An infectious disease that can be fatal: symptoms indicating diphtheria in children. Development of diphtheria in children

Diphtheria is one of the dangerous infectious diseases that arise in childhood. The inflammatory process develops mainly in the oropharynx, less commonly in the larynx, trachea and bronchi. Less typical locations: eyes, genitals and skin. The infectious agent produces a powerful toxin that can cause severe complications, including death. Therefore, it is very important for parents to know how the symptoms of diphtheria manifest in children and what ways to prevent it.

The disease is caused by a gram-positive corynebacterium (Corynebacterium diphtheriae). Since its discovery by Leffler in 1883, scientists have studied its properties and main characteristics quite well:

• diphtheria bacillus is stable in the external environment;
• it tolerates drying well;
• on the surface of furniture is viable for up to two months;
• When exposed to chlorine, it dies only after 10 minutes.

Subsequently, it turned out that the bacterium is more sensitive to the effects of alcohol - it is inactivated within a minute, and treatment with hydrogen peroxide kills it within three minutes.

The main feature of the diphtheria bacillus, which determines its pathogenicity, is the ability to produce a strong toxin. Experts classify this substance with a protein structure as a poison of bacterial etiology (origin); its potency can be compared to toxins produced during infection with tetanus or botulism. Diphtheria exotoxin is most dangerous for the heart muscle, adrenal glands, and nervous system.

Circumstances of infection

You can become infected with diphtheria from a sick person or a carrier of the infection. Bacteria are released into the external environment already in the last day of the incubation period, and most actively during the period of manifestations of the disease. Also, the possibility of contracting diphtheria from a patient during the period of recovery (convalescence) cannot be ruled out. In the latter case, the pathogen can be released within two to three months.

For children preschool age People who are healthy carriers of the infection are especially dangerous. According to some data, their number can reach 29% of the entire healthy population.

How is the bacterium transmitted?

The infection is transmitted:

• mainly through the air along with droplets released when coughing or sneezing;
• Another route of transmission is through contact through contaminated hands.

In the latter case, a disease may occur with localization of the main focus:

• on the skin;
• on the genitals;
• in the eye area.

Cases have been reported in which infection occurred through consumption of foods containing live diphtheria pathogens. The most common way this happened was through raw milk or confectionery.

Immunity

The degree of susceptibility to this infection depends, first of all, on the state of immunity and the presence of protective antibodies.

• Newborns and infants. Up to six months of age, they have antibodies that are transmitted to them in utero and protect against diphtheria.
• At an older age. To create immunity, preventive vaccination is required. Vaccinated children develop stable antitoxic immunity.
• People who have had diphtheria. For a certain period of time, they retain immune protection against diphtheria, which, however, does not exclude the recurrence of the disease.

How the disease develops

When diphtheria bacillus gets on the mucous membrane of the upper respiratory tract or skin, an inflammatory process develops, which has certain characteristics. The following specific step-by-step tissue reaction occurs:

• at the site of local inflammation, vascular permeability increases;
• an effusion (fluid accumulation) containing the protein fibrinogen forms;
• corynebacterium destroys epithelial cells;
• fibrinogen is converted into the insoluble protein fibrin;
• A dense film forms at the site of inflammation.

Therefore, a characteristic symptom of diphtheria is the appearance of dense fibrin films on inflamed mucous membranes. Such films formed on the tonsils are usually tightly fused to the underlying tissues and, when they are attempted to be peeled off, cause bleeding. When located in the trachea and bronchi, on the contrary, the film peels off easily. And when separated, it can cause obstruction (blockage) of the airways.

Dangerous exotoxin

The main pathogenic effect of diphtheria infection is associated with the release of exotoxin. Once in the systemic bloodstream, it quickly spreads throughout the body and penetrates various organs and tissues.

On cellular level The action of diphtheria exotoxin occurs in two stages.

1. Reversible stage.
2. Toxin molecules can still be destroyed by antitoxic antibodies circulating in the body of a vaccinated or recovered child. Irreversible stage.

During this period, the toxin exerts its damaging effect on organs and tissues.

• The following changes occur under the influence of diphtheria toxin:
• in all cells there is a disturbance in energy processes and the synthesis of protein structures; in the nervous system
• - exotoxin has a damaging effect on the myelin sheath; in the heart muscle
• - swelling and disruption of microcirculation occurs; in the kidneys - observed dystrophic changes

in the tubules; in severe cases, necrosis may develop in certain areas of the adrenal glands.

Variants of the course of the disease After the infectious agent enters the mucous membrane and until the first appearance clinical signs

some time passes. This is the so-called incubation period. In the case of diphtheria, it lasts from two to ten days.

Signs of diphtheria in children depend, first of all, on the localization of the process, the state of immunity, and the presence of concomitant diseases. By clinical course

• The following variants of the disease are distinguished:
• localized (having a relatively mild course);
• widespread (moderate course);

toxic (characterized by a severe course with complications).

Depending on the primary localization of the infection, diphtheria croup, diphtheria of the oropharynx, skin, nose, conjunctiva, and external genitalia are distinguished.

Oropharyngeal diphtheria

• This is the most common variant of the disease. It is diagnosed in almost 90% of children with diphtheria. The localized form of damage to the oropharynx, which occurs in more than 50% of patients, is characterized by the presence of the following symptoms:
• elevated temperature for two to three days;
• moderate intoxication syndrome (weakness, weakness, headache);
• inflammatory phenomena in the pharynx (swelling of the tonsils, redness of the pharynx);
• a specific gray film on the tonsils;

a slight increase in the size of nearby nodes.

Localized diphtheria in a baby has a favorable course without complications. First, the temperature normalizes and the sore throat goes away. Fibrin films usually last for a week.

Severe cases

A more severe course is observed with widespread and toxic variants of the disease. In the "common case":

• signs of intoxication are more pronounced;
• characterized by prolonged high temperature;
• plaques are detected both on the tonsils and beyond.

The toxic variant of diphtheria is especially difficult. Depending on the severity of clinical symptoms, it can have three degrees. It is characterized by:

• sudden onset;
• a sharp rise in temperature up to 40 °C;
• signs of damage to the nervous system (convulsions, impaired consciousness, psychomotor agitation);
• disorder of the heart and blood vessels.

With the toxic variant of diphtheria bacillus damage, signs of local inflammation with plaque persist much longer, up to two weeks. A specific sign of the toxic type of diphtheria is swelling of the subcutaneous fat in the cervical region.

The swelling is painless, can spread to the collarbone, and in advanced cases goes even lower. Often toxic diphtheria is complicated by myocarditis on the fifth or sixth day of illness.

A very severe variant of diphtheria is the hemorrhagic form. It is characterized by the occurrence of bleeding on the fourth or fifth day of the disease. If not treated promptly, this pathology can cause death.

Diphtheria croup

This variant of diphtheria is characterized by the spread of the inflammatory process to the larynx, trachea, and sometimes the bronchi. The disease is accompanied by fever and moderate manifestations of intoxication. At the same time, pathological changes in the nasal cavity and oropharynx can be detected.

The diphtheria croup clinic includes three stages.

• Dysphonic. Lasts up to three days. The child's voice becomes hoarse and worries barking cough.
• Stenotic.
• Duration from several hours to two to three days. Due to swelling of the larynx, the voice almost completely disappears, breathing is difficult, there is retraction of the intercostal spaces, “graying” of the skin, and rapid heartbeat. Asphyxial. Characterized by shallow breathing, pronounced bluishness of the skin, a sharp decrease in

The danger of diphtheria croup lies in the occurrence of an obstruction to the flow of air through the respiratory tract with the development of respiratory failure and even death. Therefore, it is so important to know how laryngeal diphtheria manifests itself in children and to immediately seek medical help at the first signs.

Nasal diphtheria

Most often, this variant of the disease is combined with simultaneous damage to the oropharynx. Characterized by a rise in temperature and minor signs of intoxication. In addition, the following symptoms are observed with nasal diphtheria:

• breathing problems through the nose;
• mucous discharge with bloody impurities;
• characteristic grayish deposits on the nasal mucosa;
• irritation of the skin and crust around the nose.

Other localizations of diphtheria

Relatively rarely diagnosed:

• eye damage,
• skin;
• genitals.

When the process is localized on the conjunctiva, you can notice its redness, filmy deposits, and swelling of the eyelids. In severe cases, bloody or purulent discharge appears, and signs of intoxication increase. Swelling of the subcutaneous fat in the facial area may also occur.

Skin lesions occur when the diphtheria bacillus gets into areas of wounds, erosions, and diaper rash. With this pathology, swelling of adjacent tissues and the presence of a grayish coating in the area of ​​inflammation are detected.

Diphtheria of the external genitalia occurs in boys on the foreskin, in girls - on the labia and at the entrance to the vagina. Symptoms:

• swelling with a characteristic coating;
• painful urination;
• serous discharge with bloody impurities.

Complications

Mainly, complications of diphtheria are caused by the damaging effects of exotoxin on organs and tissues. The most commonly diagnosed consequences of diphtheria:

• myocarditis;
• adrenal insufficiency;
• polyradiculoneuritis (peripheral paresis, paralysis);
• diphtheria hepatitis (liver damage).

Complications caused by the addition of a secondary bacterial infection - pneumonia, inflammation of the middle ear (otitis) - can also develop. Particularly dangerous complications of the disease include infectious-toxic shock and bleeding disorders.

Diagnostics

To make a correct diagnosis it is often enough correct assessment existing clinical symptoms. However, it is necessary, especially with erased and atypical variants of the disease, to carry out a number of additional laboratory research:

• general clinical blood test;
• swab from the throat and nose to identify Loeffler's bacillus;
• polymerase chain reaction;
• detection of antitoxic antibodies.

The main diagnostic method is to take biomaterial from the oropharynx and then inoculate it on a special nutrient medium. This method is most often used to diagnose diphtheria.

How is diphtheria treated in children?

The main thing in the treatment of diphtheria of any localization is the timely administration of antitoxic anti-diphtheria serum to the sick child. According to clinical guidelines, the drug is prescribed in the first four days of the disease. It is usually administered once, and if necessary, a repeat dose is prescribed every other day. The amount of serum is calculated depending on the form of the disease.

Table - Doses of antitoxic antidiphtheria serum required

Form of the disease	Serum dosage
Localized variant of diphtheria	10-20 thousand IU
Laryngeal lesion	40-50 thousand IU
Subtoxic form	40-50 thousand IU
Toxic forms	50-80 thousand IU
Hemorrhagic form	100-120 thousand IU

Side effects of anti-diphtheria serum include the occurrence of allergic reactions of varying severity.

Treatment of diphtheria in children also includes:

• carrying out antibiotic therapy;
• drinking and prescribing IVs with salt solutions;
• correction acid-base balance blood.

Severe forms require the administration of glucocorticoids (dexamethasone, prednisolone).
Quality child care and nutrition rich in protein and vitamins are also important. Recommended strict adherence bed rest.

Prevention

To date, an effective method of preventing this disease in children has been developed - the administration of diphtheria toxoid, which causes the formation of appropriate antibodies in the body. For children, complex vaccinations are used that protect not only against diphtheria, but also against other infections.

DPT vaccine

To build immunity in young children, the DPT vaccine (whooping cough, diphtheria, tetanus) is used. Children under one year old are vaccinated against diphtheria at the age of three months, then at four to five months, and at six months.

When the child reaches the age of 18 months, the first revaccination is given. Subsequently, the ADS-M vaccine is used for revaccination; it is given at six to seven and at 14 years of age. For adults, booster vaccinations against diphtheria are given every ten years since the last booster dose.

In some cases, the timing of revaccination may be delayed. Thus, vaccination is postponed if the child has recently had an acute respiratory disease or has severe allergic reactions for drug administration. In any case, you should consult your pediatrician about the need to change the timing or cancel vaccination.

