Diphtheria: symptoms, diagnosis, causes, treatment, vaccination. Diphtheria

Diphtheria is an infectious disease provoked by the action of a specific bacterium, the transmission of which (infection) is carried out by airborne droplets. Diphtheria, the symptoms of which consist in the activation of the inflammatory process mainly in the area of \u200b\u200bthe nasopharynx and oropharynx, is also characterized by concomitant manifestations in the form of general intoxication and a number of lesions that directly affect the excretory, nervous and cardiovascular systems.

general description

In addition to the listed variants of the lesion, diphtheria can also manifest itself in its own benign form, which, accordingly, is accompanied by a lesion of the nose and the absence of pronounced manifestations characteristic of intoxication.

Inflammation, which is relevant for diphtheria, proceeds in combination with such a process as the appearance of fibrin films that look like a white plaque, and if we are talking, again, not about a benign form of the disease, then general intoxication also manifests itself.

Leffler's bacillus was identified as the causative agent of the disease. Its peculiarity lies, first of all, in a significant degree of stability to the conditions of influence from the external environment. So, the standard conditions determine such resistance for the causative agent of the disease for a period of 15 days, resistance to the effects of low temperature indicators can be about 5 months, but the resistance when being in an aqueous medium or in milk is about three weeks. Death within one minute is achieved by boiling the pathogen or by processing it using a disinfectant solution (chlorine).

Diphtheria: causes

The source of the spread of infection is a sick person or a carrier of a strain of a toxigenic sample (in this case, a certain type of pathogen that provokes the development of the disease is meant). In the spread of infection, the greatest significance is determined for patients with diagnosed diphtheria of the oropharynx, especially when it comes to the erased form of the course of the disease or its atypical form. Significant danger has been identified for bacteria carriers, in which the excretion of the causative agent of the disease occurs through the oropharynx. Depending on the specific group of patients, long-term carriage of infection in frequency ranges from 13-29%. Due to the continuity characteristic of the epidemic process, carriage is defined as long-term, and even without the possibility of registering the overall incidence.

The route of transmission is airborne, the transmission mechanism is aerosol. In some cases, options in the form of objects used in the environment (dishes, toys, clothes and linen, etc.) are considered as transmission factors. If the causative agent of the disease is on the hands, then the development of such forms of diphtheria as diphtheria of the eyes, diphtheria of the genitals and diphtheria of the skin is allowed - a specific option, as you can understand, is determined on the basis of further spread. In addition, the path of food contamination is also possible, for example, when a virus multiplies in a confectionery cream, in milk, etc.

If we talk about the natural susceptibility to infection, then it is quite high and is determined on the basis of the actual antitoxic immunity of each individual patient. For example, if the blood contains specific antibodies in an amount within the order of 0.03 AU / ml, then protection against diphtheria is considered as a possibility, which, however, does not exclude the possibility of obtaining the status of a carrier of a pathogenic pathogen. With transplacental transmission of antitoxic antibodies in newborns, they are protected from diphtheria during the first 6 months after birth.

As for patients who have had diphtheria, as well as patients who have undergone the correct vaccination procedure, they develop antitoxic immunity, which determines, due to their own level, a reliable degree of protection from the subsequent possible impact of the infection we are considering.

For diphtheria, the autumn-winter seasonality, traditional for many diseases, is determined, although such variants of the periodicity of the occurrence of epidemics are not excluded, in which the cause of their occurrence lies in negligence in relation to prevention through vaccination. Cases of negligence can be tolerated by both medical personnel and the public. The explanation for this is the increase in the number of persons who have lost the antitoxic immunity, which is acquired during vaccination or during repeated vaccination (revaccination). Thus, the following causes of diphtheria can be distinguished as factors causing infection:

• violations associated with preventive vaccination of the population (this factor causes the largest number of outbreaks of diphtheria epidemic);
• disorders associated with the work of the immune system;
• factor of the relative resistance of the pathogen to environmental conditions, due to which its prolonged survival in it, reproduction and migration is allowed.

Epidemiological features of diphtheria

It is argued that diphtheria as a disease is subject to successful control, which, in particular, is ensured by the vaccination of the population. In European countries, the beginning of massive immunization programs was noted in the 40s, due to which a rapid decrease in the incidence rate was revealed, and down to single diagnosed cases in a number of countries. Remarkably, with a significant decrease in the immune layer, an increase in the incidence is subject to a corresponding increase. Involvement in epidemiological processes is noted not only for adult groups of the population, but also for children, in particular, this applies to cases with unreasonable withdrawals from the need for preventive vaccination, as a result of which the transmission of the pathogen from adults occurs due to their lack of the required antitoxic immunity to avoid this. ...

A separate item is assigned to the increase in migration in recent years among the population, due to which the spread of the pathogen has increased. The already noted autumn-winter outbreaks of the disease (in other words, intra-annual morbidity), as well as periodic outbreaks (caused by long-term dynamics), in particular, reach a peak in the event of actual defects in preventive vaccination.

Such conditions also dictate the possibility of a "shift" from childhood to an older age with the predominant defeat of those persons whose professional activity most predisposes to infection (trade and transport workers, service workers, teachers, health workers, etc.) ... Due to a sharp deterioration in the general epidemiological situation, the course of the disease is more severe, as a result of which the risks in terms of mortality in the background of the disease also increase.

Features of the pathogenesis of diphtheria: how does the disease proceed?

The mucous membranes of the oropharynx act as the main gateway for the infection to enter the body, somewhat less often - the mucous membranes of the larynx and nose. Also, as highlighted above, the possibility of affecting the ears, conjunctiva, skin and genitals is allowed. Toxigenic bacterial strains release enzymes and exotoxin, due to the effect of which inflammation foci are subsequently formed.

The peculiarities of the local effect produced by the diphtheria toxin are non-coagulation necrotic processes in the epithelium, vascular hyperemia (overflowing with blood within a certain organ or part of the body), as well as in blood stasis (slowing down the blood flow and stopping it) in the capillaries and in increasing the degree of permeability of the walls of blood vessels. Exudate (a cloudy liquid saturated with hematogenous and histogenic cells and protein, sweating in the focus of inflammation from the blood vessels), which also includes macrophages, leukocytes, fibrinogen and erythrocytes, leaves the normal vascular bed. Subsequently, fibrinogen, under the influence of a reaction against the background of contact of the mucosa with thromboplastin (related to tissues that have undergone necrotization), is converted into fibrin.

Further, fibrin, or rather the fibrin film, begins to concentrate and fix in a dense manner on the epithelium of the pharynx and pharynx. During this period, it is easily eliminated from the mucous membrane on the basis of monolayer epithelium in the bronchi, trachea and larynx. At the same time, the mild course of diphtheria can be limited only to the development of the usual catarrhal process, which is not accompanied by the appearance of fibrinous plaque.

Nevertheless, further the picture of the course of the disease may be as follows. Neuraminidase of the causative agent of diphtheria (a specific glycoprotein complex, due to which enzymatic activity is provided, which, in turn, determines the ability of a viral particle to penetrate the host cell with subsequent release from it after reproduction) has a pronounced potentiating effect on exotoxin. Its main part is histotoxin, due to which the blocking of the synthesis process in cells of protein and transferase, which acts as an inactivating enzyme and is responsible for the formation of a polypeptide bond, is ensured.

Diphtheria exotoxin spreads through the blood vessels and lymph nodes, which, in turn, determines the conditions for the development of intoxication with the corresponding symptoms, as well as the conditions for the development of regional lymphadenitis in combination with edema of tissues in the immediate environment of the affected environment. Severe cases of the course lead to the fact that the swelling of the tonsils, palatine arches and the palatine uvula causes the development of swelling for all tissue concentrated in the neck, the degree of swelling in this case corresponds to a specific stage of the course of the disease.

Due to the actual process of toxinemia (a condition accompanied by the circulation of bacterial exotoxin through the circulatory system with its delivery to the so-called target cells), inflammatory-degenerative processes and microcirculatory disorders develop in various systems and organs (nervous and cardiovascular systems, adrenal glands, etc. kidneys).

