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Pediatric Diphtheria Treatment & Management

  • Author: Cem S Demirci, MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: Mar 10, 2016
 

Medical Care

Critical care needs and complications must be addressed. Mechanical ventilation may be inevitable because the combination of airway obstruction by the diphtheritic membrane and peripharyngeal edema pose a fatality risk in patients with diphtheria.

Specific antitoxin is the mainstay of therapy and should be administered on the basis of clinical diagnosis because it neutralizes free toxin only. Efficacy diminishes with elapsing time after the onset of mucocutaneous symptoms. Only an equine preparation is available in the United States from Connaught Laboratories (Swiftwater, Pennsylvania) or from the CDC.

Antitoxin is administered once at an empiric dose based on the degree of toxicity, site and size of the membrane, and duration of illness. Most authorities prefer the intravenous route, with infusion over 30-60 minutes. Antitoxin is probably of no value for local manifestations of cutaneous diphtheria, but its use is prudent because toxic sequelae can occur. Commercially available immunoglobulin preparations for intravenous use contain antibodies to diphtheria toxin; their use for therapy of diphtheria is not proved or approved. Antitoxin is not recommended for asymptomatic carriers.

When an asymptomatic carrier is identified, the following steps are taken:

  • Antimicrobial prophylaxis is administered for 7-10 days.
  • An age-appropriate preparation of diphtheria toxoid is immediately administered if the patient has not received a booster injection within 1 year.
  • Individuals are placed in strict isolation (respiratory tract colonization) or contact isolation (cutaneous colonization only) until at least 2 subsequent cultures taken 24 hours apart after cessation of therapy demonstrate negative results.
  • Repeat cultures are performed at a minimum of 2 weeks after completion of therapy in patients and carriers; if results are positive, an additional 10-day course of oral erythromycin should be administered and follow-up cultures performed.
  • Antimicrobial agents fail to eradicate carrier status in 100% of individuals.
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Surgical Care

Otolaryngeal assessment is needed in patients with severe respiratory or neurologic complications or as part of critical care.

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Consultations

See the list below:

  • Cardiologist: Elevation of serum aspartate aminotransferase concentrations closely parallels the severity of myonecrosis. In electrocardiographic tracings, a prolonged PR interval, changes in the ST-T wave, and single or progressive cardiac dysrhythmias can occur, such as first-degree, second-degree, and third-degree heart block, atrioventricular dissociation, and ventricular tachycardia. Toxic cardiomyopathy and myocarditis are also complications that need to be evaluated and monitored by a pediatric cardiologist.
  • Neurologist: Neurologic complications parallel the extent of primary infection and are multiphasic in onset.
    • Hypesthesia and local paralysis of the soft palate occur commonly. Weakness of the posterior pharyngeal, laryngeal, and facial nerves may follow, causing a nasal tone in the voice, difficulty in swallowing, and risk of death from aspiration.
    • Cranial neuropathies characteristically occur in the fifth week and lead to oculomotor and ciliary paralysis, which manifest as strabismus, blurred vision, or difficulty with accommodation.
    • Symmetric polyneuropathy begins within 10 days to 3 months after oropharyngeal infection and principally causes motor function deficit with diminished deep tendon reflexes.
    • Proximal muscle weakness of the extremities progressing distally and, more commonly, distal weakness progressing proximally are described. Clinical and cerebrospinal fluid (CSF) findings in distal weakness are indistinguishable from findings of polyneuropathy of Landry-Guillain-Barré syndrome. Paralysis of the diaphragm can ensue.
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Long-Term Monitoring

Data from a study by Januszkiewicz-Lewandowska et al showed that considerable number of child cancer patients lose immunity against diphtheria and tetanus after therapy.[7]

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Contributor Information and Disclosures
Author

Cem S Demirci, MD Consulting Staff, Division of Endocrinology/Diabetes, Connecticut Children's Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Walid Abuhammour, MD, MBA, FAAP Professor of Pediatrics, Michigan State University College of Medicine; Director of Pediatric Infectious Disease, Department of Pediatrics, Al Jalila Children's Hospital

Walid Abuhammour, MD, MBA, FAAP is a member of the following medical societies: American Medical Association, Infectious Diseases Society of America, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur;Astra Zeneca;Novartis<br/>Consulting fees for: Sanofi Pasteur; Novartis; Merck; Astra Zeneca.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Ashir Kumar, MD, MBBS FAAP, Professor Emeritus, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine

Ashir Kumar, MD, MBBS is a member of the following medical societies: Infectious Diseases Society of America, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

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