Vaccination

Technique of prof. DPT vaccination consists of intramuscular administration in an amount of 0.5 ml. For infants, the drug is injected into the area of ​​the quadriceps femoris muscle, and at older ages - into the deltoid muscle. Where to give the vaccine and how to administer it correctly is regulated by the nursing process developed by the Ministry of Health for medical institutions.

Vaccination tolerance

As a rule, most children tolerate the introduction of a complex vaccine well. Sometimes there is a reaction to the vaccine - a slight rise in temperature within a day or two. This is a normal reaction that goes away on its own. If the child is restless and does not tolerate fever well, an antipyretic (paracetamol) can be given.

Sometimes after a diphtheria vaccine, a child's leg hurts or there is slight redness at the injection site. Such phenomena usually disappear within a few days without any treatment.

Whether the child needs vaccination, as well as all questions about contraindications or side effects, should be resolved individually with the pediatrician observing the child.
Modern prevention methods have made it possible to protect the majority of children from the possibility of contracting diphtheria.

However, in last years The percentage of children who have not been vaccinated is steadily growing. As a result, cases of severe forms of diphtheria with complications in unvaccinated children are increasingly being recorded.

Parents should remember that diphtheria in a child is a dangerous disease that causes a number of serious complications. Therefore, you should not avoid vaccination, justifying your refusal with negative reviews on the Internet.

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Diphtheria- an acute infectious disease caused by Loeffler's bacteria. It is characterized by local fibrinous inflammation mainly of the mucous membranes and symptoms of general intoxication.

History of diphtheria

Diphtheria has been known since ancient times; mentions of it are found in Hippocrates and Homer. The first clinical descriptions under the name “deadly pharyngeal ulcer”, “Syrian and Egyptian ulcer” date back to the 1st-2nd centuries AD. e. Classic description of anatomical changes and clinical forms was done in early XIX century by the French scientist Bretonneau, who proposed the name “diphtheria” (from the Greek diphthera - film, membrane). At the end of the 19th century, Trousseau replaced the anatomical term “diphtheria” with the word “diphtheria”. Since then this name has become generally accepted.
The history of diphtheria can be divided into 3 periods, the boundaries between which are determined by important discoveries that influenced this disease. The first period, which began in ancient times, was characterized by high morbidity, extreme severity, high mortality, reaching 50-60% during epidemics, and high mortality among children. It continued until the end of the last century. The second period began with the discovery of the causative agent of the disease by Klebs in 1883 and Loffler in 1884 and subsequently the production of anti-diphtheria antitoxic serum (Behring - in Germany, Roux - in France, Y. Yu. Bardakh - in Russia). It was characterized by a significant reduction in mortality and mortality among children from diphtheria. The incidence rate continued to remain high and showed the same high rises as before as the severity of the disease increased. The second period lasted until 1923, when Ramon proposed toxoid and active immunization against diphtheria began. The third and final period in the history of diphtheria continues to this day, it is characterized by active immunization throughout the world and a decrease or complete elimination of the incidence in a number of countries.
Among domestic scientists, K. A. Rauchfus, V. I. Molchanov, A. I. Skvortsov, P. F. Zdrodovsky, S. N. Rozanov, S. D. Nosov, M. E. Sukhareva, paid much attention to the study of diphtheria. M.G.
Danilevich, N.I. Nisevich, K.V. Blumenthal, V.A. Khrushchova and many others.

Etiology of diphtheria in children

The causative agent of diphtheria is Loeffler's bacillus (Coryne bacterium diphteriae). The rods are motionless, do not form spores, have inclusions at the ends and in strokes are located at an angle to each other, forming a Roman numeral V; They dye well using Gram and all aniline dyes. With double staining with Neisser, the body is colored brownish-yellow, and the inclusions at the ends are colored Blue colour.
The best media for growth are Loeffler's medium - clotted blood serum and blood agar. For in-depth diagnostics, the same media are used with the addition of tellurium salts (Clauberg's medium).
The main properties of the diphtheria bacillus are great variability depending on living conditions and fairly high stability in the external environment. The rod can change morphologically; its ability to produce toxins may increase or decrease (up to total loss), change in virulence and antigenic structure. The bacillus can withstand temperatures below 0°C well. It persists for quite a long time when dried. If it is protected by mucus or film, then, once dry, it can remain viable and toxigenic for several months. A culture sprayed in the form of tiny drops can remain in the air for 1-2 days, even in sunlight it dies only after a few hours. In disinfectant solutions it dies quite quickly - from up to 10 s. When boiled, it dies immediately.
During the process of reproduction, the diphtheria bacillus releases an exotoxin; it belongs to the so-called true bacterial toxins and is very poisonous to humans.
Anatoxin- this is a toxin that has lost its toxic properties and retained its antigenic properties; it is harmless, but when administered subcutaneously or intramuscularly, the body produces an antitoxin.

Epidemiology of diphtheria in children

The source of infection for diphtheria is only humans- sick or a bacteria carrier.
The patient becomes infectious on the last day of incubation; the end of the infectious period is determined not by calendar dates, but by bacterial purification, which can only be detected in the laboratory. On average, in 75% of cases, cleansing ends by the 20-25th day of illness. It is extremely rare that convalescent bacteria carry the bacteria for many months. It is promoted by various pathological conditions of the pharynx and nose.
Bacteria carrier has great, and in many cases major, epidemiological significance; in the past, the number of healthy carriers many times exceeded the number of patients. In large cities, carriage reached 1-6-10%, in the environment of the patient - 20-50%.
Recently, in parallel with the decrease in the incidence of diphtheria, there has been a decrease in the frequency of carriage of toxigenic strains; atoxigenic strains do not play a role in the incidence.
Transmission routes. The diphtheria bacillus is released from a patient or carrier with droplets of saliva or nasal mucus, so the main route of transmission is airborne droplets. In droplets of mucus and tiny particles of film, the diphtheria bacillus can remain viable on linen, toys, books for up to several weeks, sometimes even months, so transmission through objects or third parties is possible. A food route of transmission is possible when food products on which the bacillus can reproduce (milk, cream) are infected, but it is extremely rare.
Susceptibility to diphtheria depends on the presence of antitoxic immunity and its intensity. Before the introduction of active immunization against diphtheria, antitoxic immunity was developed in two ways: after exposure to the disease and as a result of repeated or prolonged bacterial carriage, with the so-called silent, household immunization. Since carriage was widespread, as a result of household immunization, immunity to diphtheria was developed in most children. The susceptibility coefficient to diphtheria was approximately 0.15-0.2, i.e., out of 100 non-sick contacts, 15 - 20 people became ill.
The greatest susceptibility to diphtheria was observed at the age of 7-10 years. Susceptibility to diphtheria can be determined using the Schick test, as well as using serological methods.
The Schick reaction is performed by intradermal injection of 0.2 ml of diphtheria toxin containing 1/40 DLm. In persons who do not have antitoxic immunity, a red spot appears at the injection site after 72 hours and then an infiltrate measuring 1-2 cm. If there is at least 1/3 AE of antitoxin in the blood, the reaction is negative.
Incidence of diphtheria in the past it was high and gave periodic rises every 5-8 years. Epidemic rises lasted 2-4 years, the incidence reached 40-43 per 100,000 population and was accompanied by an increase in the number of toxic forms and an increase in mortality. The incidence increased in winter and sharply decreased in summer, greatest number cases of illness accounted for senior preschool and junior school age. Among older schoolchildren, the incidence fell and among adults it reached isolated cases. After the introduction of universal immunization of children, the proportion of cases of diseases after the age of 15 years increased significantly.
The mortality rate for diphtheria in pre-serum times was very high, reaching 40-50% during epidemics. There was a high mortality rate child population from diphtheria. After the advent of antitoxic serum, a progressive, consistent decline in mortality began. Following the introduction of active immunization, the incidence rate began to decline rapidly, and diphtheria almost ceased to play a role in the mortality of the child population.

Pathogenesis and pathological anatomy of diphtheria in children

Depending on the specific immunity, the massiveness of the infectious dose, the toxicogenicity of the pathogen, nonspecific reactivity and, probably, other reasons, infection with diphtheria bacilli leads to the emergence of various forms of the disease or to bacterial carriage. In the genesis of the development of toxic forms great importance Allergy is given as a violent hyperergic reaction to the pathogen of a sensitized organism. According to some authors, a certain role in the occurrence of severe forms of the disease is played by the association of the diphtheria bacillus with other microorganisms, in particular with the coccal flora, and the spread in the body of not only the toxin, but also the diphtheria bacillus itself. Probably, in the pathogenesis of the formation of different forms of diphtheria, a complex of different reasons is important.
The basis of the diphtheria process is a local inflammatory focus that develops at the site of introduction of the pathogen into the body, and the main pathogenic factor is the toxin. It is secreted by diphtheria bacilli in the local focus of inflammation, spreads through the lymphogenous route to surrounding tissues, and through the hematogenous route throughout the body and causes general intoxication. The local inflammatory focus is most often localized in the pharynx, but it can also be in the nose, larynx, ear, on the mucous membranes of the genital organs, on the skin (wound surface), and possible damage to the eyes.
Changes in the local focus are characterized by fibrinous inflammation. Under the influence of the toxin, coagulation necrosis, dilation and increased porosity of blood vessels occur on the mucous membrane and skin. sweating of exudate containing fibrinogen. Under the influence of thrombokinase, released during cell necrosis, fibrinogen coagulates and the formation of a fibrinous film occurs.
Based on anatomical changes, fibrinous inflammation is usually divided into lobar and diphtheritic. The first is characterized by a more superficial lesion of the mucous membrane or is due to a weaker connection of the affected epithelium with the submucosa: for example, in the trachea the film is easily separated from the underlying tissues. With diphtheritic inflammation, the lesion is deeper, fibrinous effusion penetrates into the underlying tissues, the film is tightly connected to them. In the surrounding tissues, swelling of the mucous and submucosal membranes, as well as fiber and muscles, develops. In the regional lymph nodes, fibrinous inflammation, plethora and edema appear, which can spread to the fiber and reach significant sizes. In the most severe forms, hemorrhages are observed in the local focus, in the lymph nodes; they may also have other localizations.
General intoxication is characterized by selective damage to the nervous, cardiovascular systems, adrenal glands and kidneys. Changes in the central nervous system are usually minor; In the first days of the disease with a toxic form of diphtheria, with fatal outcomes, swelling of the brain, plethora, and foci of perivascular edema are determined. Changes in the sympathetic ganglia and ganglia of the cranial nerves with vascular disorders and degeneration are common; they develop somewhat later, from the 6-7th day of illness.
Changes in the peripheral nerve trunks are characteristic of the late period of diphtheria; they boil down to the development of toxic neuritis with the development of a periaxonal degenerative process in nerve fibers without damage to nerve cells. Therefore, they are distinguished by a benign course followed by gradual recovery. However, during the course of the disease, severe functional impairments in life may occur. important organs, for example, breathing problems due to paralysis of the respiratory intercostal muscles and diaphragm. In toxic forms, changes are constantly detected in the adrenal glands, both in the cortex and in the medulla. They boil down mainly to circulatory disorders: sharp hyperemia, hemorrhages and destructive changes up to cell necrosis are noted.
For early stage The disease is characterized by the following hemodynamic disorders: accumulation of blood in internal organs, formation of stasis, areas of edema and hemorrhage; in the heart, vascular disorders, necrobiosis of the vascular walls, perivascular edema, and hemorrhages also predominate. Later, from the end of the first - beginning of the second week, myocarditis develops, which is characterized degenerative changes muscle fibers and interstitial tissue. The heart increases in size, becomes flabby, and sometimes wall thrombi form. These blood clots can cause embolisms in the vessels of the brain (with the development of central paralysis).
In toxic forms of diphtheria, toxic nephrosis develops in the kidneys, which reverses as it is detoxified.
In mild forms of diphtheria, intoxication is insignificant and transient, but in toxic forms it can lead to death in the coming days, the cause of which is a complex of changes in which vascular disorders and toxic damage to the adrenal glands predominate. Subsequently, with toxic forms of diphtheria, death can occur from acute interstitial myocarditis, which develops from the end of the first - beginning of the second week with symptoms of acute heart failure, and even later, in the 5th - 6th week, from polyneuritis with dysfunction of vital organs (paralysis of breathing, swallowing).
As a rule, there is a parallelism between the size of the local focus and the degree of general disorders: the larger and deeper the inflammatory focus, the more pronounced the general changes.
Some differences can be noted in the genesis of laryngeal diphtheria. Cartilage tissue, absence loose fiber limit the absorption of the toxin, so toxic forms do not arise, which eliminates the possibility of developing toxic complications. The severity of the condition and deaths are due to other reasons: impaired respiratory function, secondary inflammatory processes in the respiratory organs.
Recovery in the natural course of diphtheria occurs due to the production of antitoxin in the body. In combination with other protective mechanisms, the elimination of intoxication and the development of specific immunity are ensured. In the local focus of fibrinous inflammation, melting and rejection of the film occurs through demarcation inflammation with the formation of superficial ulcerations and subsequent regeneration of the epithelium.
The introduction of anti-diphtheria antitoxic serum to the patient ensures the delivery of the finished antitoxin and thereby faster elimination of the process. However, in severe toxic forms, the toxin manages to contact the tissues and therefore the serum cannot completely prevent the occurrence of subsequent changes in the heart and peripheral nervous system.