The process of binding toxin and specific cellular receptors occurs in accordance with two phase variants, in particular, it is a reversible and irreversible phase. Reversible phase conditions the possibility of maintaining the viability of cells at the same time an admissible possibility of neutralizing the toxin due to antitoxic antibodies. Concerning phase irreversible, then here, accordingly, the neutralization of the toxin due to antibodies does not occur, therefore there are no obstacles to the implementation of the cytopathogenic activity produced by it.

To complete the consideration of this section, which to some extent clarifies the features of the course of the disease, we add that the antitoxic immunity that develops in a patient against the background of diphtheria transfer does not always act as a sufficient protection to further prevent this disease in a second variant when infected with a pathogen.

Diphtheria: symptoms

The duration of the incubation period (i.e., the period that lasts from the moment of infection until the moment the first symptoms appear relevant for the disease) is about 2-10 days. During these days, in the area of \u200b\u200bthe entrance gate of infection (respiratory tract, genitals, oropharynx, skin or eyes), the pathogen of diphtheria penetrates into the body. At the same time, when it enters the epithelial cells, diphtheria bacteria begin to provoke cell dissociation in tissues, which is ensured by suppressing the synthesis process in their protein fractions (the so-called "line of first defense", it is she who is affected).

In a parallel way, in accordance with the picture of the pathogenesis of diphtheria discussed above, the exotoxin begins to exert a corresponding effect, due to which tissues are killed, edema develops and an intercellular fluid (exudate) appears, which is subsequently converted into fibrin. Fibrin externally appears as a yellowish film (plaque) covering the mucous membranes.

The classification of diphtheria determines a number of forms of this disease, which, in turn, are characterized by their own characteristics of the course. Diphtheria of the oropharynx, and she is the first on the list, is diagnosed most often.

• Diphtheria of the oropharynx
  • form of localization with insular, membranous and catarrhal variants;
  • common form;
  • subtoxic form;
  • toxic form (I-III degree);
  • hypertoxic form.
• Diphtheria croup (laryngeal diphtheria)
  • localized diphtheria croup (laryngeal diphtheria);
  • widespread diphtheria croup (diphtheria of the larynx and trachea);
  • descending diphtheria croup (diphtheria with damage to the larynx, bronchi and trachea).
• Genital diphtheria
• Eye diphtheria
• Diphtheria of the nose
• Skin diphtheria
• Forms of combined diphtheria, characterized by damage to several organs at the same time

Below we will consider the symptoms and features of each of the options.

• Diphtheria of the oropharynx: symptoms

This form of diphtheria is diagnosed in about 90-95% of cases of morbidity, both for diphtheria in adults and in children. In about 75% of cases, its course is localized.

The onset of the disease in this form is characterized by the severity of its own manifestations, in patients the temperature rises (from indicators within the range of up to 37.5 degrees and to higher), the duration of its preservation is about 3 days. The severity of the manifestations of intoxication is characterized by moderation, as these manifestations, we recall, are headache, pallor of the skin, decreased appetite, increased heart rate and general malaise. A further decrease in temperature is opposed, on the contrary, by the activation of manifestations from the side of the entrance gate of the infection, which not only persist, but can also gradually increase in intensity.

The severity of pain in the throat, noted during swallowing, is determined on the basis of actual changes in the oropharynx area, it also shows a diffuse and dim form of hyperemia, moderate swelling in the tonsils, arches and in the soft palate. Localization of the raids is noted only from the side of the tonsils; in this case, they do not go beyond their borders, the location of these raids is carried out either in the form of separate islands, or in the form of a membranous layer.

In the first hours after the onset of the onset of the disease, the filmy deposits resemble a jelly-like mass in consistency, after which they are transformed into a spider-like thin film. From the second day of its appearance, this film acquires a pronounced density and smoothness, and its color also changes (to grayish with a pearlescent sheen). Such a film is eliminated with difficulty, after which the surface of the mucous membrane bleeds. By the next day after removing the film, a new layer is formed. If such a film is placed in water after being removed, you will notice that it does not sink and is not subject to separation and decay.

The localized form of diphtheria is accompanied by the formation of typical fibrinous plaques in about a third of cases of this disease in adults, in other cases (including in the case of considering the later terms of manifestation of the disease, 3-5 days), plaques are characterized by looseness and ease of removal, while removal is accompanied by the practical absence of mucosal bleeding. There is also a moderate increase in regional lymph nodes and submandibular lymph nodes, they are sensitive to feeling (palpation). Actual processes in the tonsils, as well as the reaction following from the regional lymph nodes, can be one-sided and asymmetrical.

When catarrhal variantmanifestations of a localized form of diphtheria of the oropharynx, there is a minimum of local and general symptoms. However, this form is rarely diagnosed. Here there is a normal or short-term manifesting itself subfebrile temperature (within the range of up to 37.5 degrees) and mild symptoms characteristic of intoxication, they also proceed in combination with unpleasant sensations arising from swallowing in the throat. The tonsils are edematous, the oropharynx is subject to a mild form of hyperemia. Diphtheria as a diagnosis in this case can be considered only on the basis of taking into account the data of the anamnesis (medical history) of the patient in combination with the results of laboratory examinations and taking into account the peculiarities of the general epidemiological situation.

As a rule, this form is characterized by its own good quality. Following the normalization of the temperature, the pain that appears in the throat when swallowing disappears, the duration of the plaque on the tonsils can be about 8 days. Meanwhile, if we ignore the need to treat oropharyngeal diphtheria, then the possibility of progression of the disease is not excluded, and, even worse, the possibility of transformation into more severe forms.

Oropharyngeal diphtheria in a common formdiagnosed relatively rarely - in about 3-11% of cases of diphtheria. The difference from the localized form lies in the widespread nature of the manifestation of raids that extend beyond the tonsils to any areas located in the mucous membrane of the oropharynx. The nature of the symptoms (swelling of the tonsils, intoxication, enlargement and soreness of the lymph nodes of the submandibular region) has a more pronounced form (in comparison with the localized form). Edema of the cervical subcutaneous tissue does not develop in this case.

Next, subtoxic form of diphtheria of the oropharyngeal region,characterized by the manifestation of intoxication and severe soreness, noted in the throat when swallowing. In some cases, the soreness appears in the neck area. A characteristic plaque appears on the tonsils (it is localized in nature, only slightly spreads to the tongue and to the palatine arches), the tonsils themselves change in color (become purple-cyanotic). Puffiness (uvula, arch, soft palate and tonsils) is moderate, regional lymph nodes are indurated. This form of diphtheria has a characteristic feature, it consists in the development of edema in the area above the regional lymph nodes, often such edema is unilateral.

Further - a toxic form of oropharyngeal diphtheria. Now it is diagnosed quite often (in about 20% of cases of general morbidity), especially diphtheria in adults in this form is relevant. It develops either because of an incompletely treated localized form of the disease or because of its widespread form, although in the overwhelming majority of cases there is still a spontaneous independent development of the disease with its subsequent rapid progression.

As a rule, patients are diagnosed with a high temperature (within 39-41 degrees), and it occurs already in the first hours of the disease. In addition, there is another symptomatology of intoxication, and this is weakness and headache, severe sore throat is also added to these manifestations, in some cases - pain in the abdomen and neck. The possibility of vomiting, the development of such a disorder of the masticatory muscles as painful trismus (restrictions in opening the mouth) is not excluded.

Delirium (a form of mental disorder accompanied by impairment of consciousness), excessive agitation, delirium and euphoria may develop. In addition, pallor of the skin is noted (III degree of the toxic form of the disease can manifest itself in the form of hyperemia, that is, in redness of the skin of the face). Severe edema in combination with diffuse hyperemia of the oropharyngeal mucosa in the framework of II and III degrees is accompanied by complete closure of the throat lumen, which is considered as a precursor to the formation of fibrinous plaque.

The spread of plaque occurs in this case in a rapid manner, to each of the parts of the oropharynx. Subsequently, such films thicken and become coarser, the period of their retention on the mucosal surface is on average 2 weeks, although a longer period for this manifestation is allowed. Often the process is one-sided, an increase in regional lymph nodes occurs early, to a significant size, their soreness and density are also noted, the tissues surrounding them gradually become inflamed (periadenitis).

