|Classification according to ICD-10|
|J05||Acute obstructive laryngitis (croup) and epiglottitis|
|Z22.2||Diphtheria germ carrier|
|ICD-10 online (WHO version 2019)|
The diphtheria , even tan or quinsy (in ancient times and even later throat tightness , dog strangler called, and other names), at the beginning of the 20th century is still "angel of death of children" is occurring primarily in children, acute, contagious infectious disease that caused by an infection of the upper respiratory tract with the gram-positive Corynebacterium diphtheriae , the "diphtheria bacillus" (pharyngeal diphtheria). The diphtheria toxin secreted by this pathogen is feared , an exotoxin that can lead to life-threatening complications and long-term effects. The diphtheria vaccine protects against this . Diphtheria is a reportable or notifiable disease in Germany, Austria and Switzerland.
The term diphtheria (English diphtheria , French diphthérie ) introduced Pierre Fidèle Bretonneau from 1826 as diphtherite ("diphtheritis") in medical parlance. It is a word formation with Greek origin ( French Graecism ), derived from διφθέρα, diphthéra for " pair of leather rolls" and the ending -itis for inflammation. The word refers to the sore throat , dark pseudo- membranes (leather-like brown coverings in the larynx and in the windpipe) from dead mucous membrane and blood components.
In French, the word diphthérie developed from this, from which the German form is derived. The disease was also known as throat tan and (as for the first time as breune 1525 in Paracelsus ) tan and later as ( real ) croup ( cough) or croup (from Scottish croup , "hoarseness"). Diseases similar to diphtheria are called diphtheroid .
Diphtheria is triggered by the toxin-producing (poisonous) bacterium Corynebacterium diphtheriae and can be transmitted from person to person through droplet or smear infections , for example through close contact when sneezing, coughing or kissing, rarely also via contaminated objects. Although humans are the main reservoir, they are not the only source of transmission. Clinically healthy bacterial carriers can also transmit the disease, as the vaccine works against the symptoms of diphtheria toxin, but is not directed against the bacterium. The zoonotic bacterium C. ulcerans, which is closely related to C. diphtheriae and very rarely C. pseudotuberculosis, can also cause the systemic symptoms of the disease and, in contrast to C. diphtheriae, are transmitted by animals. In tropical regions, diphtheria can also break out through scratch wounds after insect bites or scabies .
It described two forms: the diphtheria as severe sore throat, and the skin diphtheria punched as part and greasy occupied skin lesions. For the latter, the pathogens have to get into wounds or skin lesions, in particular via a smear infection.
A toxin of the pathogen, diphtheria toxin named after the bacterium , inhibits protein synthesis by inactivating the elongation factor EF-2. However, the pathogens only produce the phage- coded diphtheria toxin if they are infected with a bacteriophage . They are also transported in the blood to organs that are far from the site of inflammation, such as the heart, liver and kidneys. This can lead to the (life) dangerous complications of diphtheria.
Frequency and distribution
The frequency of the disease has decreased significantly due to the passive vaccination with serum introduced by the physician and Nobel Prize winner Emil von Behring and the active vaccination with diphtheria toxoid introduced by Gaston Ramon . During the Second World War, the last major epidemic in Europe was rampant with around 3 million diseases. Before morbidity fell sharply in Europe in the 1960s, the most common diseases were recorded in autumn and winter. However , unlike smallpox , for example, the disease is not eradicated. As soon as the vaccination rate falls below a certain value, the number of illnesses increases again significantly. This was seen in Russia , where 48,000 cases occurred after the collapse of the Soviet Union in 1994 . There the vaccination coverage had dropped to 73-77%, planned vaccination measures were canceled due to the failure of state and health authorities.
In 2018, 27 cases were submitted to the PEI in Germany, 26 cases as skin diphtheria and one case as throat diphtheria. While in western countries like Europe or the USA only isolated cases occur, diphtheria occurs in developing countries. Endemic diphtheria occurs in the eastern Mediterranean, in many parts of Asia, South America and Africa.
The severity and shape of the symptoms that occur two to six days (rarely eight days) after infection ( incubation period ) depend on the patient's immune system . It must be differentiated from pseudocroup and epiglottitis in the differential diagnosis. Carriers of bacteria themselves can be contagious for weeks without showing symptoms. The primary place of settlement are the almonds .
- Localized diphtheria (almond and pharyngeal diphtheria ) begin with feeling tired, nauseated and swallowing pain, often combined with pain in the abdomen and limbs; Vomiting is rare. Increasing fever. A yellowish-white coating develops on the almonds. This can quickly spread throughout the throat. A putrid, sweet smell is usually also present.