Clinic of diphtheria in children

The incubation period for diphtheria lasts from 2 to 10 days; the disease develops acutely.
The clinical manifestations of diphtheria are so diverse that until the 19th century, its individual forms were considered various diseases. Bretonneau combined them into one nosological unit and proposed a classification based on the localization of the process. Subsequently, the classification of diphtheria was developed by A. A. Koltypin, M. G. Danilevich, V. I. Molchanov and others and was based on the localization and degree of spread of the process. There are diphtheria of the pharynx, larynx, nose and forms of rare localization (diphtheria of the ear, eye, oral mucosa, skin and genital organs). In addition, isolated forms are distinguished - with localization of the process in one organ and combined - with damage to 2 or 3 organs at the same time, for example, diphtheria of the pharynx, nose and larynx; pharynx and eyes; nose and genitals, etc.

Diphtheria pharynx

Diphtheria of the pharynx is the most common form. Before the introduction of active immunization, it was 40-70%, subsequently - 90-95%. There are toxic and non-toxic forms of diphtheria of the pharynx.
The criterion for differentiation is swelling in the area of ​​regional lymph nodes: its presence indicates toxic forms. In non-toxic forms, localized and widespread forms are distinguished.
Localized form diphtheria is observed most often, is characterized by the location of the local process within the tonsils and with timely treatment proceeds favorably, without significant complications. Based on the severity of local changes, tonsillar, island and catarrhal forms are distinguished. The disease begins with a disturbance in well-being; moderate increase in body temperature, usually not higher than 38°C. although sometimes in the first 1-2 days it can be greater: slight pain when swallowing, moderate hyperemia of the tonsils and plaques appear on them. At first they are tender, thin, and in the next 1-2 days they take the form of a film with a smooth surface and fairly well-defined edges, protruding above the surface of the tonsils. Plaques are difficult to remove. In the tansillar form, they can cover the entire or significant part of the surface of the tonsils; in the insular form, they look like plaques or small islands. There is a slight increase in the upper cervical lymph nodes with slight pain on palpation.
In the catarrhal form, there are no plaques, the temperature is low, and there are no symptoms of intoxication. A number of clinicians question its existence; the diagnosis is established only with bacteriological confirmation.
In localized forms, one day after the administration of anti-diphtheria serum, the patient’s well-being improves, body temperature decreases, plaque becomes looser, decreases in size, and after 1-2 days the pharynx clears. Without serum treatment, the process can progress, the plaque increases, the localized form can turn into a widespread one, and then into a toxic one.
Common form diphtheria of the pharynx is characterized by the location of plaque not only on the tonsils, but also beyond them (on the arches, on the uvula). Symptoms of intoxication are usually more pronounced than with localized forms, and complications occur more often. This form is observed relatively rarely, since with such extensive fibrinous deposits, changes characteristic of toxic forms usually occur, i.e. swelling not only in the pharynx, but also in the area of ​​regional lymph nodes.
Toxic diphtheria of the throat may develop gradually from a localized form if the diagnosis of diphtheria is not established and anti-diphtheria serum is not administered. However, it usually begins violently: the body temperature immediately rises to high levels, there may be vomiting, often abdominal pain, headache, weakness, lethargy, and less often, agitation. Sometimes the symptoms of intoxication can be expressed moderately, the state of health is mildly disturbed, and the body temperature is low. Pain when swallowing is usually mild. Fibrinous plaques are located not only on the tonsils, but also on the arches, on the uvula, often turning into soft and even solid sky. The local process, as a rule, extends to the nasopharynx, resulting in bloody discharge from the nose, difficulty in nasal breathing and, at the same time, a sickly-sweet odor from the mouth. Swelling around the lymph nodes is preceded by swelling of the pharynx; in more severe toxic forms, it interferes with breathing. The patient usually lies with his head thrown back and his mouth open, and “snoring breathing” appears.
The initial degree of edema around enlarged dense regional lymph nodes is determined by the smoothness of the cervical fold, then swelling appears in the area of ​​the lymph nodes - more massive above them and gradually thinning along the periphery, which, in accordance with changes in the pharynx, is often asymmetrical in nature (more on one side than on the other). another).
Swelling of the subcutaneous tissue is loose, painless, without changing skin color. Based on the size of the edema, toxic forms of grade I (swelling around the regional lymph nodes up to the first cervical fold), grade II (extends to the collarbone) and III degree(swelling below the collarbone).
In toxic forms of diphtheria of the pharynx without serum treatment, plaque quickly spreads along the mucous membrane to the hard palate, to the back wall of the pharynx, and into the nasopharynx. Swelling of the cervical tissue also increases. In parallel with the local process, intoxication rapidly increases and death may occur within the next few days. With proper, timely serum treatment, in most cases children recover, but improvement occurs slowly. First, the temperature drops, after 2-3 days the symptoms of intoxication soften, and the reverse development of the local process begins; swelling of the pharynx and subcutaneous tissue of the neck gradually decreases. The deposits seem to gradually melt, sometimes being torn off in layers, leaving an eroded surface. After 7-8 days, the local process is eliminated, but then toxic complications begin to develop.
In addition to the toxic forms, there is a subtoxic form of diphtheria, which is characterized by an insignificant amount of edema, located, as a rule, on one side only at the regional lymph nodes.
The size of the lymph nodes corresponds to the size of the edema; in severe cases, they can reach a significant size, become dense and moderately painful.
The phenomena of general intoxication increase parallel to the magnitude of the local process. With toxic diphtheria I degree, pallor, lethargy, and vomiting are observed; in toxic forms of degree II and III, pallor is more pronounced, there may be a bluish tint, adynamia, drowsiness are noted, complete failure from food. The pulse becomes soft and frequent, heart sounds become muffled, and blood pressure drops.
The most severe forms are hypertoxic forms: fulminant and hemorrhagic. The main signs of the hemorrhagic form are rapidly progressing intoxication with a parallel increase in local changes in the pharynx and swelling. The latter increases “by the clock”, spreading to the area below the collarbone. Widespread plaques become brown in color (soaked in blood); hemorrhages appear on the skin already in the first days of the disease, first in the injection area, and then spontaneously; Nosebleeds and bleeding gums are often observed.
For lightning fast form diphtheria of the pharynx is characterized by a particularly acute onset and rapid development of general toxicosis, which may outstrip the spread of local changes in the pharynx. The patient quickly develops general adynamia, blackouts, tachycardia, deafness of heart sounds and a sharp drop in blood pressure. Progressive intoxication can lead to death within the next 24 hours from the onset of the disease. Death occurs due to symptoms of vascular insufficiency.

Diphtheria of the larynx

Diphtheria of the larynx, occurring with symptoms of laryngeal stenosis, is called croup. The diphtheria process can sometimes occur immediately in the larynx - the croup is primary, but more often the process is secondary, that is, it begins in the pharynx or nose (sometimes with a very small, almost imperceptible lesion) and quickly spreads to the larynx. Diphtheria of the larynx is characterized by a gradual increase in the main symptoms: a rough barking cough, hoarseness, aphonia, stenosis: the increase in changes occurs in parallel. There are three stages of the disease: catarrhal, stenotic and asphyxic.
Catarrhal stage usually begins with low-grade fever or single rises in temperature up to 38.5 ° C, hoarseness and a rough barking cough. The transition to the stenotic stage occurs mainly after 1-2 days. Stenosis develops due to the appearance of a dense fibrinous film, spasm of the laryngeal muscles and swelling of the mucous membrane.
Signs of stenosis develop gradually; four degrees are distinguished. For 1st degree The appearance of noisy breathing in the inspiratory phase is characteristic. At II degree stenosis, auxiliary muscles are involved in the act of breathing, the voice becomes muffled and then disappears completely (aphonia), when inhaling, retractions of the intercostal spaces and subclavian fossae appear. At first, the child tolerates his condition quite well, continues to be interested in his surroundings, but gradually the condition progressively worsens and develops. III degree stenosis It is characterized by symptoms of oxygen deficiency, hypoxemia, pallor, perioral cyanosis, and increased heart rate. The child becomes restless, sweats (especially the head), and the pulse becomes paradoxical. IV degree stenosis is characterized by the development of tissue hypoxia and especially the cerebral cortex, and most importantly by symptoms of carbon dioxide poisoning. The child seems to calm down, calm down, and even fall asleep under the narcotic influence of carbon dioxide. At this time, death can occur very quickly.
Before the introduction of anti-diphtheria serum, the changes progressed steadily and sharp boundaries between individual degrees of stenosis at the patient’s bedside were often difficult to establish.
According to the prevalence of the process, there are localized cereals (only in the larynx) and widespread ones - laryngotracheitis or laryngotracheobronchitis. The latter is especially difficult. The phenomena of laryngeal stenosis are obscured and come to the fore respiratory failure, pallor, cyanosis, tachycardia. Breathing becomes shallow and frequent, the temperature remains high and the serum does not have such a good effect as with localized diphtheria laryngitis.

Nasal diphtheria

Membranous nasal diphtheria It is more often observed in infants and begins in the same way as the localized form of pharynx diphtheria, with an increase in temperature to low numbers, then difficulty in nasal breathing. Liquid serous, mucous-bloody discharge appears from one, and later from the other, nostril. During rhinoscopy on the mucous membrane of the nasal septum or wings of the nose, it is possible to examine a dense fibrinous film; sometimes its edge is noticeable during normal examination. Complications usually do not occur, but in the absence of timely treatment, the process can spread to the mucous membranes of the pharynx, larynx, etc.
The catarrhal-ulcerative form of nasal diphtheria is observed extremely rarely. Such forms are taken to be pathological processes in the nose of a different etiology, in which favorable conditions are created for the carriage of diphtheria bacilli. They can occur in weakened children with chronic diseases or hypovitaminosis. Local lesions often involve coccal flora, sometimes Frenkel's diplobacillus. Long-lasting mucous, sometimes mucopurulent discharge is observed; there may be an admixture of ichor; the wings of the nose turn red, cracks, excoriations, and crusts appear around the nasal passages.