The peculiarities of local manifestations that are relevant for this toxic form of the course of the disease distinguish it from other forms in that a painless pasty edema is formed in the cervical subcutaneous tissue. Grade I diphtheria here is accompanied by reaching the mid-neck area, grade II is accompanied by a similar lesion of the clavicle, and grade III proceeds with a characteristic lesion of the clavicle, descending from top to bottom, and the spread of the lesion can affect the back of the neck, back and face, all this happens with a gradual progression of the disease.

General toxic syndrome has a pronounced character of manifestation, there is an increase in heart rate, blueness of the lips, low blood pressure. The temperature also rises, and if it decreases, then the manifestations of the rest of the symptoms still remain pronounced. A characteristic feature in this case is a specific type of cloying-putrid smell and nasal voice. Often, toxic diphtheria is accompanied by the addition of damage to the nose and larynx, in this case, the form, as is clear, is combined, is characterized by the severity of its own course and the difficulty of influencing therapeutic measures against it.

The most severe manifestation of diphtheria is its hypertoxic form.Basically, such a course of diphtheria is diagnosed in patients with the actual negative nature of the premorbid background for them (that is, with concomitant alcoholism, chronic hepatitis, diabetes mellitus, etc.). The symptoms of diphtheria consist, first of all, in a rapid increase in temperature indicators, and the temperature in this case is accompanied by chills and a pronounced form of intoxication in the corresponding manifestations (headache, dizziness, general malaise and vomiting). In addition to this, progressive forms of disorders related to hemodynamics are noted, which manifests itself in the form of a rapid heartbeat, pallor of the skin, and low blood pressure.

Skin hemorrhages also appear, bleeding from the internal organs is relevant, fibrinous deposits are soaked in blood (DIC develops). The clinic is characterized by a dominant state of signs accompanying the development of an infectious-toxic form of shock, and this, in turn, can lead to death within 1-2 days from the onset of the onset of the disease, which, accordingly, indicates the inadmissibility of any delays in part of the treatment for the indicated symptoms.

• Diphtheria croup

This form of the disease can occur in its localized form (the larynx is affected, respectively, this is laryngeal diphtheria) or in the form of a widespread (both the larynx and the trachea, and sometimes the bronchi are affected at the same time).

If a variant of the common form is considered, then here it is mainly noted its combination with diphtheria of the nose and oropharynx. It should be noted that the symptoms of diphtheria in adults have recently been found in this form quite often. Features of the manifestation of croup are in the alternating following three stages of the course. So, this is a dysphonic stage, a stenotic stage and an asphyxical stage. The manifestations of intoxication in all cases are characterized by their own moderation.

As leading manifestations corresponding dysphonic stage, there is a barking cough in a rough form of its own manifestation, as well as an increase in hoarseness. Symptoms of diphtheria in children at this stage appear in the period of 1-3 days, while adults tolerate it a little longer - up to 7 days.

Next, stenotic stage, characterized by a course duration of up to 3 days. The voice in patients loses its sonority (switches to a whisper), the cough manifests itself silently. The pallor of the patient, his anxiety is noted. Breathing is noisy, inhalation is lengthened, signs indicating difficulty in breathing gradually increase. The skin and mucous membranes are characterized by pallor and cyanosis, and the heartbeat also increases. With an increase in the listed signs, the question arises of the need to provide tracheostomy or intubation, due to which it is possible to prevent the transition of the disease to the next stage.

The next stage is asphyxia stage, it is accompanied by superficiality and rapidity of the patient's breathing, subsequently it becomes rhythmic. The cyanosis of the skin and mucous membranes gradually increases, blood pressure decreases, the pulse is threadlike. Further, there is a disturbance of consciousness, the occurrence of seizures and, ultimately, death occurs due to asphyxia (suffocation, accompanied by a shortage of oxygen in the tissues and in the blood with the simultaneous accumulation of carbon dioxide in them).

Given the peculiarities of the larynx in adults in anatomical terms (in comparison with the larynx in children), it takes longer for them to develop diphtheria croup than to develop it in children. It is noteworthy that a certain proportion of cases account for the course of the disease only with concomitant hoarseness, combined with a feeling of lack of air. In addition, you should pay attention to pallor of the skin, increased heart rate, weakened breathing. The diagnosis in this case is facilitated by carrying out a laryngoscopic or bronchoscopic examination, due to which it is possible to detect hyperemia of the larynx and its edema, the possibility of studying the features of membranous formations in the vocal cords, as well as the peculiarities of damage to the bronchi and trachea within the course of the disease.

• Diphtheria of the nose

The disease in this form is characterized by an insignificant degree of intoxication, the appearance of serous-purulent secretions or secretions of a sacral type, difficulty in nasal breathing. Redness of the nasal mucosa, swelling and the appearance on its surface of ulcers, erosive formations or fibrinous film overlays resembling “shreds” is noted. In the area surrounding the nose, irritation develops, weeping is also noted in combination with the crusts that form here, and in this form of the disease, a runny nose persists. As a rule, nasal diphtheria occurs in combination with another type of diphtheria lesions, that is, with diphtheria of the larynx and / or oropharynx, in some cases - with diphtheria of the eyes, the features of which we will consider below.

• Eye diphtheria

This form of diphtheria, in turn, proceeds in a catarrhal, filmy and toxic form.

Catarrhal formis characterized predominantly by unilateral inflammation of the conjunctiva, which is accompanied by the appearance of a certain amount of eye discharge. The temperature, as a rule, either does not change, or reaches the limits of subfebrile indicators (up to 37.5 degrees). Regional inflammation and enlargement of lymph nodes in this case is absent, as well as symptoms of intoxication.

Film formdiphtheria of the eyes is accompanied by mild general toxic symptoms in combination with subfebrile temperature, and the formation of a fibrin film on the conjunctiva undergoing reddening is also accompanied by this. Additionally, there is an increase in swelling of the eyelids, serous-purulent eye discharge appears. Initially, the process can manifest itself unilaterally, however, after a few days, the possibility of its subsequent transition to another, that is, to a healthy eye, is allowed.

And finally toxic formdiphtheria, accompanied by an acute onset and the subsequent rapid development of symptoms of intoxication. The eyelids swell, there is abundant purulent-purulent eye discharge, the skin around the eye is prone to weeping and general irritation. Subsequently, the course of the disease is a gradual spread of edema, and therefore the subcutaneous tissue in the face is affected. Often, this form of the disease is accompanied by damage to other ophthalmic regions, which can even achieve panophthalmia (inflammation of the eyeball), regional inflammation of the lymph nodes also manifests itself in combination with their soreness.

• Skin diphtheria, genital diphtheria, ear diphtheria

The listed variants of diphtheria manifestation are rarely diagnosed. As a rule, they develop in combination with other forms of diphtheria, for example, nasal diphtheria or pharyngeal diphtheria. As general features of these options, we can note the manifestations common to diphtheria as a whole, and these are edema, oozing, hyperemia of the skin and mucous membranes, the appearance of fibrinous plaque in the affected area, inflammation and soreness of regional lymph nodes.

Genital diphtheria in men is accompanied by the concentration of the pathological process within the foreskin. As for diphtheria of the genital organs in women, here it can have a more common form of the course, accompanied by the seizure of the perineal region, vagina and labia, as well as the anus, while serous-bloody discharge coming from the genital tract is considered as concomitant manifestations ... Urination becomes difficult, this process is also accompanied by pain.

Skin diphtheria has its own characteristics, which is characterized by the development of a pathological process in the area of \u200b\u200bconcentration of diaper rash, wounds, eczema or fungal lesions in combination with visible cracks in the skin during the formation of a dirty gray plaque and with the release of serous-purulent exudate. As for the traditional general toxic manifestations, in this case they are insignificant, the regression of the local process occurs slowly (a month or longer).

As predisposing factors for the development of the forms of diphtheria indicated in this paragraph, trauma to the skin or mucous membranes is considered, which is subsequently accompanied by the introduction of the pathogen.

Diagnosis

The diagnosis of diphtheria is mostly clinical, which makes it possible to establish it on the basis of visual examination. As for additional diagnostic methods, they are also used - this is done, in particular, to diagnose atypical forms of the course of the disease, to identify specific strains, as well as to deregister the patient for this diagnosis.

