seen on the pharynx and tonsils, tightly adhered to the mucous membrane and difficult to wipe off. Attempting to scrape them with a tongue depressor may cause bleeding. In severe cases, the pseudomembranes extend beyond the tonsils, develop rapidly, and become thick, with foul breath. Swelling of the neck and submandibular lymph nodes is present, with significant edema in surrounding tissues, leading to a "bull neck" appearance. Systemic toxic symptoms are severe and may complicate into myocarditis, cardiogenic shock, or circulatory failure.
   2. Laryngeal diphtheria: Often develops from pharyngeal diphtheria. Symptoms include hoarseness, a barking cough, and progressive inspiratory dyspnea, commonly seen in children aged 1 to 3. Primary laryngeal diphtheria requires laryngoscopy to detect pseudomembranes. The pseudomembranes may spread to the trachea and bronchi, worsening respiratory distress and potentially leading to fatal suffocation.
   3. Nasal diphtheria: Mostly seen in infants and young children, presenting as persistent stuffy nose with serosanguineous discharge and mild systemic symptoms.
   4. Diphtheria in other areas: Such as the conjunctiva, skin, female external genitalia, ears, anterior oral cavity, and neonatal umbilical cord, often forms persistent pseudomembranous ulcers.

bubble_chart Auxiliary Examination

1. Direct smear of nasopharyngeal swab: After direct smearing, specific staining is used to identify diphtheria bacilli for early diagnosis.
2. Potassium tellurite test: Apply 2% potassium tellurite glycerol to the pseudomembrane. If the pseudomembrane turns black within 10–20 minutes, the result is positive.
3. Bacterial culture is performed using the swab smear.
4. Total white blood cell count and neutrophil levels are elevated.
5. Routine urine tests may reveal varying degrees of proteinuria.

bubble_chart Diagnosis

History of epidemiology, vaccination, and exposure.

bubble_chart Treatment Measures

1. Diphtheria Antitoxin: Should be administered in sufficient doses as early as possible to neutralize free toxins in local tissues and blood. Toxins already bound to tissues are ineffective, and highly suspected cases should also be treated as diphtheria. For mild cases in children, 20,000–40,000 units intramuscularly; for severe cases, 60,000–80,000 units intramuscularly. For pharyngeal diphtheria with severe toxic symptoms, 100,000 units intramuscularly. For severe cases treated late, half the dose (50,000 units) is administered by slow intravenous drip at 50–300 units/minute, with the remaining half given intramuscularly. A skin test must be performed before administration. For those with a positive skin test, desensitization therapy should be used, starting with a 1/10 dilution: the first injection is 0.2 ml, and if no reaction occurs after 20 minutes, double the dose is injected once. If no reaction occurs after three or more injections, the full dose is administered intramuscularly.
2. Antibiotics: Penicillin is the first choice, effective against all types of diphtheria, with a dose of 800,000–1,600,000 units/day intramuscularly for 7–10 days. For those allergic to penicillin, erythromycin 40–50 mg/kg/day can be used, divided into four oral doses, with the same treatment duration. Antibiotic therapy should continue until three consecutive diphtheria cultures are negative.
3. Treatment of Complications: For myocarditis, manage as myocarditis; for severe laryngeal obstruction, perform a tracheotomy early to remove the pseudomembrane and prevent asphyxia. Corticosteroids may be used appropriately. For pseudomembranes that are difficult to remove, trypsin or chymotrypsin can be instilled to dissolve the pseudomembrane.
4. General Treatment: Provide a high-calorie liquid or semi-liquid diet. If soft palate or pharyngeal paralysis occurs, nasogastric feeding and intravenous fluids should be given to maintain water and electrolyte balance. Administer large doses of vitamin B1 and B12. For cases with intercostal muscle
5. and diaphragmatic paralysis, promptly use a mechanical ventilator. Bed rest for 2–6 weeks, depending on the severity of the condition. Strengthen nursing care to avoid complications such as pneumonia.

AD

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bubble_chart Prevention

1. Isolate the affected child until two consecutive diphtheria cultures are negative. Contacts should be isolated for 7 days, with throat cultures taken every other day and monitored for changes.
2. Administer the DPT (diphtheria, pertussis, tetanus) triple vaccine as part of planned immunization.

bubble_chart Differentiation

1. Suppurative tonsillitis: Sudden onset, high fever, obvious sore throat and red, swollen tonsils with yellowish-white purulent exudate that can be easily wiped away without bleeding, and no systemic toxic symptoms.
2. Thrush: More common in small infants, weak children, and those who have been on long-term broad-spectrum antibiotics. Lesions are mostly on the buccal mucosa, inner lips, and may extend to the pharynx and uvula. They appear as fine white membranes resembling bean curd residue floating on the surface, easily wiped away without bleeding. Smears reveal hyphae and spores of Candida albicans.
3. Acute laryngitis: Subglottic edema, sudden onset, barking cough, with or without fever, progressive dyspnea but less severe than diphtheria, no pseudomembrane in the throat, and rapid response to antibiotics plus steroids.
4. Nasopharyngeal and tracheal foreign bodies: A history of foreign body ingestion can usually be obtained. There should be no bloody nasal discharge. Direct smear method can aid in diagnosis. Tracheal foreign bodies cause irritative cough and inspiratory dyspnea, with X-rays assisting in diagnosis.