Forms of rare localization

Diphtheria eye occurs in two clinical forms - lobar and diphtheritic. The lobar form is characterized by the superficial location of a fibrinous film on the conjunctiva. Clinically, it is manifested by the development of significant swelling of the eyelids, the palpebral fissures are narrowed, and there is bleeding. The conjunctiva is mildly hyperemic and covered with a grayish thin filmy coating, which can be removed quite easily. General state almost undisturbed, the temperature may be normal.
The diphtheritic form is characterized by the formation of a dense thick film, closely adhered to the underlying tissue. It is difficult, with high temperature and pronounced swelling of the eyelids, characterized by high density. The skin of the eyelids is hyperemic, cyanotic, and there are dense deposits on the conjunctiva that are difficult to remove, often soaked in blood. The eyeballs are swollen, often also covered with a film passing from the conjunctiva of the eyelids. Despite treatment with serum, the disease may result in panophthalmitis with loss of vision.
Diphtheria of the external genitalia characterized by the appearance of yellowish-grayish fibrinous deposits on the mucous membranes of the labia and vagina; the mucous membrane is slightly hyperemic, but edematous. Plaques with this localization of the process often have a less typical appearance: they are more loose and dirty in color. In patients not treated with serum, plaque may spread, swelling of the subcutaneous tissue of the perineum, and then the groin areas, appears. In this case, general toxemia develops with complications caused by diphtheria toxin. Toxic forms of diphtheria of the genital organs, as well as diphtheria of the pharynx, have three degrees depending on the amount of local edema with the same complications (myocarditis, polyneuritis).
Diphtheria ear usually occurs secondary to diphtheria of the pharynx or nose: the skin is affected ear canal and the tympanic membrane, where a fibrinous film may be found.
Skin diphtheria occurs at the site of wounds, diaper rash or weeping eczema and is manifested by the formation of a dense fibrinous film with swelling of the surrounding tissues. With a large spread of plaque, toxic forms with all the toxic complications can develop. Along with this, there may also be atypical forms with the formation of eczema, blisters, pustules, impetigo; diagnosis is possible only on the basis of bacteriological data.
In anecdotal cases in the past, diphtheria of the mucous membrane of the stomach, esophagus and intestines was described; it arose secondary to large widespread processes in the pharynx and was discovered posthumously.
In recent years, asymptomatic forms of diphtheria have been isolated, which include cases of isolation of toxigenic cultures of diphtheria bacilli without clinical changes; An immunological examination reveals an increase in specific antibodies.

Complications of diphtheria in children

Specific complications occur in toxic forms of diphtheria as a result of exposure to the toxin in the acute stage of the disease during maximum toxemia, although some changes and functional disorders of the affected organs appear later, in different terms after the acute period. The main toxic complications include acute adrenal insufficiency, nephrosis, myocarditis, mononeuritis and polyneuritis.
Acute adrenal insufficiency develops only with very severe toxemia; it is a consequence of extensive damage to the adrenal cortex (toxic form of grade III and hypertoxic forms). The deficiency is reflected in the fact that on the 2-3rd day of illness, severe pallor and adynamia appear, the pulse becomes very frequent, thread-like, blood pressure drops sharply, and with increasing symptoms of collapse, death can occur. Administration of large doses of serum in combination with corticosteroid therapy may help eliminate these conditions in children.
An early complication that occurs even in acute period disease, is also toxic nephrosis, which is manifested by significant albuminuria and cylindruria. Kidney failure however, it does not develop. The course of nephrosis is favorable, all phenomena disappear as the local process is eliminated and the condition of the patients improves. The appearance of nephrosis is not life-threatening, but always indicates severe intoxication, the possibility of developing other toxic complications and requires especially careful attention to the child.
Myocarditis occurs at the end of the 1st - 2nd week of illness. Signs of myocarditis are deterioration in health, increasing pallor, bluish lips, general anxiety, nausea, sometimes vomiting, and abdominal pain. At the same time, expansion of the borders of the heart, an increase in the size of the liver, muffled or dull heart sounds, tachycardia or bradycardia are observed, and rhythm disturbances often and quickly occur (sinus arrhythmia, extrasystole, gallop rhythm). Myocarditis can begin gradually and develop gradually; in such cases it proceeds more favorably. Along with this, particularly severe forms are observed with the rapid development of symptoms in the form of severe pallor, cyanosis, very frequent vomiting, a drop in blood pressure, a rapidly increasing (“clockwise”) increase in the size of the liver and its sharp pain, expansion of the boundaries of the heart and the appearance of a gallop rhythm, which indicates the extreme severity of the process, which can quickly lead to death.
For early and more complete detection of myocarditis in patients with toxic diphtheria, electrocardiography provides significant assistance, which makes it possible to identify this complication in the initial stages, even before the appearance of clinical symptoms.
The reverse development of myocarditis occurs slowly - within 1-2 months, in severe cases it can be longer. In many patients, the changes disappear completely.
Almost simultaneously with myocarditis, symptoms of early paralysis may appear, most often occurring as mononeuritis; usually the cranial nerves (III, VI, VII, IX and X pairs of nerves) are affected. Most often and the earliest, paralysis of the soft palate occurs: nasal sound appears, there is a decrease or disappearance of the mobility of the soft palate (detected when examining the pharynx), choking while eating; paralysis of accommodation, etc. may be recorded. Paralysis itself does not pose a danger to the patient, but indicates changes in the body and is unfavorable with respect to the further prognosis (possibility of polyneuritis).
Polyradiculoneuritis develop after the 3rd week of the disease, more often in the 4-5th week of the disease, according to the type of flaccid paralysis. An early symptom is a decrease in tendon reflexes (primarily on lower limbs), but their complete disappearance is also possible. Paralysis of the muscles of the neck and torso may occur. Changes in the nervous system are reversible. Their danger lies in the occurrence severe violations functions individual organs and systems, especially with paralysis of the swallowing, respiratory muscles and diaphragm; cough becomes silent during inhalation rib cage motionless, and retraction epigastric region absent. Breathing becomes shallow, and pneumonia that occurs can hasten death. Severe myocarditis and polyneuritis are observed more often in hemorrhagic and toxic forms of grade III diphtheria.
In rare cases, central paralysis may occur as a result of embolism. cerebral vessels particles of parietal thrombi formed in the heart during severe myocarditis.
Nonspecific complications caused by secondary infection, in severe forms of diphtheria are very frequent and appear in different periods diseases. These are mainly pneumonia and otitis media. Pneumonia contributes to increased mortality in toxic diphtheria and croup.
Diphtheria diagnosis in children
Clinical diagnosis of diphtheria. Early diagnosis diphtheria is necessary for timely use of serotherapy. Late diagnosis may cause the development of toxic forms and widespread damage to the respiratory tract. Early diagnosis is also necessary to prevent the spread of diphtheria among the population. Excessive diagnosis (overdiagnosis) and the associated serum treatment lead to sensitization that is unfavorable for the patient.
The rate of misdiagnosis for diphtheria is much higher than for other childhood infections. Diagnostic errors are caused by diversity clinical manifestations diphtheria, and on the other hand - insufficient knowledge of doctors.
Despite big variety clinical manifestations of diphtheria, there are a number common features characteristic of this disease.
1. Specific fibrinous inflammation clinically manifested by the presence of a dense, grayish-white film located on the mucous membrane (pharynx, larynx, vulva, eyes, etc.) or on the skin. The film protrudes above the affected surface; the process is often bilateral, but the plaques are predominantly unequal in size.
Difficulty in identifying diphtheria film during examination of the patient can occur with isolated damage to the larynx, nasopharynx or posterior parts of the pharynx, especially if there is swelling in the area of ​​the uvula and tonsils. If the larynx is affected, in these cases they resort to laryngoscopy (direct).
2. Fibrinous inflammation characterized by low severity of other signs of inflammation. Pain in the area of ​​the local process is insignificant and often does not cause complaints. Hyperemia of the surrounding tissues is moderate; in toxic forms, it sometimes acquires a cyanotic tint. Diphtheria is not characterized by purulent inflammation. Sharp pain, pronounced hyperemia, juiciness, looseness of the mucous membranes, especially the tendency to suppuration, indicate against diphtheria or indicate a mixed form of the disease. The enlargement of regional lymph nodes occurs parallel to the prevalence of the local process. Changes in the area of ​​the lymph nodes are also characterized by the absence of other signs of inflammation; they are dense to the touch, moderately painful, there is no skin hyperemia.
3. Temperature, as a rule, does not reach high numbers, often not higher than 37.5-38.5°C. In toxic forms, it can rise to 39°C and higher, but usually it stays at these numbers for only a few days and; decreases to normal long before local changes are eliminated. High temperature for a long time indicates either a mixed infection, or speaks against the diagnosis of diphtheria.
4. Degree of general intoxication, as a rule, corresponds to the magnitude of the local process. With small plaque sizes it is negligible, but with a large distribution of local changes it has a pronounced character. Intoxication during diphtheria is manifested by lethargy and pallor of the patient, in contrast to agitation during processes of other etiologies. (In hypertoxic forms, in the first days of the disease, pronounced toxicosis with symptoms of excitement can be observed).
5. Dynamic process characteristic of all forms of diphtheria. Without the introduction of serum, the plaque increases in size, as if spreading and at the same time thickening; significant spread of the local process is most often accompanied by edema. After administration of antitoxic diphtheria serum, the changes decrease and plaque disappears. In toxic forms, an increase in plaque and swelling may continue for another 1-2 days after administration of the serum. Sometimes, especially in immunized children, plaque may disappear without specific treatment, which creates great difficulties in diagnosis.
Taking into account the epidemiological situation - the presence of contacts with patients or carriers of the diphtheria bacillus - is of great help in diagnosis.
A preliminary diagnosis is made on the basis of clinical data; it is necessary to resolve the issue of timely administration of antitoxic diphtheria serum. You can wait for the results of laboratory tests only if you regularly monitor the dynamics of the process and in patients with the most light forms diseases - with diphtheria of the nose, island form, diphtheria of the pharynx, etc.
Laboratory diagnostics diphtheria is carried out by bacteriological and serological methods. The bacteriological method can confirm the diagnosis in 90-99% of cases. In this case, a number of conditions must be met:
1. Correct collection of material. Under visual control, the swab is passed along the edge of the plaque so that enough material remains on it; for croup, the crop is removed at the entrance to the larynx with a special curved swab on an empty stomach or before meals, be sure to exclude pre-treatment with medications (rinsing, taking powders, etc.)
2. Transportation should ensure that the material reaches the laboratory no later than 2-3 hours after collection.
3. Culture media must be prepared exactly in accordance with current recommendations.
4. For more accurate diagnostics, in addition to the usual Leffler’s medium, you need to use special elective media (Clauberg’s medium).
Due to the fact that with a conventional bacteriological study the answer can be obtained only after 48 hours from the start of the study, it was proposed accelerated methods. The oldest of them, used by Leffler, is bacterioscopic examination. This method can only be used as a preliminary method, with mandatory subsequent bacteriological examination. Currently, it is almost never used to detect diphtheria. In the 30s of our century, it was proposed to diagnose diphtheria accelerated method Folger and Zolle. Mucus from the lesion is taken with a serum swab, which already serves as a nutrient medium, and placed in a thermostat. The smears are examined after 4-6 hours. This method is worse than the classical one, since with a small number of rods in the inflammatory focus, it more often gives a negative result. In 1961, the immunofluorescence method was proposed, which allows you to get an answer within an hour; the results are positive only in the presence of toxic diphtheria bacilli.
Serological method consists of performing an agglutination reaction of the patient’s blood serum with a laboratory culture of diphtheria bacillus. It is considered positive if agglutination occurs when the serum is diluted at least 1:80; 1:100. Evidence of an increase in serum dilution titer. The best time for the first examination is the first week of illness; the second examination is carried out in the 3rd week (V.A. Khrushchova). The reaction is also used to identify asymptomatic forms when toxigenic diphtheria bacilli are detected in a healthy person. It has also been proposed to determine the level of antitoxin in the blood serum: at the onset of the disease it is absent or not higher than 0.5 AE/ml (K.V. Blumenthal).
A clinical blood test is not indicative in the diagnosis of diphtheria. Moderate leukocytosis with slight monocytosis is usually observed; ESR remains within normal limits.