Laboratory diagnostic methods:

• Bacteriological method.This method consists in taking a smear from the patient from the oropharyngeal region, where healthy mucosal tissue and tissue affected by fibrin films border each other. The effectiveness of this diagnostic method is determined within a period of 2-4 hours after the material was removed. With the help of a bacteriological research method, the pathogen is isolated, after which it becomes possible to study its toxic characteristics (if at all this pathogen is present in the material).
• Serological method.The degree of immunity tension is determined, antitoxic and antibacterial antibodies are detected. On the basis of the data obtained, the possibility of obtaining specific provisions for the severity of the manifestation of the process (acute or recently transferred form of the disease) is determined.
• Genetic method (PCR method). This method allows you to examine the DNA of the pathogen.

The need for diagnostics in terms of possible complications is considered as a separate item. So, in case of suspicion of carditis, ultrasound of the heart, phonocardiography, ECG are performed, in addition, the features of the activity of aspartate aminotransferase, creatine phosphokinase and lactate dehydrogenase are studied. If there are suspicions of nephrosis that is relevant to the patient, then the following diagnostic procedures are carried out: biochemical blood test (for urea and creatinine indicators), ultrasound of the kidneys, UAC and OAM.

Treatment

Diphtheria treatment is based on a number of the following basic principles:

• The use of anti-diphtheria antitoxic serum. Its appointment is necessary at the earliest possible date for the detection of the disease, because this determines the possibility of subsequent exclusion (or minimization) of complications. In particular, the effectiveness is noted during the first four days from the moment of the onset of symptoms in patients; ideally, it should be used even in case of suspicion of infection against the background of previous contact with a patient with diphtheria.
• The use of antibiotics (macrolides, cephalosporins, aminopenicellins), the duration of their treatment is about 2-3 weeks.
• Treatment at the local level (immunomodulator in the form of interferon ointment, neovintin, chemotrypsin ointment) using drugs that help eliminate fibrin plaque.
• Treatment focused on eliminating symptoms (taking into account the specific damage to the system or organ in the patient's body).
• Antihistamines.
• Antipyretic drugs.
• Multivitamin preparations.

In hospitals, intensive care units and intensive care units, the following additional therapy measures can be implemented:

• Plasmaphoresis, hemosorption, hormonal therapy using glucocorticosteroids.
• Detoxification-scale therapy, which consists in the introduction of liquid media into the desired area.
• The use of membrane-protective antioxidants.

Mandatory is the appointment of a three-week bed rest (a condition under strict adherence). In the future, it is necessary to register with a cardiologist for this disease - this will provide an opportunity to diagnose complications in this profile in a late form of their manifestation with an actual connection with diphtheria. The diet for diphtheria is prescribed sparing, the need to reduce hypoallergenic foods is taken into account.

Complications of diphtheria can consist in myocarditis, as well as in dysfunctions of the nervous system, which, as a rule, manifests itself as paralysis. Diphtheria is often complicated by the development of paralysis of the soft palate, neck muscles, respiratory tract, vocal cords, and extremities. It should be noted that paralysis of the respiratory tract can lead to asphyxia (which is important for croup), which, as we have already indicated, can lead to death.

When symptoms appear that correspond to the picture of the course of diphtheria, it is necessary to contact the attending physician and infectious disease specialist; in the future, the patient can be registered with a cardiologist.

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Diphtheria is an acute infectious disease caused by diphtheria bacteria, transmitted mainly by airborne droplets, characterized by inflammation, most often of the mucous membranes of the oropharynx and nasopharynx, as well as phenomena of general intoxication, damage to the cardiovascular, nervous and excretory systems.

The causative agent of diphtheria is a toxigenic strain of the diphtheria microbe. It looks like a stick with thickening at the ends. Microbes are arranged in the form of the letter V. They secrete dangerous poisons - exotoxin and neuraminidase. In addition, they break down cystine and ferment glucose, and are able to reduce nitrates to nitrites.

In connection with the ability of microorganisms to ferment starch, the disease was divided into three clinical forms: the first is light, in which starch is not fermented, the second is medium, intermediate, and the third is heavy, with the ability to ferment starch. But in essence, such a relationship does not exist at all. Only the largest microorganism can produce toxins.

The causative agent of diphtheria

Why does diphtheria develop, and what is it? The incubation period for diphtheria ranges from 3 to 7 days. The manifestations of diphtheria are diverse and depend on the localization of the process and its severity.

The source of infection is humans. The transmission of the pathogen is carried out mainly by airborne droplets, but infection is also possible by contact-household (through infected objects). For diphtheria, autumn-winter seasonality is characteristic. In modern conditions, when mostly adults are sick, diphtheria occurs throughout the year.

The causative agent of diphtheria is a diphtheria bacillus, the carrier of which is a sick person or a person who carries an infection during the incubation period of diphtheria bacillus, as well as for some time after recovery.

Diphtheria symptoms

The incubation period for diphtheria is from 2 to 10 days. When a diphtheria bacillus enters the body, a focus of inflammation develops at the site of its introduction, in which the pathogen multiplies, releasing a toxin.

With lymph and blood, the toxin is carried throughout the body, causing damage to both the mucous membrane (or skin) at the site of introduction of the pathogen, and internal organs and systems. Since the pathogen most often enters the pharynx, local changes most often occur in it. In addition, an inflammatory focus can develop in the nose, larynx, ear, genitals, eyes, wound surface of the skin.

Signs of diphtheria depend on the location of the pathogen. Among the general symptoms characteristic of all forms of the disease, the following can be distinguished:

• thick gray deposits covering the throat and tonsils;
• sore throat and hoarseness;
• and swelling around them (the so-called "bull's neck");
• difficulty breathing or rapid breathing;
• discharge from the nose;
• fever and chills;
• general malaise.

Symptoms of diphtheria depending on the clinical form:

• Most often (in 90% of all cases of morbidity) occurs oropharyngeal diphtheria... The duration of the incubation period is from 2 to 10 days (from the moment of human contact with the carrier). When Leffler's stick penetrates the oral mucosa, it damages it and causes tissue necrosis. This process is manifested by severe edema, the formation of exudate, which is later replaced by fibrin films. Hard-to-remove plaque covers the tonsils, can go beyond them, spreading to adjacent tissues.
• With diphtheria croup, the larynx, bronchi, trachea can be affected... There is a strong cough, which leads to the fact that the voice becomes hoarse, the person turns pale, it is difficult for him to breathe, the heart rhythm is disturbed, cyanosis. The pulse becomes weak, blood pressure drops sharply, disturbances in consciousness, and a convulsive state may disturb. The form is dangerous because it can lead to suffocation and death.
• Diphtheria of the nose. In cases with nasal diphtheria, a very slight intoxication of the body, bloody discharge, serous-purulent discharge, nasal breathing difficulties will be characteristic. In this form of diphtheria, the nasal mucosa: swollen, hyperemic, with sores, with erosions or fibrinous overlays (easy to remove, look like shreds). Also on the skin around the nose, irritation and crusts sag. Basically, diphtheria of the nose is manifested in combination with: diphtheria of the oropharynx, sometimes the eyes, and / or larynx.
• With common diphtheria first, the body temperature rises to thirty-eight degrees and above. Patients move less, feel tired, sometimes there are attacks of nausea and vomiting. Plaque on the tonsils after a couple of days spreads throughout the oral cavity - on the tongue, pharynx, palate. The lymph nodes are significantly enlarged, they are painful on palpation.
• Toxic form - complication of untreated previous forms. The body temperature rises to 40 ° C, symptoms of intoxication syndrome appear: chills, weakness, joint pain, sore throat. Patients experience vomiting, agitation, euphoria and delirium. The skin turns pale, and the mucous membrane of the pharynx swells and turns red. Complete closure of the larynx is possible. Fibrinous plaque covers most of the mucous membrane of the oropharynx, and the films become coarse and thick. Patients develop cyanosis of the lips, heart rate increases, blood pressure drops, and an unpleasant, putrid odor emanates from the mouth.

Early treatment of diphtheria ensures complete recovery, without any complications, although the duration of cure depends on the severity of the infection. In the absence of timely treatment, serious complications are possible, including those of the heart, which can lead to coma, paralysis or even death.