- The nasal diphtheria preferably occurs in infants and young children, associated with nasal obstruction, anxiety and eating disorders. Serous or purulent- bloody runny nose occurs, often associated with tissue destruction and crust formation at the nasal entrance.
- Laryngeal diphtheria is the first disease that usually occurs in the wake of pharyngeal diphtheria . Symptoms are barking cough , increasing hoarseness and voicelessness (aphonia), summarized as true croup . Inhalation is difficult and associated with whistling noises ( stridor ).
- Less common forms of diphtheria are skin diphtheria with ulcers and injuries as well as conjunctival diphtheria with bloody-watery secretion and membrane formation and frequent involvement of the cornea.
- In the advanced stage of diphtheria, membrane formation spreads rapidly and intensively to the tonsils , palate , uvula and nasal mucosa ; local lymph node swelling occurs.
A local infection (nasopharynx, skin) can turn into a general reaction (general toxic disease) towards the end, which affects other organs (see complications).
The diagnosis by a bacteriological test can be obtained in twelve hours at the earliest. Therefore, in suspected cases, especially in the case of toxic diphtheria , treatment must be given immediately based on the clinical picture .
The diagnosis can be made clinically. Characteristic is the sweetish, bland halitosis as well as pseudomembranous, firmly adhering gray-yellow coatings on swollen, reddened tonsils.
The diphtheria vaccination prevents serious illnesses in the vaccinated for a number of years after an infection, but not the implantation (colonization) of the pathogens in the mucous membrane of the throat and nose and on the skin, so that diphtheria symptoms can occur even among vaccinated persons, but this is by far not the case are dangerous as with the classic appearance of the disease in people without antitoxin antibodies. These more or less asymptomatic germ carriers can pass the pathogen on to other people or to objects, so the vaccination does not definitely interrupt the chain of infection . Such germ carriers should be treated with antibiotics to eliminate the pathogens .
If diphtheria is suspected, treatment should take place in a clinic immediately; the type of treatment has hardly changed since the time of Emil von Behring . In order to immediately neutralize the toxin from C. diphtheriae that has not yet been bound to cells, the following is given immediately:
- Antitoxin (immune serum from horses ) - passive immunization: Antibody serum (antitoxin) are administered for treatment (10,000–100,000 IU im or iv ). The antibody serum binds the bacterial toxins and makes them harmless. The antitoxin is available in Germany from drug depots of the federal states (emergency depots of the regional pharmacy chambers) for toxicological emergencies.
- In the case of a severe infection that shows symptoms for more than three days, additional high-dose antibiotics: Penicillin is used for at least 10 days to kill the bacteria. If you have a known allergy to penicillin, you can switch to erythromycin , tetracyclines , rifampicin or clindamycin .
If the airways are blocked, endotracheal intubation or a tracheal incision must be made - this was introduced as an emergency by Pierre Fidèle Bretonneau . Bed rest for five to six weeks is necessary to minimize the risk of heart damage. With good and correct treatment, hardly any damage remains and the mortality rate is low.
For prophylaxis, people who have come into contact with the patient's breath are recommended to have a booster vaccination if necessary, a daily check-up for a week, administration of penicillin V and isolation.
As toxic complications due to a toxic general disease (at the beginning or end of a local infection) occur v. a. Heart damage ( myocarditis , endocarditis ), kidney damage and polyneuritis (nerve inflammation): During the diphtheria epidemic in Kyrgyzstan in 1995, 656 patients had to be hospitalized. Heart muscle inflammation was diagnosed in 22% and polyneuritis in 5%.
- Myocarditis is associated with the possibility of conduction disorders , cardiac enlargement and circulatory failure ; a sudden cardiac death in the first week of the disease, or as a "Spättod" appears as "early death" in the convalescence on.
- The polyneuritis expresses itself as paralysis of various cranial nerves or brain nerve branches as of the facial nerve or recurrent laryngeal nerve and can lead to paralysis of the soft palate , the eye muscles or a sip of disability or swallowing paralysis lead, so ingested food can be regurgitated through the nose. The peripheral polyneuritis can one develop normally until three months after onset of the disease.
- A pneumonia occurs in half of the deaths.
- Less common complications are nephritis with impaired kidney function or kidney failure , bacteremia , endocarditis , pulmonary embolism or encephalitis .
The background to these serious complications is the spread of the pathogen to other organs. Nerve cells, liver cells or muscle cells are damaged or killed. In the 1980s, every fourth diphtheria patient died from toxin-related damage to the heart muscle. Purulent-bloody nasal diphtheria is also an important complication in small children or infants.