Differential diagnosis of diphtheria in children

Diphtheria pharynx

This disease most often has to be differentiated from infectious mononucleosis, with in different forms sore throat
Follicular, lacunar tonsillitis more often caused by hemolytic streptococcus. The common signs for them are a more acute onset than with diphtheria and a greater severity of inflammatory changes in the pharynx in the form of bright hyperemia, juiciness, looseness of the mucous membranes, accompanied by pain. Greater severity of inflammation streptococcal tonsillitis is also typical for regional lymph nodes; they are enlarged and painful, elastic in consistency, and not dense, as with diphtheria. The symptoms of intoxication (fever, poor health, agitation and vomiting) are also usually more pronounced than with localized forms of diphtheria.
For follicular tonsillitis The location of the follicles under the mucous membrane is characteristic (they are visible through it), while plaque in diphtheria is always on the surface of the mucous membrane. When the follicle suppurates, the integrity of the mucous membrane covering the tonsils is destroyed, but in these cases the purulent nature of the lesion is determined (type purulent plugs), which is not characteristic of diphtheria.
Lacunar tonsillitis usually mixed with the tonsillar form of diphtheria. With lacunar angina, the plaque is of a loose consistency, it is most often concentrated in the lacunae, often purulent, and does not have the tendency to spread characteristic of diphtheria. Lacunar tonsillitis with large, rather dense plaques can present difficulties for diagnosis; in these cases, attention is also paid to pronounced inflammatory changes, the absence of process dynamics characteristic of diphtheria, and the rapid therapeutic effect when using penicillin. More difficult for differential diagnosis are lacunar tonsillitis caused not by streptococcus, but by other microbial forms, especially diplococcus. With tonsillitis of diplococcal etiology, plaque can be dense, extending beyond the lacunae, and other inflammatory changes are not clearly expressed. In such cases, laboratory data and observation of patients provide significant assistance in deciding the diagnosis of the disease; the absence of dynamics characteristic of the diphtheria process is revealed.
At necrotic sore throat , which is usually caused by hemolytic streptococcus, hyperemia of the pharynx, soreness, purulent nature of local changes, enlargement and tenderness of the cervical lymph nodes are especially pronounced, body temperature rises to 40 ° C and above. Necrotic films, which are mistaken for plaque, are gray in color, located in a depression (minus tissue instead of plus tissue in diphtheria), are usually located symmetrically, most often on the tonsils, can be on the arches, at the base of the uvula. The change in their value without treatment occurs very slowly, penicillin has a rapid therapeutic effect.
Fusospirillous tonsillitis(Simanovsky-Rauchfus or Vincent) raises suspicion of diphtheria when the plaque is large, especially when it spreads beyond the tonsils.
At the onset of the disease, correct diagnosis is facilitated by the one-sided nature of the lesions of the pharynx and regional lymph nodes (the enlargement of the latter is usually more pronounced than in diphtheria), as well as the superficial location of the plaque. In the following days, changes unusual for diphtheria form in the pharynx in the form of a tissue defect, the plaque becomes looser, acquires a greenish tint, and a putrid odor appears from the mouth. The presence of spindle-shaped rods and spirochetes during bacterioscopy of an ordinary smear of mucus from the throat on a fuchsin-stained glass slide helps to clarify the true nature of the disease.
Sore throats of fungal etiology usually discovered by chance during other diseases or during routine examinations. The temperature in these cases remains normal, there is no pain or hyperemia of the pharynx, the plaque looks like white or yellowish spikes growing into the tissue of the tonsils. Regional glands are not enlarged. The absence of disease dynamics is very characteristic (the raids last a long time).
Infectious mononucleosis(Filatov's disease), an anginal form, raises suspicion mainly of a toxic form of pharynx diphtheria. The disease begins with an increase in temperature, often to high numbers, an increase in first the cervical, then other groups of lymph nodes, as a result of which polyadenitis develops; Symptoms of swelling of the tissues of the nasopharynx increase, which causes difficulty in nasal breathing. In the pharynx, against the background of hyperemic, loosened mucous membranes, grayish or white, often dense deposits appear, sometimes covering the entire surface of the tonsils. Characterized by an increase in the size of the liver and spleen. The temperature during mononucleosis can remain long time- up to 7-10 days or more. Plaques, having appeared, do not change for 7 - 8 days (despite treatment), while with diphtheria the size and density of plaques change daily.
Significant enlargement of the lymph nodes and high temperature in mononucleosis appear with relatively small plaques in the pharynx, while in diphtheria they are observed only with widespread lesions of the pharynx. Characteristic changes in the blood during mononucleosis are leukocytosis, lymphocytosis, altered forms of lymphocytes (monolymphocytes, according to Kassirsky) and monocytosis.
Paratonsillitis (phlegmonous tonsillitis) occurs more violently than diphtheria, and at high temperatures Swallowing and opening the mouth is painful and difficult, salivation is observed; characterized by one-sidedness of the lesion, bright hyperemia of the pharynx, protrusion of the tonsils, density and tenderness of the cervical lymph nodes on the affected side. Toxic diphtheria of the pharynx is taken for phlegmonous sore throat, when the swelling of the pharynx is so great that the tonsils are connected along midline and cover plaques located on their inner surface. These most severe cases of the disease require a detailed assessment of changes in the pharynx and general symptoms (pallor, adynamia in diphtheria, hyperemia and agitation in paratonsillitis).
At mumps a reason to suspect diphtheria is sometimes swelling that can spread to the neck. Crucial For diagnosis, examination of the pharynx is necessary - the absence of damage to the pharynx and the presence of changes in the area of ​​the parotid glands.

Differential diagnosis of respiratory tract diphtheria

Differential diagnosis of respiratory tract diphtheria is most often carried out in patients with croup syndrome with acute respiratory viral infection. measles, less often in patients with a foreign body in the respiratory tract, pneumonia, etc.
Croup with OVRI occurs at higher temperatures and other intoxication phenomena. In contrast to diphtheria, there are no patterns in the development of major changes. Laryngeal stenosis can occur at any time of the disease, but can immediately reach II - II degrees without a consistent increase characteristic of diphtheria. There is usually no aphonia. The hoarseness of the voice is inconsistent, at times a clear voice appears, a rough cough, barking. In contrast to diphtheria, there is no parallelism in the development of individual symptoms. The dynamics of the disease are also different: the phenomena of severe stenosis can be replaced by periods of complete calm and, therefore, free breathing and can quickly disappear completely. In patients with croup developing as a result of acute respiratory viral infection, in addition to the listed signs, there is a bright diffuse hyperemia, swelling of the mucous membranes of the pharynx, back wall pharynx, mucous and mucopurulent discharge from the nose.
For measles laryngitis, which occurs in the early stages of measles, other symptoms of measles are characteristic (conjunctivitis, enanthema on the mucous membrane of the palate, Filatov-Velsky spots, etc.). Late measles laryngitis occurs as a result of a secondary infection; in the past it was often caused by diphtheria bacilli, in recent years - mainly by staphylococcus.
Foreign body, getting stuck in the larynx or trachea.
gives a picture of stenosis, however clinical picture differs sharply from diphtheria: stenosis occurs suddenly in the midst of complete health; the voice remains clear; temperature is normal; Sometimes a clapping sound is heard foreign body(when listening in the tracheal area). When a foreign body moves into the bronchus, atelectasis of the corresponding part of the lung, emphysema of other lobes and a shift of the mediastinum towards atelectasis appear. Anamnesis is of great importance in diagnosing a foreign body.
Congenital stridor- narrowing of the larynx - mixed with diphtheria during the addition of acute respiratory viral infection, when the phenomena of stenosis intensify. The differences are that the phenomena of stenosis in children with congenital stridor are observed from birth, the voice remains clear, and when inhaling, a loud, peculiar noise is often heard, reminiscent of the clucking of chickens.
For laryngeal papillomatosis aphonia and difficulty breathing, which intensify when catarrh of the upper respiratory tract occurs, may be a reason to suspect diphtheria.
The difference is that stenosis and aphonia develop very slowly - over 1 - 1.5 years, difficulty breathing is most pronounced at night and with increased movements of the patient. The child reacts calmly to the phenomena of stenosis (gets used to it), and long-term adaptation of the body ensures less pronounced oxygen starvation.
Of great importance for diagnosing diphtheria of the respiratory tract is a thorough, detailed history, analysis of the dynamics of the disease and the laryngoscopy method, which allows for examination of the mucous membrane of the larynx. In early childhood, when this localization of the process is predominantly observed, direct laryngoscopy is used. Diphtheria is characterized by fibrinous films in the area of ​​the true vocal cords.

Nasal diphtheria

Nasal diphtheria is often mistaken for a simple runny nose. Distinctive signs of diphtheria are bloody discharge, crusts at the entrance to the nose, and often a fibrinous film on the mucous membrane of the nasal passages. The final diagnosis is made based on observation of the dynamics of the process and data from bacteriological examination.

Rare diphtheria

Diphtheria of rare localization is characterized by the same basic signs of the diphtheria process, the main of which are fibrinous inflammation and a tendency to tissue edema.
Membranous conjunctivitis of diplococcal and adenoviral etiology is most often mistaken for eye diphtheria. Membranous conjunctivitis of adenoviral etiology is characterized by an acute onset with high fever, which can last for a week or more. Eye disease is often preceded by upper respiratory tract catarrh and sore throat. Unlike diphtheria, the plaque is more loose, the swelling of the eyelids is less pronounced. The film does not extend to the eyeball; changes are characterized by low dynamics. The process is predominantly one-way. Diseases of membranous conjunctivitis occur in groups, while with a focal outbreak of diphtheria, forms of other localization often occur, and not just eye damage.
Even vulgar purulent conjunctivitis. It is characterized by bright hyperemia of the conjunctiva, purulent discharge, slight mild swelling of the eyelids, and the absence of a filmy coating.
Diagnosis diphtheria ear sometimes it is mistakenly diagnosed in chronic purulent otitis media if diphtheria bacillus is cultured during bacteriological analysis. Such cases, in the absence of changes characteristic of diphtheria, should be considered as bacterial carriage.
Diphtheria of the oral mucosa more often occurs in combination with diphtheria of the pharynx and is characterized by the appearance of films on the mucous membrane of the cheeks, tongue, and palate. It is mixed with aphthous and ulcerative stomatitis. Differential diagnosis difficult, based on the presence of dense fibrinous films and bacteriological data.

Prognosis of diphtheria in children

The prognosis for diphtheria depends on the form of the disease and the timing of administration of antitoxic diphtheria serum. For localized forms of diphtheria and timely administered serum, it is quite favorable. With toxic forms, there can be deaths both in the acute period and subsequently, mainly from myocarditis. Early and correct serum treatment using antibiotics and other means of complex therapy, including regimen, contributes to sharp decline lethality. With croup, the outcome depends entirely on the timeliness and correctness of treatment; serotherapy carried out in the early stages of the disease prevents progression of the process. The cause of death in these cases is mainly secondary pneumonia.