Diagnostics

It can be difficult to diagnose diphtheria because the symptoms are similar to a number of other diseases -, etc. In order to accurately establish the diagnosis and prescribe the proper treatment, laboratory tests are necessary:

• Bacteriological (swab from the oropharynx). Using this method, the pathogen is isolated and its toxic properties are established;
• Serological. Ig G and M are determined, indicating the strength of the immune system, which speak of the severity of the ongoing inflammatory process;
• The PCR method is used to identify the DNA of the pathogen.

It also requires a diagnosis of complications caused by diphtheria.

Diphtheria: photo

How people diagnosed with diphtheria look like, the photo is presented below.

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Complications

The reasons for the development of complications are the effect of diphtheria bacillus toxins on the body and the late administration of serum:

• myocarditis;
• infectious toxic shock;
• DIC syndrome;
• damage to the adrenal glands;
• multiple organ failure;
• respiratory failure;
• poly- or mononeuritis;
• toxic nephrosis;
• cardiovascular insufficiency;
• and etc.

The time of occurrence of the above complications depends on the type of diphtheria and its severity. For example, toxic myocarditis can develop at 2-3 weeks of the disease, and neuritis and polyradiculoneuropathy - against the background of the disease or 1-3 months after complete recovery.

Diphtheria treatment

Regardless of the severity of the course of diphtheria, treatment in children and adults is carried out in a hospital (in a hospital). Hospitalization is mandatory for all patients, as well as for patients with suspected diphtheria and bacterial carriers.

Upon confirmation of the presence of diphtheria, antitoxic antidiphtheria serum is immediately administered, which helps to neutralize the exotoxin in the blood. The dose of antidiphtheria serum is determined by the severity of the disease. If a localized form is suspected, serum administration can be postponed until the diagnosis is clarified. If the doctor suspects a toxic form of diphtheria, then serum treatment should be started immediately. Serum is injected intramuscularly or intravenously (for severe forms).

In combination with serum, antibacterial drugs are prescribed. Of the entire spectrum, erythromycin (as well as penicillin, ampiox, ampicillin, tetracycline) is the most popular, which destroys the pathogen. Already at this stage, a person not only begins to recover, but his body is no longer exposed to the action of the diphtheria bacillus, which is the most important at the time of diagnosis.

Another important aspect in the treatment of diphtheria is the weakening of the intoxication of the body. For this, the introduction of polyionic solutions, glucocorticoids, and a potassium mixture is used. If such measures do not bring results, then blood purification (plasmapheresis) is indicated.

Prevention

Non-specific prevention consists in observing the following rules:

1. Timely identify and isolate patients and bacteria carriers.
2. Carry out current and final disinfection.
3. Examine all persons in contact with the patient once.
4. Monitor patients with angina for three days.
5. Conduct an annual medical examination of schoolchildren.
6. Monitor diphtheria convalescents for 3 months after discharge from the infectious diseases department.

Diphtheria vaccine

The most effective prevention of diphtheria is active vaccination. This is the introduction of a small amount of bacilli, which stimulate the body to produce antibodies. Although these antibodies do not interfere with further infection with diphtheria, they are able to neutralize the causes of complications - a bacterial toxin, and, thus, weaken the progression of the disease (antitoxic immunity).

You can get vaccinated against diphtheria at any vaccination office. Vaccinations against diphtheria are included in the National Vaccination Schedule. Children are vaccinated in three stages (at 3, 4.5 and 6 months). At 18 months, 6-7 and 14 years old, revaccinations are performed. Thereafter, children and adults should be vaccinated against diphtheria every 10 years.

After a previous illness, an unstable immunity is formed, and after about 10-11 years a person can get sick again. Recurrent disease is mild and easier to tolerate.

Forecast

In the case of localized forms of mild and moderate diphtheria, as well as with the timely administration of antitoxic serum, the prognosis for life is favorable. The prognosis may be aggravated by a severe course of a toxic form, the development of complications, and a late start of treatment.

At present, due to the development of means to help patients and mass immunization of the population, mortality from diphtheria is no more than 5%.

One of the vaccine infections, along with whooping cough and tetanus, is diphtheria. It has been known for a very long time, before the era of vaccine prevention and antibiotic therapy, epidemics mowed down up to 10% of the population of Europe and Asia. Diphtheria is often mentioned in the fiction of Russian (Bulgakov and Chekhov) or foreign writers of the 18-20th centuries; it was called a "strangled loop" or a fatal ulcer of the pharynx. Before the appearance of serum, mortality among children ranged from 70 to 100%, and the smaller the child, the more rapidly it developed.

What is diphtheria?

Diphtheria refers to acute bacterial infections of adults and children, which are caused by special microbes - diphtheria corinobacterium. This is a disease in which inflammatory changes occur on the mucous membranes or skin, special films are formed and many internal organs are affected - the heart, kidneys, nervous and respiratory systems. Like tetanus, diphtheria is a disease in which all pathological processes are triggered not by the bacterium itself, but by the product of its vital activity - a special diphthyritic toxin (DT). In general, there are several varieties of diphtheria bacillus, and not all of them are toxic, there are absolutely safe types. However, in laboratory conditions, experiments have proven that under special circumstances mutations occur, and non-dangerous forms of diphtheria rods become toxic, therefore, this is not excluded when carried in humans, then they can cause illness.

About the prevalence of diphtheria

I will cite the numbers of medical statistics, because many people think that diphtheria is an extremely rare disease. Until the beginning of the 40s, when the universal compulsory vaccination of the population was introduced, the mortality rate from diphtheria among children, as I have already mentioned, reached almost 100%, the parents knew that if this terrible disease befell the baby, he has practically no chance of getting out. Since the middle of the 20th century, the incidence has dropped sharply, in the 80s there were two outbreaks in the incidence, with 96% of all cases registered in Europe in Russia and Ukraine. Since the beginning of the 90s, when the issue of vaccination changed, as a result of the turmoil in the country, there was no time for vaccination, the universal compulsory vaccination was canceled. In just a year from 1990 to 1991, the incidence of diphtheria increased 8.5 times, especially among children in the first three years of life. And by 1994 it reached its maximum - it is 52.1 cases per 100,000 population, at the beginning of the year, and then, as a result of the development of the epidemic, it reached a level of up to 150.5 people per 100,000 population, which is a lot. Of course, it is difficult to analyze dry numbers, but in terms of a level that is easier to understand, every 1-2 babies out of a thousand fell ill, that is, in each school there were at least several sick babies. In addition, the number of carriers, that is, potential sources of infection, increased by 25%. All this made it necessary to re-conduct active vaccination against diphtheria, which has now reduced the incidence by more than half. But, we still cannot reach the level of the late 1980s - vaccination coverage is still insufficient, and the incidence of diphtheria is quite possible.

How can you get sick?

Only people are ill with diphtheria; you cannot get infected from domestic or wild animals or birds. A source of diphtheria for a baby can be sick relatives or carriers of toxic forms of diphtheria corinobacterium. The main method of transmission of infection is airborne, that is, when talking, coughing, sneezing, but for diphtheria, transmission through third parties, household items and even food, through infected food, especially dairy products, is also relevant. The greatest number of cases of diphtheria is noted in the cold season, due to more favorable conditions for storing the microbe. Diphtheria bacilli are very stable in the external environment, on objects in the cold season they can persist up to 5-6 months without losing their dangerous properties. Direct sunlight, high temperatures and chemical disinfectants are dangerous for them.

What happens in a child's body with diphtheria?

Due to the fact that in each organism, depending on its immunity, diphtheria behaves in its own way, there are no clear terms for incubation with it, usually from several hours to 2-4 days. Diphtheria is not limited to the pharynx and respiratory tract - it can affect the eyes, skin, genitals or wounds. When a child's body enters the body, diphtheria corynebacterium begins to multiply actively, releasing a number of toxic and damaging substances - necrotoxin, hemolysin and several enzymes. The bacteria themselves, as such, are not dangerous; it is these substances that cause all the negative consequences.