History of diphtheria
Diphtheria has been known since ancient times; Hippocrates had already described the disease. In 1640, Guillaume de Baillou described a diphtheria epidemic that occurred in Paris in 1576. The Scot Francis Home called diphtheria in the 18th century "croup". Diphtheria was recognized as a specific general disease by the French Armand Trousseau (1801-1867), accordingly the paralysis occurring in diphtheria and its connection with the disease was first recognized by Martino Ghisi (1747), Jean Baptiste Louis Chomel (1748) or Samuel Bard (1771) ) was described.
Discovery of the pathogen
- 1826 - Pierre Fidèle Bretonneau introduces the term diphtheritis into medical parlance
- 1858 - Investigations into the triggering of diphtheria by microorganisms
- 1883 - Edwin Klebs (Zurich) discovers the bacterium in diphtheric membranes under the microscope
- 1884 - Friedrich Loeffler (Berlin) identifies the Corynebacterium diphtheriae as the pathogen of diphtheria at the Imperial Health Department , he succeeds in the pure culture in the "Löffler Serum"
- 1896 - Group: Corynebacteria (coryne, Greek: "club")
- 1951 - Victor J. Freeman : Identification of non-pathogenic (avirulent) strains of diphtheria
- 1888 - Émile Roux & Alexandre Yersin : Detection of toxins in aseptic culture filtrates
- 1889 - Emil Adolf von Behring : Antitoxin. Serum carrier of immunity
- 1890 - by Behring & Shibasaburo Kitasato : Discovery of the antitoxin (antibody) in the blood of sick animals, antitoxin is in principle transferable
- 1894 - William Hallock Park and Anna Wessels Williams develop an antitoxin in the New York City Department of Health; von Behring introduces the "diphtheria healing serum"
- 1898 - von Behring & Erich Wernicke : Immunity through injection of neutralized diphtheria toxin ( diphtheria vaccine )
- 1900 - Paul Ehrlich : Heat inactivation of the toxin
- 1901 - Contamination of the Jim antiserum leads to the testing of vaccines for pathogens
- 1901 - Nobel Prize in Physiology or Medicine for von Behring
- 1913 - von Behring: toxin-antitoxin mixture for immunization
- 1913 - Béla Schick discovers the toxin skin reaction
- 1924 - Gaston Ramon treats the toxin with heat / formalin for vaccination ; Diphtheria toxoid (then still called "anatoxin")
- 1960 - In the GDR , the toxoid vaccination against diphtheria becomes part of the mandatory vaccinations
- 1961 - In Germany , the toxoid vaccination against diphtheria becomes part of the officially recommended vaccinations
In Germany, suspected illness, illness and death from diphtheria must be reported by name in accordance with Section 6 of the Infection Protection Act (IfSG). Likewise, the direct or indirect detection of toxin-forming Corynebacterium spp. Specifically notifiable in accordance with Section 7 IfSG, provided that evidence indicates an acute infection. The diagnosing doctors or laboratories etc. are obliged to report ( § 8 IfSG).
In Austria, diphtheria is a notifiable disease in accordance with Section 1 (1) of the 1950 Epidemic Act . The reporting obligation relates to cases of illness and death. Doctors and laboratories, among others, are obliged to report this ( Section 3 Epidemics Act).
In Switzerland, if the disease diphtheria is clinically suspected, a pathogen-specific laboratory diagnosis is required for doctors, hospitals, etc., as well as a positive laboratory analysis (or a negative result for a test for the toxin gene) for the pathogen Corynebacterium diphtheriae (and other toxin-producing corynebacteria ) for Laboratories are notifiable according to the Epidemics Act (EpG) in conjunction with the Epidemics Ordinance and Annex 1 or Annex 3 of the Ordinance of the FDHA on the reporting of observations of communicable diseases in humans .
- Diphtheria - information from the Robert Koch Institute
- Diphtheria - impfen–info.de: Comprehensive information from the Federal Center for Health Education (BZgA) on the subject of vaccinations.
- Barbara I. Tshisuaka: Diphtheria. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , p. 315.
- RR MacGregor: Corynebacterium diphtheriae. In: Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 6th edition, 2005.
- Karl Wurm, AM Walter: Infectious Diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 9-223, here: pp. 87-95.
- Paul de Kruif : Roux and Behring. Against diphtheria! In: Paul de Kruif: Microbe hunters. (Original edition: Microbe Hunters. Harcourt, Brace & Co., New York 1926) Orell Füssli Verlag, Zurich / Leipzig 1927; 8th edition ibid 1940, pp. 175-197.