Treatment of diphtheria in children

A specific treatment for diphtheria is antitoxic diphtheria serum. Changes in diphtheria are caused by a specific toxin; The production of antitoxin in the body occurs slowly, the introduction of serum compensates for this deficiency, leads to the rapid neutralization of the toxin and the elimination of the local inflammatory focus. Serum treatment effective if the following conditions are met:
1) early introduction, since the serum neutralizes only the toxin circulating in the blood and has no effect on the toxin already fixed by the cells;
2) administration of sufficient serum, especially its initial dose, to completely neutralize the toxin.
Serum treatment used for all forms of diphtheria. The issue of administering serum for an unspecified diagnosis of diphtheria or for suspected diphtheria is decided individually. Waiting is permissible only in mild forms with mild local changes, with constant medical supervision in the hospital. If a toxic form is suspected, the serum is administered immediately. Upon diagnosis in late dates in patients with spontaneous recovery, the administration of serum is unnecessary. The dose of serum depends on the form of diphtheria, the day of illness and, to some extent, on the age of the patient. The frequency of administration is also determined by the form of the disease, taking into account its dynamics. In localized forms and in the initial stages of croup, a single administration is usually sufficient and only with delayed improvement in the later stages of croup is it repeated. For toxic forms, the serum is administered for 2-4 days; in case of toxic form II - III degree - in the first 1-2 days, 2 times a day. The first dose should be the maximum and be about 1/2 or 1/3 of the total amount. Serum treatment is stopped after the disappearance of toxic edema, significant thinning and reduction of plaque.
Pathogenetic agents necessary for toxic forms and cereals. For localized forms of diphtheria they are used much less frequently.
Antibiotics can be classified as both specific and pathogenetic agents. In vitro, many antibiotics have a bacteriostatic and even bactericidal effect on the diphtheria bacillus (penicillin, erythromycin, oletethrin, ceporin). However, they have no independent significance in the treatment of diphtheria, but in combination with serum they are widely used, mainly to combat secondary infection.
Corticosteroids in toxic forms of diphtheria, in addition to detoxification and anti-inflammatory effects, replacement therapy, since due to toxic damage to the adrenal cortex, their synthesis in the body is sharply reduced. Apply I-2 mg/kg prednisolone per day depending on the degree of toxicosis. The route of administration can be intravenous (for hypertoxic forms), intramuscular and oral. The duration of the course is 10-12 days with a gradual decrease as the patient’s condition improves.
For croup, corticosteroids are used to influence the swelling of the mucous membrane of the larynx and bronchi, and the spastic state of their muscles; the course of treatment may be shorter - 5-6 days. Prednisolone can also be used topically, by instillation from a pipette onto the mucous membrane of the larynx.
To eliminate the resulting deficiency, patients with toxic diphtheria are prescribed ascorbic acid up to 800-1000 mg/day orally, or intravenously, intramuscularly in a 5-10% solution, 2-3 ml. After 7-10 days, the dose is reduced. Its administration helps to weaken the effect of the toxin, reduce and mitigate complications and reduce mortality. Prescribed for the same purpose nicotinic acid 15 - 30 mg 2 times a day orally or intramuscularly, intravenously in a 1% solution of 1-2 ml for 2-3 weeks. Due to severe damage to the peripheral nervous system, vitamin B is prescribed | (thiamine) 0.5-1.5 mg 3 times a day for the first 10 days, then repeat the course after 1-2 weeks. Children over 2 years of age are prescribed strychnine as a nervous system tonic (for 4-5 weeks); for more severely ill patients, it is administered subcutaneously in a solution of 1:1000, 0.5-1 ml 3 times a day. Every day for 2-4 days, plasma is administered at a dose of 50-150 mg, an intravenous infusion of 20-40% glucose solution in an amount of 30-50 ml with corglycone and cocarboxylase is performed; Other drugs are also prescribed depending on the indications.
With croup, in addition to the administration of anti-diphtheria serum, the main task is to combat stenosis, as well as treat pneumonia, which in these cases occurs in most patients. In the fight against respiratory distress, the first thing that is needed is rest, thermal procedures (general baths, hot wraps), steam inhalations from soda solution, and mustard plasters. Any procedures are permissible provided the child has a calm attitude towards them and without violence, since any excitement increases the stenosis. For many patients good action provides fresh cold air, so it is recommended to stay on the veranda in front of open window(in this case, the child should be well wrapped and warm). Sedatives, sleeping pills should be used with caution as they may mask respiratory distress. The mucus is sucked out using an electric suction device. Oxygen therapy should be used.
If there is no effect from conservative therapy, resort to surgical intervention. Indications are prolonged stenosis of the II - III degree and, even more so, the appearance of symptoms of carbon dioxide poisoning. For croup of diphtheria etiology (localized form), intubation is considered the most rational. Lack of improvement in breathing upon extubation (2 to 3 days after intubation) is an indication for tracheostomy.
Patients with a combined form of croup and toxic diphtheria of the pharynx undergo a primary tracheostomy (without previous intubation) in the same way as with widespread croup. Patients with croup are prescribed antibiotics in sufficient dosage. The reason for this is the almost constant presence of pneumonia, which aggravates the phenomena of stenosis.
In the treatment of patients with specific complications (myocarditis, polyneuritis), the complex use of large doses of vitamins, plasma and glucose, and the use of symptomatic drugs according to indications are of primary importance; The appropriate regime is extremely important.
Nonspecific complications (pneumonia, otitis media) are treated according to general rules.
When serum sickness occurs, diphenhydramine, calcium chloride, ephedrine are used, and in severe cases, corticosteroids.
Treatment of bacteria carriers. The reasons for prolonged bacterial carriage may be a decrease in general resistance under the influence of any concomitant or chronic diseases; pathological condition of the mucous membranes (rhinitis, chronic tonsillitis and etc.). Therefore, the main thing in treatment is measures aimed at eliminating associated pathological conditions, systematic vitaminization, good nutrition, rich in proteins, irradiation ultraviolet rays etc. Among the strengthening agents, metacil and pentoxyl are used. Local treatment carried out with iodinol, erythromycin-syntomycin emulsion. For long-term persistent carriage of toxigenic bacilli, the use of tetracycline and erythromycin is recommended. Recently, ultrasound has been used.

Regime, care, diet

Patients with diphtheria of any form, as well as those with suspected diphtheria, are subject to hospitalization in specialized diagnostic departments, where they must be placed in boxes and examined very carefully. In the absence of diagnostic departments, patients are hospitalized in wards.
The regimen varies depending on the form of the disease. In mild forms (localized form of diphtheria of the pharynx, nose, etc.), bed rest is prescribed for the period of acute symptoms. In more severe forms, strict bed rest is required: for widespread, subtoxic and toxic diphtheria of the 1st degree - at least 3 weeks, for toxic diphtheria of the 2nd degree - until the 40th day, and for toxic diphtheria of the 3rd degree - until the 50th day of illness. With the development of myocarditis and polyneuritis, this period may be increased depending on clinical changes. Transition to normal mode needs to be done very gradually.
Patients with diphtheria complicated by myocarditis, polyneuritis, croup should be provided with individual care.
Discharge of patients from the hospital to clinical indications produced no earlier than 2 weeks from the onset of the disease; for localized forms - after 3 weeks; for toxic forms of the first degree - no earlier than the 30th day; for toxic forms of degree II - III - on the 50-60th day, i.e. after the deadline for the possible occurrence of complications. According to epidemiological indications, discharge is allowed after bacteriological cleansing, determined by bacteriological analysis.
Diet in the acute period of diphtheria, it is usual for febrile patients: liquid, semi-liquid, possibly less traumatic to the pharynx and pharynx. After the temperature drops and the plaque disappears, the usual varied diet including large quantities vitamins Feeding of intubated patients, patients after tracheostomy with complications (myocarditis, polyneuritis) should be carried out nurse under the guidance of a physician, prevention of aspiration pneumonia is necessary. Food in these cases should be semi-liquid or liquid, well crushed.

Prevention of diphtheria in children

Measures aimed at neutralizing the source of infection include early isolation of a patient not only with obvious diphtheria, but also with suspected diphtheria (mandatory hospitalization).
The patient is discharged from the hospital after recovery, subject to a negative result of a double bacteriological examination carried out with an interval of 2 days.
To identify sources of infection and persons who could have become infected with diphtheria from a person with diphtheria, all contacts are subject to repeated bacteriological examination of mucus from the throat and nose for diphtheria bacillus. Quarantine and medical observation are carried out until the results of the study are received. If a bacteriological examination cannot be carried out, then quarantine is imposed for 7 days.
After isolating the patient, final disinfection is performed. Isolation and treatment of carriers of toxigenic diphtheria bacilli can be done at home. If rehabilitation is unsuccessful according to the current situation, they can be admitted to the group of healthy, immunized children 30 days after carrier status is established.

What is the likelihood of a small child getting diphtheria? Many young parents, kindergarten teachers and even some doctors will answer that the risk of contracting such a dangerous disease at such a young age is minimal. And they will make a fatal mistake.

It is children under 3-4 years of age who account for the lion's share of all cases of diphtheria. Therefore, everyone needs to know what it is and how to deal with its manifestations.

Infection with diphtheria occurs when its causative agent, the bacterium Corynebacterium diphtheriae, enters the child’s body, a pathogenic exotoxin that is considered one of the strongest bacterial poisons.

Infection can occur through:

• mucous membranes of the oropharynx and nose;
• thin conjunctiva covering the eye;
• genitals;
• skin if it is damaged.

It is not difficult to determine the source of infection. At the point where the bacteria enters the body, various irritations and purulent discharge immediately begin to form.

As for the causes of infection, the disease is mainly spread by airborne droplets, especially when children are in direct contact with a patient with diphtheria or its carrier.

However, you can also receive a similar “gift”:

• through surrounding objects touched by the infected person;
• when consuming milk and dairy products, in which the pathogen can sometimes be found.

Symptoms of the disease

As such, it is difficult to identify the features of the course of diphtheria in children. In many ways, its symptoms are similar to the manifestation of the same disease in adults.

There are still small differences, but in order to identify them, it is necessary to initially determine the form of the disease based on the affected area.

Oropharyngeal diphtheria

Being the most common disease today, it is diagnosed in more than 90% of cases, 75% of which are localized. The disease is usually classified into the following forms.

Diphtheria in drawings.

Initial

The child’s temperature rises sharply, but not higher than 37.5-37.7 degrees, and without drug intervention it is not possible to lower it for 3 days.

Intoxication is expressed moderately, with pronounced pain in the throat. The tonsils swell slightly, and a filmy coating forms on them, initially resembling a jelly mass and then a cobweb. Attempts to eliminate it can lead to bleeding, and a new one will form in place of the removed film the next day.

Localized

The plaque becomes more loosened, and its removal causes virtually no harm to the mucous membrane. The submandibular and regional lymph nodes are slightly enlarged, their sensitivity to palpation (palpation) increases. The damage to the tonsils is more active, and can be either bilateral or asymmetrical.

Sometimes (quite rarely) it develops into catarrhal diphtheria, which is characterized by minimal manifestation of general symptoms: an increase in temperature to 37.5 degrees, discomfort when swallowing, signs of general intoxication of the body, etc. In this case, the tonsils swell, the oropharynx becomes hyperemic.

Common

Despite the name, this form of the disease is diagnosed in no more than 11% of cases.

In contrast to localized, it is characterized by more pronounced symptoms and the active spread of film plaque, which almost immediately extends beyond the tonsils. No swelling of the cervical subcutaneous tissue is observed.

Subtoxic

Signs of intoxication become pronounced, pain when swallowing intensifies. The baby begins to complain more actively about general malaise. A clear film coating appears on the tonsils, which rarely extends beyond them. They themselves change color to something close to burgundy or even purple.