They lead to tissue necrosis and impaired blood circulation at the site of introduction and reproduction of the microbe, which increases the permeability of the vessel walls. Various active substances, especially fibrin, are released from them. Participates in the clotting and formation of a blood clot or crust on wounds. Roughly the same crust, a dense fibrin film, begins to form at the site of tissue destruction. This film adheres tightly to the damaged surface and attempts to remove it cause bleeding. The damage area grows, and, accordingly, such dense films are formed on all damaged surfaces.

Among other things, depending on which organ of the respiratory or other systems is affected, two types of inflammation can develop - croupous or diphthyritic. It depends on the type of epithelium (surface tissue lining the mucous membranes and skin). Croupous inflammation can develop only on a single-layer columnar epithelium, such as located in the respiratory tract - the larynx, trachea and bronchi. With this development, signs of intoxication are not very pronounced. However, a lot of mucus is formed (it does not allow toxins to be absorbed into the blood) and films, and due to the peculiarities of the structure of the epithelium, they can easily peel off and mechanical asphyxia will occur (suffocation due to overlapping of breathing films).

Diphthyritic inflammation develops on mucous membranes with stratified squamous epithelium - this is the oropharynx and nose, sometimes the mucous membranes of the eyes. In this case, necrosis of the entire epithelium and the tissues underlying it occurs, which leads to the formation of very dense, as if soldered films, which are very difficult to separate. The diphthyritic toxin also affects the lymphatic vessels adjacent to the oropharynx, they cease to drain fluid from the oropharynx, as a result of which tissue edema develops. First, it affects the tonsils, and then spreads to the neck and even the chest.

In addition, with this form, toxins are actively absorbed into the blood, leading to pronounced damage to internal organs. Particularly sensitive to toxin damage are the heart with the development of myocarditis - inflammation of the heart, the kidneys with the development of toxic nephritis, the lungs with the development of fibrinous pneumonia, and the nervous system with the development of neuritis of individual nerves.

How does it manifest itself clinically?

Diphtheria is a multifaceted disease, it has many localized, widespread and also general, affecting almost the entire body, forms. In addition, the special danger of diphtheria and its complexity lies in the fact that it has a typical (that is, classical, with films) form and an atypical one, which is more dangerous. Distinguish between diphtheria of the pharynx, larynx, nose, eyes, genitals, skin, less often ear or wound. There may be a combined form - two areas distant from each other.

Diphtheria of the oropharynx
It can begin as a sore throat, therefore, for all sore throats, a so-called "smear on BL" is always taken. It usually starts with a high fever, sore throat when swallowing. With a catarrhal form, deposits on the tonsils are not formed, with an insular usually there is swelling of the tonsils and arches, they are bright red with a bluish tinge, covered in depressions with a gray coating. With a membranous form, plaques cover all surfaces of the oropharynx, at first they are light pink, by the end of the first day they are saturated with fibrin and turn into smooth gray surfaces. Beginning films can be removed with a film or a spatula, but fibrin films are usually very difficult to remove. A bloody surface remains under them. In addition, in order to distinguish diphtheria from other diseases with films, there is a characteristic test - when the film is immersed in a glass of water, it does not dissolve, does not sink and does not change shape, it is impossible to grind the film on a slide.

With a widespread form in the oropharynx, films and inflammation transition to the soft and hard palate. Uvula, oral mucosa, larynx and nose. The toxic form is very dangerous - with it, the disease develops extremely hard, temperature up to 40 degrees, pain in the neck, soreness of the lymph nodes with progressive neck edema, and it can be spread to the level of the collarbones in the third degree. There is a painful spasm of the masticatory muscles, severe headaches, chills, refusal to eat, severe pallor, repeated vomiting, abdominal pain, the onset of arousal of consciousness, turning into severe depression. It can develop in up to two days. One of the characteristic signs of diphtheria edema and membranes is the characteristic sugary-sweet odor from the mouth of a child.

Laryngeal diphtheria
It begins not as acutely as diphtheria of the oropharynx, however, it is very dangerous with the development of true croup, laryngeal edema - diphtheria, from which children mostly die in this form. Moreover, diphtheria of the larynx can develop both independently and during the transition of the process from the mouth or nose. Three stages are distinguished in the development of croup - it all starts with a sharp, loud cough, which quickly turns into a rough, barking, then losing sonority, becomes hoarse. At the same time, the child's voice becomes hoarse, impure, and then completely silent. The cough gradually turns into the stage of stenosis. Where noisy breathing is observed in the retraction of the pliable places of the chest. if proper help is not provided, it all goes into the stage of asphyxia. After psychomotor agitation, the child's forces are depleted, the respiratory muscles become fatigued, the tone of the respiratory center decreases, the child becomes calmer, and drowsiness appears. adynamia. Breathing becomes quickened, shallow, retraction of pliable places becomes less pronounced. The limbs become cold, the pulse is threadlike, very frequent, then there is a violation of blood circulation and respiration with death.

Diphtheria of the nose, skin and other places is rare.

How to treat?

A sick child with the slightest suspicion of diphtheria must be admitted to a hospital. When the diagnosis is confirmed, specific therapy with anti-toxic anti-diphtheria serum APDS is performed. By the way, in the middle 40-50s, when diphtheria was widespread, APDS was in the pocket medicine cabinet of all pediatricians. This was justified - the serum was injected early, thereby saving the lives of children. Today, this serum is not in the doctor's medicine cabinet, since, to our great joy, diphtheria is rare.

The dose of serum is calculated depending on the type and form of diphtheria, usually it is injected either intramuscularly, and in very severe forms intravenously. If the form is not severe, it is usually a single injection, if severe, repeated injections may be required.

In addition, drip injections of detoxifying solutions are shown to relieve intoxication, and antibiotics are prescribed to suppress the multiplication of diphtheria microbes. All steel measures are carried out based on the symptoms of the disease - these are antipyretic, and antiallergic, and restorative measures.

Isolation and strict bed rest are indicated for the entire duration of treatment. With timely initiation of treatment and the introduction of APDS, the prognosis is favorable, the child can be saved.

Prevention

The main method of prevention today is vaccination of children, starting from the age of three months, with individual or combined vaccines together with tetanus and pertussis. Today, many vaccines have been approved for use - the anti-diphtheria component is contained in the combined DPT vaccines produced in Russia, Tetrakok, Bubokok, Infanrix, Infanrix PENTA or GEXA, Pentaxim. In addition, ADS and ADS-toxoid are released, and separately AS toxoid. All of them are used for routine vaccination and revaccination in children and toxoid in adults.

Vaccination with combined vaccines is carried out three times, with an interval of one and a half months, starting from the age of three months, and a revaccination is carried out a year later. In addition, every 10 years a revaccination of the ADS vaccine is carried out to maintain antitoxic immunity against tetanus and diphtheria.

Almost every resident of Russia can find in the vaccination certificate a record of the setting of DPT or ADS. These vaccines are of great importance in protecting people from diphtheria from an early age. Before the introduction of their mass production, this acute infectious disease was one of the most common causes of infant mortality in the world. Due to the lack of immunity in humans, the toxins of corynebacteria quickly affected various organs, leading to their failure, the development of shock and death.

Fortunately, in the modern world, diphtheria in children and adults has a completely different prognosis and course. Vaccination has fundamentally changed the situation, significantly reducing the prevalence of the disease. The developed drugs and medical tactics make it possible to successfully cope with diphtheria in 96% of cases. Diagnosis of the disease is also not difficult, since the mechanism of development and the cause of this pathology are precisely known.

A little about bacteria

The causative agent of diphtheria - Corynebacteria (corynebacterium) diptheriae. It is quite stable (survives when dried, low temperatures) and is well preserved in an apartment. To get rid of it, you will need to boil the water for about 1 minute, and treat household items or walls with disinfectants (bleach, phenol, chloramines, etc.) for at least 10 minutes. There are many forms, but the symptoms and treatment of diphtheria do not depend on this.

Cause and predisposing factors

Diphtheria develops for only one reason - it is contact with a sick person or a carrier of the infection. It should be noted that in the first case (upon contact with a patient) the probability of infection is 10-12 times higher, but this situation occurs much less frequently. Since 97% of Russians, according to Professor V.F. Uchaikin, vaccinated, bacteria carriers are the main sources of diphtheria.