- ↑ Georg Sticker : Hippokrates: The common diseases first and third book (around the year 434-430 BC). Translated from the Greek, introduced and explained by Georg Sticker. Johann Ambrosius Barth, Leipzig 1923 (= Classics of Medicine. Volume 29); Unchanged reprint: Central antiquariat of the German Democratic Republic, Leipzig 1968, p. 103.
- ↑ a b c d e f g h i j k l m n Marlies Höck, Helmut Hahn: Corynebacteria . In: Sebastian Suerbaum, Gerd-Dieter Burchard, Stefan HE Kaufmann, Thomas F. Schulz (eds.): Medical microbiology and infectious diseases . Springer-Verlag, 2016, ISBN 978-3-662-48678-8 , pp. 310 , doi : 10.1007 / 978-3-662-48678-8_37 .
- ↑ Pierre Fidèle Bretonneau: Des inflammations spéciales du tissu muqueux, et en particulier de la diphthérite. Ou inflammation pelliculaire, comme sous le nom de croup, d'angine maligne, d'angine gangréneuse, etc. Paris 1826.
- ^ Friedrich Kluge , Alfred Götze : Etymological dictionary of the German language . 20th edition. Edited by Walther Mitzka . De Gruyter, Berlin / New York 1967; Reprint (“21st unchanged edition”) ibid 1975, ISBN 3-11-005709-3 , p. 97.
- ↑ see also list of historical disease names
- ^ Albrecht N. Rauch: disease names in German. A dialectological and etymological study of the names for diphtheria, Febris scarlatina, Morbilli, parotitis epidemica and varicellae. Stuttgart 1995 (= Journal for Dialectology and Linguistics , Supplement 84).
- ↑ a b c d e f g h Friedrich Hofmann: Diphtheria . In: Heinz Spiess, Ulrich Heininger, Wolfgang Jilg (Eds.): Impfkompendium . 8th edition. Georg Thieme Verlag, 2015, ISBN 978-3-13-498908-3 , p. 148 ff .
- ↑ Documentation of the benefits of standard vaccines: Diphtheria. arznei-telegramm , September 15, 2017, pp. 77-80 , accessed on November 4, 2019 .
- ↑ Cutaneous diphtheria: Increase in infections with Corynebacterium ulcerans. In: Deutsches Ärzteblatt . March 15, 2018, accessed November 4, 2019 .
- ↑ a b c Infection epidemiological yearbook for 2018. (PDF) Robert Koch Institute , January 16, 2020, p. 75 ff. , Accessed on February 9, 2020 .
- ↑ Diphtheria - RKI-Ratgeber , as of October 10, 2018, accessed September 19, 2019
- ↑ Vaccination against diphtheria: Frequently asked questions and answers. Robert Koch Institute , as of January 11, 2018; accessed September 19, 2019
- ↑ Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures: recommendations of the Immunization Practices Advisory Committee (ACIP). Morbidity and Mortality Weekly Report 1991: 40 (No. RR-10). Centers for Disease Control, MMWR, Aug. 8, 1991/40 (RR10); 1-28
- ^ Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , p. 198.
- ↑ Marlies Höck and Helmut Hahn: Corynebacteria . In: Sebastian Suerbaum, Gerd-Dieter Burchard, Stefan HE Kaufmann, Thomas F. Schulz (eds.): Medical microbiology and infectious diseases . Springer-Verlag, 2016, ISBN 978-3-662-48678-8 , pp. 313 .
- ↑ Marianne Abele-Horn (2009), p. 198.
- ↑ G. de Baillou: Epidemiorum et ephemeridum libri duo. Paris 1640.
- ↑ Karl Wurm, AM Walter: Infectious Diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 9-223, here: p. 87.
- ↑ Diphtheria (PDF)
- ↑ Georg Sticker : Hippokrates: The common diseases first and third book (around the year 434-430 BC). Translated, introduced and explained from the Greek. Johann Ambrosius Barth, Leipzig 1923 (= Classics of Medicine. Volume 29); Unchanged reprint: Central antiquariat of the German Democratic Republic, Leipzig 1968, p. 103.
- ^ Edwin Klebs, board member 1872–1873. Pathological Institute of the University of Würzburg
- ^ VJ Freeman: Studies on the virulence of bacteriophage-infected strains of Corynebacterium diphtheriae . In: Journal of Bacteriology . tape 61 , no. 6 , June 1951, p. 675-688 , PMID 14850426 .
- ↑ Karl Wurm, AM Walter: Infectious Diseases. 1961, p. 87.