Regional lymph nodes become denser, and swelling forms in the area above them, which, however, is moderate.

Toxic

Today it manifests itself in more than 20% of cases of the total number of diseases, but mainly in adults. It develops both from a localized or widespread form of diphtheria, and independently.

Accompanied by a sharp rise in temperature to 39-40 degrees in the first hours after the onset of the disease. Severe sore throat is accompanied by general symptoms of intoxication, and sometimes unpleasant sensations in the abdomen and/or neck area.

Vomiting, painful trismus (when restrictions occur when opening the mouth), delirium and hyperemia often appear. A dough-like swelling forms in the subcutaneous tissue in the neck area, which does not cause pain, which over time partially affects the back and face. A specific putrid-sweet smell comes from the mouth, and the voice becomes more nasal.

Hypertoxic

It is considered the most severe and, as a rule, is diagnosed when a young patient has chronic diseases (for example,).

Expressed by a rapid rise in temperature, chills, vomiting and other symptoms acute intoxication. Hemodynamic problems may occur (expressed as low blood pressure, pallor, etc.). Skin hemorrhages and bleeding of internal organs occur, and DIC syndrome manifests itself.

All this can at any time cause shock of an infectious-toxic form and lead to fatal outcome literally 1-2 days from the moment the symptoms first appear.

Diphtheria and tetanus - School of Dr. Komarovsky - Int

Diphtheria croup

This form of diphtheria today is not as common as oropharyngeal diphtheria, but its spread is gradually gaining momentum. The disease can have 2 variations: localized (the so-called diphtheria of the larynx) and widespread (when the infection also spreads to the trachea and bronchi).

In its development, it alternately goes through 3 stages:

1. Dysphonic. At this stage, the voice becomes hoarse and a barking cough begins. Moreover, if in adults this stage lasts about a week, in children the signs make themselves felt already in the first 2-3 days.
2. Stenotic. Here the sick person loses his voice, his cough becomes silent, breathing problems appear, and the skin acquires a bluish tint.
3. Asphyxial. Breathing problems and bluish skin become worse. The child begins to have convulsions and consciousness is impaired. If the baby has not been given proper assistance up to this point, death follows.

How to recognize diphtheria croup.

This disease almost never starts on its own. As a rule, it goes hand in hand with other types of diphtheria (diphtheria of the eyes, larynx, oropharynx).

Despite the low degree of intoxication, the child develops severe irritation in the area around the nose, purulent or sanguineous discharge begins. The nasal mucosa swells noticeably, and fibrinous deposits, ulcers and erosive formations appear on its surface.

Diphtheria eye

A disease in which the organs of vision suffer the most damage.

It occurs in 3 forms:

1. Catarrhal. It has to be here unilateral inflammation conjunctiva and a significant increase in eye secretions. However, neither regional inflammation nor enlargement of the lymph nodes is observed in the child. The temperature remains at 37.5 degrees.
2. Membranous. In this form, symptoms of general intoxication of the body already make themselves felt. The conjunctiva gradually becomes covered with a fibrinous film, the eyelids swell, and serous-purulent discharge appears in the eyes. Moreover, even if the disease initially affects only one eye, it quickly spreads to the second.
3. Toxic. Symptoms of intoxication from the very first days of infection appear quite acutely; pronounced swelling of the eyelids is observed. The skin around the eyes becomes irritated and excessive purulent discharge begins. In the absence of timely treatment, the child may encounter pathologies such as panophthalmia (inflammation eyeball) or regional inflammation of the lymph nodes.

Diphtheria of the skin, ear, genitals

All of these variants of diphtheria in children are observed extremely rarely, so it is appropriate to combine them into a single group. Nevertheless, these forms of the disease exist, and therefore we should still talk about them.

Diphtheria of the ear predominantly develops together with diphtheria of the pharynx or nose. The patient experiences swelling, fibrinous plaque in the affected area, hyperemia of the mucous membranes and skin, as well as pronounced pain in the regional lymph nodes.

Diphtheria of the genital organs complicates the process of urination and makes it painful. In boys, the foreskin and adjacent tissues are affected; in girls, the labia, vagina, perineum, and even the anus are affected.

Diphtheria of the skin, as a rule, is observed in those areas of the skin where there are diaper rash, small cracks and serious wounds, fungus, and other types of similar damage. It is accompanied by the formation of a dirty gray plaque and copious serous-purulent discharge. Symptoms of general intoxication of the body are practically not expressed.

From the above, it is easy to conclude that the symptoms of diphtheria in children under one year old, in 5-year-old toddlers, in adolescents and adults are mostly similar. The key difference is the speed at which the defeat processes occur. Where an adult may have another week of head start on treatment, the baby will “burn out” in literally 1-2 days.

Therefore, those who want to protect their child from the consequences caused by the disease (after all, they can be quite serious), should show the child to the pediatrician at the first signs of illness.

Diphtheria and tonsillitis: looking for differences

In order to seek help in a targeted and timely manner, it is necessary not only to know the signs of diphtheria, but also to be able to distinguish it from other outwardly similar diseases.

The disease is often confused with, false croup and other diseases. However, the biggest difficulty is, of course, caused by sore throat, which, on top of everything else, is found everywhere.

Therefore, for convenience, we present the differences between these diseases in the following table:

• For the first time exactly one year after the end of stage 3 of the primary course (the same DPT vaccine is used).
• The second time is when the child turns 7 years old (ADS-M-anatoxin is used).
• The third time - at the age of 14 (vaccinated with ADS-M toxoid).
• 4 and subsequent times - 10 years after the previous procedure (the same ADS-M toxoid is used).

If you want this terrible disease to not take your child by surprise, you must strictly follow this schedule. If desired (for example, when a child is allergic to the active components), the DTP vaccine can be replaced with Infanrix, Infanrix Hexa or Pentaxim vaccines.

Good to know! If for some reason the child has not undergone primary vaccination until the age of 4-6 years, he needs to be administered ADS-toxoid twice with an interval of 45 days between vaccinations. Revaccination will be required in about a year. If primary vaccination is required for a child 6 years of age or older, then everything will be exactly the same, only the period before revaccination will be reduced to 6-9 months.

Diphtheria- an acute infectious disease caused by diphtheria bacillus. It affects the mucous membrane at the site of infection - in the pharynx, nose, larynx, trachea, less often in other organs - and is characterized by severe general poisoning of the body.

It spreads through direct and indirect contact with an infected person. Diphtheria bacilli release toxic substances that damage body tissues, especially the nervous system and heart. Long-term exposure to these substances can cause death.

Previously, diphtheria was one of the most common fatal childhood diseases, but thanks to immunization it has become a fairly rare disease.

Causes of diphtheria.

The causative agent is a toxigenic diphtheria bacillus, stable in the external environment. The exotoxin produced by the rod is absorbed into the blood and causes general poisoning with damage to the myocardium, peripheral and autonomic nervous system, kidneys, adrenal glands. Transmitted by airborne droplets.

Symptoms of diphtheria.

Films form on the back of the throat. These films eventually stick together and completely block the airway. There are other symptoms of diphtheria: sores in the throat, swollen glands in the neck, heat and fever, headache and nausea.

The incubation period is from 2 to 10 days. Depending on which part respiratory system affected, there are several types of diphtheria.

Diphtheria of the pharynx - filmy plaques form on the tonsils, the pharynx is moderately reddened, swollen, pain when swallowing is moderate or mild, body temperature is not high. As the infection spreads, plaque spreads to the mucous membrane of the palatine arches and uvula, the mucous membrane swells, and a thick dirty white plaque forms, spreading from the tonsils to the soft and even hard palate. The deposits are dense and cannot be removed from the mucous membrane. The patient's general condition is serious, with high body temperature (39-40 °C), weakness, sometimes vomiting and abdominal pain. Swelling subcutaneous tissue neck.

Diphtheria of the larynx (diphtheria, or true croup) has recently been rare and is characterized by inflammation of the mucous membrane of the larynx and trachea. The course of the disease is rapid. In the first stage, which lasts 1-2 days, there is an increase in body temperature, increasing hoarseness, and a cough that initially “barks” and then loses its sonority. In the second stage - noisy breathing, tension in the respiratory muscles when inhaling, the third stage is manifested by signs of oxygen deficiency - blue skin, sweating, anxiety, severe shortness of breath. If medical assistance is not provided in a timely manner, the patient dies from suffocation.

Diphtheria is also dangerous for its complications - such as toxic shock, severe damage to the heart (myocarditis), peripheral nerves, which can lead to the death of the patient or disability.

Treatment of diphtheria.

All patients with diphtheria are subject to hospitalization in an infectious diseases hospital. The main method of treatment is to administer anti-diphtheria serum at an appropriate dose as early as possible. For mild forms of diphtheria, the serum is administered once, for severe forms - over a number of days. With diphtheria croup, rest and fresh air are necessary. Sedatives are recommended. The administration of glucocorticoids helps to reduce inflammation of the larynx. To avoid and treat complications, antibiotics are prescribed.

Treatment with antibiotics and antitoxic drugs at an early stage of the disease is often successful. Those who have had diphtheria acquire immunity; The diphtheria vaccine also provides immunity.

Diphtheria in children - acute illness caused by the entry of an infectious agent into the body. The pathology is considered severe and life-threatening. The patient's respiratory system becomes inflamed; the lesions are quite large; at the same time, the eyes and skin suffer. As a rule, the infectious agent affects the genitals. Self-treatment of such a problem can easily cause death or numerous severe complications and irreversible health problems. Only qualified doctors treat diphtheria. At the first suspicion of a disease, you should immediately seek the help of a specialist. To clarify the presence of the disease at the appointment, the doctor takes a swab from the throat. To prevent diphtheria infection, you should get vaccinated on time. Currently in our country this is available to everyone; the vaccine is given completely free of charge.

Where did the trouble come from?

If a child falls ill with diphtheria, it means that a colony of corynebacteria, known to science under the second name “diphtheria bacillus,” has developed in the body. This infectious agent is not only dangerous, but also tenacious - it is not afraid of freezing or drying. Once it gets onto an object used in everyday life, the microscopic pest waits long and patiently for the opportunity to move into the human body. The most effective method of eliminating danger is boiling. Just one minute allows you to completely get rid of infectious colonies. Ten-minute disinfection using chloramine, hydrogen peroxide - another reliable way eliminating pathogenic life forms from household items.

Most often requiring urgent treatment symptoms of diphtheria in children are observed due to contact with a carrier of an infectious agent or a sick person. The incubation period lasts only three days. As soon as the first signs of infection are observed, the child himself becomes a source of danger to others. He spreads harmful microbes around himself until he fully recovers. Bacteria are transmitted mainly from person to person by airborne droplets, and somewhat less frequently - through household objects. The typical route of entry into the body is through the larynx, nasal cavity.

Forms and varieties

The division into types is based on the degree of damage to different organs. There is diphtheria of the pharynx in children, the larynx and the nasal cavity. The disease may be concentrated in the organs of vision, reproductive system, in the ear. Each variant of localization of the inflammatory process requires its own unique approach to therapy. The most common type in children is laryngeal diphtheria. In some patients, the inflammatory process is isolated, in others, lesions are observed in one organ first, after which new lesions arise in other parts of the body. Gradually, the diphtheria film spreads to the larynx and covers the glottis. This leads to difficulty breathing. To clarify the specifics of the case, the doctor takes a smear and sends samples of organic tissue for laboratory testing.

The first symptom of diphtheria in children is fever. As a rule, the heat reaches 38 degrees. The child coughs and his voice becomes hoarse. Over time, the cough transforms into a barking cough, and after a couple of days from the onset of the disease, breathing is accompanied by a whistle, which is difficult for the patient. In the absence of adequate treatment, the fever subsides over time, but this only indicates the progress of the pathology. The patient breathes arrhythmically, possible: uncontrolled stool, urination, loss of consciousness, convulsive state. If emergency medical care is not provided, there is a high probability of death due to suffocation.