From the source, the infection is transmitted in two ways:

• Airborne: sneezing, coughing, blowing your nose, when sputum droplets with bacteria get on the mucous membranes or skin wounds of another person;
• Contact and household: Sharing objects / clothes with the infected, sharing food - due to the settling of bacteria in the environment.

It should be noted that healthy and vaccinated people do not get diphtheria. The predisposing factors that occur before infection are:

• Lack of timely vaccination (vaccinations - DTP or ADS);
• Age from 3 to 7 years - in this period of development, the mother no longer feeds the baby with milk, so he loses her antibodies. And their own immunity, at the moment, is only being formed;
• Weakening of immunity for any reason (at the end of the menstrual cycle; after an illness; the presence of hypothyroidism, HIV, blood tumors, and so on);
• A long period of time after vaccination, without contact with patients (since there is a weakening of immunity against diphtheria). For an adult to fall ill, a combination of this factor with a decrease in immunity is necessary.

The presence of the above factors leads to one of the forms of diphtheria. Since the disease is transmitted by airborne droplets, it spreads quickly in confined spaces and confined communities, in the presence of susceptible people.

Risk groups for the spread of infection are:

• any organized group dominated by unvaccinated people;
• inmates of boarding schools and orphanages;
• educational groups (both students of secondary and higher educational institutions, and schoolchildren);
• persons serving in the army (usually recruits);
• the population of the third world countries and refugees;
• patients who are inpatient treatment in neuropsychiatric dispensaries.

Since diphtheria spreads quickly enough, it is necessary to isolate the patient in a timely manner. It is placed in the wards of an infectious hospital of the "semi-box" type - with its own bathroom and a tightly closing entrance.

When is the patient contagious?

The incubation period (the time from infection until the first symptom appears) can take up to 10 days. On average, about 2. The patient is dangerous to others, starting from the last day of the incubation period and until the pathogen is completely removed from the body, which can only be proved by bacteriological research.

Diphtheria classification

In the latest revision of the international classification of diseases, diphtheria is divided only by location:

• Unspecified - can only be in a preliminary diagnosis, since the doctor is obliged to determine the localization of the process;
• Pharynx;
• Nasopharynx;
• Larynx;
• Skin;
• Another - it includes rare forms that occur in 1-2% of cases (conjunctiva, eyes, ears, and so on).

However, this classification is not enough to characterize the disease. Russian infectious disease doctors have developed their own principles of systematization, which are used in clinical practice and are used to formulate a diagnosis:

Classification principle	Forms
By location	Diphtheria of the upper respiratory tract (larynx, mouth and nasopharynx) Diphtheria of the lower respiratory tract (diphtheria croup). It occurs in less than 1% of cases, therefore, in the future, damage to the upper respiratory tract will be considered.
By prevalence	Localized - limited to only one area (usually in the area of \u200b\u200bthe pharynx); Widespread - covers several areas.
By the presence of toxin in the blood and the severity of symptoms	Non-toxic; Subtoxic (practically absent - the body's immunity successfully copes with the toxin); Toxic; Hypertoxic.

Separately, the hemorrhagic form is isolated, which is accompanied by bleeding from the affected area. For successful treatment, it is important to understand that this is a sign of diphtheria, and not just a vascular injury. To do this, it is enough to pay attention to the patient's condition and other symptoms.

Symptoms of various forms of diphtheria

Most vaccinated people are asymptomatic for diphtheria. They become carriers of bacteria and can infect an unvaccinated person, but this probability is 10-12 times less than in contact with a patient. If bacteria get on the mucous membranes of a susceptible person, then the classic course of diphtheria begins. The first signs of diphtheria are usually:

• redness of the tonsils;
• sharp pain when swallowing;
• the formation of a diphtheria film: smooth, shiny, gray or whitish-yellow. It is not possible to separate it from the skin, since it is tightly adhered to it. If the patient tears it off, a bleeding wound remains, which is re-tightened with a film.

In the future, other symptoms are added, on the basis of which various forms of diphtheria were identified. It is important to distinguish them in order to correctly assess the danger to the patient's life and choose an adequate tactics for treating diphtheria.

Localized pharyngeal diphtheria

This is a mild form of infection, which mostly affects vaccinated children or adults with weakened immune systems. The general state of health suffers slightly. Lethargy, decreased appetite, insomnia, and mild headache may develop. The temperature in 35% of patients remains normal, in the rest it rises to 38-39 o C. A distinctive feature of this form of diphtheria is the disappearance of fever within 3 days while maintaining local symptoms, which include:

Maintaining good immunity

Diphtheria is a disease that is easier to prevent than cure. Timely actions of parents to create good immunity in a child will help him avoid an acute infection in the future.

The maintenance of good immunity belongs to non-specific measures for the prevention of diphtheria. To do this, you can use hardening (no earlier than from 5 years old), moderate physical activity, good nutrition (with the inclusion of vitamins, minerals and other nutrients in the diet), fresh air.

Frequently asked questions from patients (or their parents)

Will a child who has had diphtheria be able to get it again?

The likelihood of re-illness is no more than 5% And even if this happens, the child will suffer a mild form of diphtheria.

Do I need to remove the film that forms in the child's mouth?

Absolutely not. After adequate treatment with antitoxin, it will separate on its own, and in its place there will be a new mucous membrane. If a person removes it on his own, a wound will form, which will soon be re-tightened with this film.

Why do some unvaccinated children develop a toxic form, while others - only widespread?

This is determined by the state of the child's immunity. If he is well developed and the child has not tolerated other infectious diseases in the near past, the more likely to develop a common form.

The vaccine is quite expensive, but on the Internet they write that it is ineffective - is it worth it at all?

Clinical studies by WHO and Russian infectious disease specialists have proven the effectiveness of DTP and ADS vaccines. This vaccination has an average cost of 600-800 rubles in Russia, which can be a problem for the family budget (especially large families). However, a baby coffin is much more expensive than a DPT. And the likelihood that the parents of a child without a vaccine will need it significantly increases.

Does the diphtheria vaccine have side effects?

In the course of numerous studies, the possibility of only 4 side effects has been proven:

• Fevers (37-38 o C);
• Weakness;
• Redness at the injection site;
• The appearance of a slight edema (after injection).

Do adults need to be re-vaccinated?

WHO sees no need for this. However, if you expect contact with a patient in the near future, consult a doctor. He or she will order a test to measure antibodies to the corynebacterium toxin in your blood. If they are not enough, it is recommended to put ADS once.

thanks

The site provides background information for informational purposes only. Diagnosis and treatment of diseases should be carried out under the supervision of a specialist. All drugs have contraindications. A specialist consultation is required!

What is diphtheria?

Diphtheria Is an acute infectious disease that is caused by a specific pathogen ( infectious agent) and is characterized by damage to the upper respiratory tract, skin, cardiovascular and nervous systems. Much less often, with diphtheria, other organs and tissues can be affected. The disease is characterized by an extremely aggressive course ( benign forms are rare), which, without timely and adequate treatment, can lead to irreversible damage to many organs, to the development of toxic shock and even to the death of the patient.

Diphtheria has been known to civilization since ancient times, but the causative agent of the disease was first identified only in 1883. In those days, there was no adequate treatment for diphtheria, which is why most of the sick people died. However, a few years after the discovery of the causative agent of the infection, scientists developed an anti-diphtheria serum, which made it possible to significantly reduce mortality in this pathology. Later, thanks to the development of a vaccine and active immunization of the population, the incidence of diphtheria was also significantly reduced. However, due to defects in vaccine prevention ( that is, due to the fact that not all people are vaccinated on time) Epidemic outbreaks of diphtheria are periodically recorded in certain countries.

Epidemiology of diphtheria

The incidence of diphtheria is due to the socio-economic standard of living and medical literacy of the population. In the days before the discovery of vaccinations, the incidence of diphtheria had a clear seasonality ( increased sharply in winter and significantly decreased in the warm season), which is due to the characteristics of the pathogen. Mostly schoolchildren fell ill.