Features of the forms: affected nose, mouth

Sometimes symptoms of diphtheria in children indicate damage to the nose. This disease is also quite widespread among young children. As with any other localization, the disease manifests itself primarily by fever. The child has difficulty breathing, the mucous membranes of the nasal cavity swell, the tissues become inflamed, and one of the nostrils oozes a discharge that looks like ichor. In general, the symptoms are similar to any infectious diseases, which is why many people confuse diphtheria with a cold or flu. This is what leads to the initiation of a case - they do not go to the doctor on time, hoping that the disease will pass herself. The fever is accompanied by weakness, lack of appetite, often the child simply cannot clearly explain the sensations that bother him, and the disease is mistaken for a seasonal ARVI. One of the main signs of diphtheria is sharp, strong pain in the throat.

If the most striking sign of diphtheria in children is a fibrous membrane, visible to the eye upon examination oral cavity, it makes sense to assume an inflammatory process localized in the tonsils. These organs become covered with a gray coating that is almost impossible to remove. This symptom alone is enough to reasonably suspect diphtheria. The disease exists in two forms: complete coverage with a film, islands. Visually, they differ in the location of the plaque - it can cover the tonsils completely or cover certain limited areas. In some, diphtheria primarily manifests itself on the tongue and palate. It happens that the manifestations are most pronounced on the pharynx (the wall at the back). First, a transparent film is formed, after which the shade changes to white and the density increases.

Symptoms: what else is possible?

Signs of diphtheria in children include neck swelling and apathy. The patient practically does not move, suffers from fever, and the lymph nodes gradually enlarge. The disease is accompanied by headache. Gradually, swelling from the neck moves to the collarbones. How big square covered, the worse the patient’s condition and the higher the risk to life. As a rule, the patient’s lips are dry, the skin is pale, breathing is rapid and noisy. The nose becomes a source of uncontrollably discharged fluid. A convulsive state indicates that the baby is in particular danger.

If children are not vaccinated against diphtheria and tetanus on time, from the moment of infection the disease progresses very severely, symptoms progress rapidly, and the pathology leads to numerous severe complications. If the vaccine has been received, the disease as such does not begin, but the baby becomes a carrier of the infectious agent. If the pathology does begin, the symptoms are limited and not so pronounced. The latent period of the infectious agent is from a couple of days to one and a half weeks.

Diphtheria or tonsillitis?

As stated above, the main symptom of the disease is severe sore throat, but it is also characteristic of sore throat, which leads to confusion. To understand at home why your child is sick, you should carefully examine the baby. If diphtheria begins, children may notice white coating film type on the tonsils. But sore throat provokes a pronounced inflammatory process, so the organs acquire a reddish tint. Possible discharge of pus, plaque yellow tint. With a sore throat, a coating is observed on the tongue, the uvula swells, and the pharynx turns red. If diphtheria has begun, then the inflammatory process covers not only the tonsils, but also the palate, but this is completely unusual for sore throat.

A feature of sore throat is severe, sharp pain when trying to swallow food, so the patient completely loses his appetite. Diphtheria in children is not accompanied by such sensations; the throat is only bothered by discomfort, and appetite disappears for other reasons. However, you should not try to cure both diseases at home - the risk of complications is high. Both sore throat and diphtheria pose a threat to the patient’s life, therefore, if pathology manifests itself, it is necessary to see a doctor as quickly as possible. The baby will be sent for tests, a tissue sample will be taken from the throat, which will make it possible to determine exactly what the child is sick with and how to treat it.

Why is it dangerous?

Diphtheria in children is a serious disease that causes numerous complications. If adequate treatment is not started on time, the infectious agent can infect various internal organs. Children who have not been vaccinated are especially at risk. Against the background of diphtheria, kidney damage is possible, bad influence on the nervous system and pneumonia, which occurs in a very severe form. Diphtheria can cause toxic shock accompanied by high fever, muscle pain, vomiting. The child feels dizzy and may faint. There are cases where diphtheria provoked damage to the heart muscle. All the complications described are dangerous not just to the health, but to the life of the patient, and the only way to prevent severe consequences- get to the clinic on time.

What to do?

Every responsible parent should know what the symptoms, treatment, and prevention of diphtheria in children are in order to take all measures to protect the health of their child, and in case of infection, to minimize negative consequences diseases. As stated above, at the first suspicion of illness, you should consult a doctor. If the doctor shares concerns about the diagnosis, the baby is immediately sent to the infectious diseases department of the local hospital and samples of organic tissue are tested in the laboratory. If diphtheria is confirmed, it is necessary to urgently administer specialized serum. Only based on the results of this event, observing the body’s response, can one make predictions regarding recovery and possible complications.

If the disease is severe and a complex form has developed, treatment of diphtheria in children involves the use of highly concentrated medicinal whey products. The choice of dose remains with the attending physician. Administration of the drug is necessary immediately, as soon as the diagnosis is confirmed. As a rule, at the appointment, the doctor takes a sample from the throat and immediately sends it to the laboratory, so you will have to wait very little time for the results. If the therapy was chosen successfully, the concentration of the product was chosen correctly, the plaque gradually disappears. The patient is prescribed a course of antimicrobial drugs that help stop the activity of pathological agents. Additionally, pre- and probiotics are usually prescribed to minimize Negative influence on the intestinal tract.

How not to get sick?

Prevention of diphtheria in children involves vaccination. Vaccination is the most effective way of immunization. Everyone should get it modern child. Such a measure allows not only to ensure a healthy, happy future for the baby, but also for the entire family as a whole. The essence of vaccination is the introduction into the body of a weakened source of the disease. Scientific research has made it possible to identify at what age and how exactly diphtheria toxoids should be administered in order to achieve maximum effect, without encountering a negative response from the body.

The first is done at three months of age. It is necessary to administer toxoids three times. There are time intervals between approaches - one and a half months. Repeated vaccination is required at two years of age. As a rule, soon after the injection the child begins to feel feverish, the injection site swells, and his health may deteriorate. These reactions are explained by active struggle immune system with microbes. Since the infectious agent enters the body in a weakened form, the vaccination does not provoke such a severe reaction as a normal infection.

Another one preventative measure, which allows you to protect others from infection - urgent hospitalization of patients, carriers of pathology. To provide high level security carry out quarantine measures. This helps reduce risks for healthy people.

Some features of the disease

Most often, diphtheria occurs in children aged 3-7 years. A breastfed baby has passive maternal immunity, which minimizes risks. From the age of seven and older, a person acquires resistance to the infectious agent, which makes the chances of infection quite low. The danger of the disease is explained by the agent’s ability to generate exotoxins, enzyme compounds, factors that provoke necrotic processes, and liquefaction of organic tissues. If a toxin enters a living cell, it leads to intoxication and has a strong negative local effect. Diphtheria is necrotic processes in the epithelium, leading to an increase in the permeability of vascular walls and a slowdown in blood flow, which makes it possible to release fibrin-rich exudate through the vascular walls. The process is reflected by the formation of the very film by which diphtheria can be identified upon visual inspection.

If children under 7 years of age were not vaccinated in a timely manner, the baby became infected, mild form A complete cure is possible in just a week. If diphtheria is localized, there may be no complications, but an incorrectly chosen therapeutic program significantly increases the risk of such complications. If the disease is moderate in severity, when you try to remove plaque, the surface of the pharynx will bleed. If you don't start timely treatment, the disease soon develops into a severe form. Diphtheria can be detected by the characteristic sweetish odor from the mouth. If the infection is severe, the plaque is quite dense. With the right treatment, the fever subsides within four days, and the plaque may disappear within a week. In the absence of therapy or an unsuccessfully selected program, there is a high probability of numerous complications, including damage to the heart muscle.

Specific forms of the disease

If children are not vaccinated against diphtheria on time, the disease may develop according to a subtoxic scenario. This option is relatively safe, since the symptoms are not too severe. The opposite option is hypertoxic, when the pathology develops at lightning speed, and very quickly there is a failure of the heart and blood vessels. Already on the second day of illness there is a high probability of death. If a rash appears on the skin on the fourth day of illness, the hemorrhagic form of diphtheria is diagnosed. In addition to the skin, rashes are observed on the surface of the mucous membranes. The patient is worried about nosebleeds, myocarditis, blood is released in the gastrointestinal tract, from the gums. The consequences of this form are also assessed as very severe.

If a disease is detected, it is necessary to urgently administer a special serum if possible. The method of using the drug was developed by Bezredke. First, an injection of 0.1 ml of the diluted composition is given under the skin; after another third of an hour, a similar volume is injected, but this time undiluted. If tolerance is normal, after half an hour (sometimes the waiting period is doubled), an injection is given with the remaining medication. Therapy is continued until the plaque disappears completely. This treatment will only be effective in combination with antimicrobials. Additionally, antihistamines, glucocorticoids, and bronchial dilators are prescribed and infusion treatment is performed.

Features of vaccinations

Typically, children are vaccinated against diphtheria using a complex preparation that helps them acquire immunity to several pathogens at once. Classic version- a combination of toxoids of diphtheria, tetanus, whooping cough. Since the agents are introduced into the body in a weakened form, this usually does not cause any problems. If a child has already had whooping cough or has a very weak immune system, vaccination is carried out using a specialized ADS-M composition, developed specifically for such children. All features and timing of vaccination are prescribed in the generally accepted national calendar, indicating mandatory preventive vaccinations on the territory of our state.

Children 7 years old are vaccinated against diphtheria with the drug ADS-M. In the future, it is necessary to undergo repeated vaccinations once every decade. The same weakened drug ADS-M is used. There are certain contraindications for its use. To avoid side effects, you need to take them all into account. In particular, you should not get vaccinated during the period of influenza or ARVI. The injection is not given to a child if the body is infected or inflammatory foci are detected. If an injection has already been given that caused a strong negative response from the body, re-vaccination is not given. But, for example, the period when teeth are being cut does not impose any restrictions. Other special conditions of the child do not play a role.

Vaccine: safe and secure

It has already been indicated above when children are vaccinated against diphtheria: the first injection must be given at the age of three months, after which the injections must be repeated regularly. The task of parents is to monitor the condition of the child after receiving the drug. If the injection causes severe fever, vomiting, stool problems, or if the lump at the injection site is large and painful, you should consult a doctor. The doctor will examine the patient and determine whether this is individual characteristics organism or qualified intervention is necessary, the child needs medical care.

Although side effects Diphtheria vaccinations for children are quite negative; if the rules for using the drug are followed, they occur only in a small percentage of cases. Indeed, the symptoms described are quite unpleasant, but in any case they are much easier and safer than manifestations of the disease. Do not forget about the complications that diphtheria can cause: they are much more dangerous than the discomfort suffered after an injection of the drug. Some children become very anxious after receiving the injection. This feature is also a reason to consult a doctor. Still, there is no need to panic beyond measure: side effects, of course, require a doctor to examine the baby, but in most cases they do not indicate a danger to the child.

What else should you pay attention to?

Sometimes it happens that parents deliberately refuse to vaccinate their children against diphtheria. Adverse reactions They scare many people; people hope that their child will be spared the infection. If it was decided to refuse the vaccine, but the child gets sick, it is very important to thoroughly disinfect all surfaces in the house, as well as household items and linens with which the patient had contact. If the baby recovers, he acquires unstable immunity, and there is a risk of re-illness over time. If diphtheria is observed a second time, it usually proceeds more easily, the toxicosis of the body and local manifestations are quite weak. However, this is not a reason to treat the child yourself, at home - in any case it is necessary qualified assistance doctor