After widespread vaccination of diphtheria, the seasonal nature of the incidence disappeared. Today, diphtheria is extremely rare in developed countries. According to various studies, the incidence rate ranges from 10 to 20 cases per 100 thousand population per year, and mainly adults are ill ( men and women can get sick with the same probability). Lethality ( mortality) with this pathology ranges from 2 to 4%.

The causative agent of diphtheria

The causative agent of the disease is corynebacterium diphtheria ( Corynebacterium diphtheriae, Leffler's bacillus). These are immobile microorganisms that can survive for a long time at low temperatures or on dry surfaces, which caused seasonal incidence in the past. At the same time, bacteria die rather quickly when exposed to moisture or high temperatures.

Corynebacterium diphtheria die:

• When boiling - within 1 minute.
• At a temperature of 60 degrees - within 7 - 8 minutes.
• When exposed to disinfectants - within 8 - 10 minutes.
• On clothes and bedding - within 15 days.
• In the dust - within 3 - 5 weeks.

In nature, there are many types of diphtheria corynebacteria, and some of them are toxigenic ( produce a substance toxic to humans - exotoxin), while others are not. It is the diphtheria exotoxin that determines the development of clinical manifestations of the disease and their severity. It should be noted that, in addition to exotoxin, corynebacteria can produce a number of other substances ( neuraminidase, hemolysin, necrotizing factor and so on), which damage tissues, causing their necrosis ( doom).

Ways of transmission of diphtheria

The source of infection can be a sick person ( one that has clear signs of the disease) or an asymptomatic carrier ( a patient in whose body there are diphtheria corynebacteria, but there are no clinical manifestations of the disease). It is worth noting that during an outbreak of diphtheria, the number of asymptomatic carriers in the population can reach 10%.

Asymptomatic diphtheria carriage can be:

• Transient - when a person releases corynebacteria into the environment for 1 to 7 days.
• Short-term - when a person is contagious for 7 to 15 days.
• Long lasting - a person is contagious within 15 to 30 days.
• Protracted - the patient is contagious for a month or more.

From a sick or asymptomatic carrier, the infection can be transmitted:

• By airborne droplets - in this case, corynebacteria pass from one person to another together with microparticles of exhaled air during a conversation, when coughing, when sneezing.
• Contact-household way - this path of spread is much less common and is characterized by the transmission of corynebacteria through household items contaminated by a sick person ( dishes, bedding, toys, books and so on).
• By food - Corynebacteria can be spread through milk and dairy products.

It should be noted that a sick person is infectious to others from the last day of the incubation period until the complete removal of corynebacteria from the body.

Incubation period and pathogenesis ( development mechanism) diphtheria

The incubation period is the time interval from the introduction of a pathogenic agent into the body until the first clinical symptoms of the disease appear. In diphtheria, the incubation period lasts from 2 to 10 days, during which the causative agent of the infection multiplies and spreads throughout the body.

The entrance gate for the causative agent of diphtheria is usually mucous membranes or damaged skin.

Corynebacterium diphtheria can enter the body through:

• nasal mucosa;
• pharyngeal mucosa;
• laryngeal mucosa;
• conjunctiva ( mucous membrane of the eye);
• mucous membranes of the genital organs;
• damaged skin.

After entering the human body, the pathogen lingers at the entrance gate and begins to multiply there, while releasing an exotoxin consisting of several fractions ( that is, from several toxic substances).

Diphtheria exotoxin contains:

• 1 fraction ( necrotoxin). This substance is released by the pathogen at the site of its introduction and causes necrosis ( doom) of the surrounding epithelial tissues ( the epithelium is the top layer of mucous membranes). Also, necrotoxin affects closely located blood vessels, causing them to expand and increase the permeability of the vascular wall. As a result, the liquid part of the blood leaves the vascular bed into the surrounding tissues, which leads to the development of edema. In this case, the substance contained in the plasma fibrinogen ( one of the factors of the blood coagulation system) interacts with the necrotic tissues of the affected epithelium, as a result of which fibrin films characteristic of diphtheria are formed. It should be noted that with damage to the mucous membrane of the oropharynx, the necrotic process spreads quite deeply ( affects not only the epithelium, but also the connective tissue located under it). The resulting fibrin films are adhered to the connective tissue and are separated with great difficulty. The mucous membrane of the upper respiratory tract ( larynx, trachea and bronchi) has a slightly different structure, in view of which only the epithelial layer is affected by necrosis, and the resulting films are separated quite easily.
• 2 faction. This fraction is structurally similar to cytochrome B, a substance found in most cells of the human body and providing the process of cellular respiration ( that is, absolutely necessary for the life of the cell). 2 fraction of exotoxin penetrates into cells and displaces cytochrome B, as a result of which the cell loses its ability to use oxygen and dies. It is this mechanism that explains the damage to cells and tissues of the cardiovascular, nervous and other body systems in patients with diphtheria.
• 3 faction ( hyaluronidase). This substance increases the permeability of blood vessels, increasing the severity of tissue edema.
• 4 faction ( hemolytic factor). It causes hemolysis, that is, the destruction of red blood cells ( erythrocytes).

Types and forms of diphtheria

Symptoms of diphtheria are determined by the form of the disease, the site of introduction of the pathogen, the state of the infected person's immune system and the type of pathogen. In medical practice, it is customary to distinguish between several types of diphtheria, which are determined depending on several criteria.

Depending on the place of introduction of the pathogen, there are:

• diphtheria of the oropharynx;
• diphtheria of the larynx;

• diphtheria of the respiratory tract;
• diphtheria of the nose;
• diphtheria of the eyes;
• diphtheria of the skin;
• diphtheria of the genitals;
• diphtheria of the ear.

It should be noted right away that oropharyngeal diphtheria occurs in more than 95% of cases, while the share of other types of the disease is no more than 5%.

Depending on the nature of the course of the disease, there are:

• typical ( filmy) diphtheria;
• catarrhal diphtheria;
• toxic diphtheria;
• hypertoxic ( fulminant) diphtheria;
• hemorrhagic diphtheria.

Depending on the severity of the disease, there are:

• light ( localized) form;
• diphtheria of moderate severity ( common form);
• heavy ( toxic) diphtheria.

Symptoms and signs of oropharyngeal diphtheria

As mentioned earlier, oropharyngeal diphtheria is the most common form of the disease. This is explained by the fact that an important organ of the immune system is located in the oropharynx area - the palatine tonsils ( glands). They represent an accumulation of lymphocytes ( cells of the immune system responsible for the recognition and destruction of foreign agents). With the penetration of diphtheria corynebacteria with inhaled air, they settle on the mucous membrane of the palatine tonsils and come into contact with leukocytes, as a result of which the development of the pathological process begins.

Pharyngeal diphtheria can occur in various clinical forms, due to the strength of the pathogen and the state of the patient's immunity.

Pharyngeal diphtheria can be:

• localized;
• catarrhal;
• common;
• toxic;
• hypertoxic ( fulminant);
• hemorrhagic.

Localized diphtheria

This form of the disease occurs mainly in people who have been vaccinated against diphtheria. The clinical manifestations of the disease develop acutely, but rarely become severe or protracted.

A localized form of diphtheria can manifest itself:

• Plaque on the tonsils. The formation of smooth, shiny, whitish-yellow or gray films, located exclusively on the mucous membrane of the tonsils, is a characteristic sign of a localized form of diphtheria. Films can be located in the form of islands or cover the entire amygdala. They are separated with difficulty ( while exposing the bleeding surface of the mucous membrane), and reappear rather quickly after deletion.
• Sore throat. Pain occurs as a result of damage to the mucous membrane of the tonsils and the development of an infectious and inflammatory process in it, in which the sensitivity of pain receptors increases ( nerve endings responsible for the perception of pain). Sore throat is stabbing or cutting in nature, worse if swallowed ( especially solid food) and slightly subsides at rest.
• An increase in temperature. An increase in body temperature is a natural defense reaction of the body, the purpose of which is to destroy foreign agents that have penetrated into it ( many microorganisms, including corynebacterium diphtheria, are sensitive to high temperatures). The severity of the temperature reaction directly depends on the amount and danger of the pathogen or its toxin that has entered the body. And since in the local form of the disease, the total affected surface is limited by the mucous membrane of one or both palatine tonsils, the amount of toxin formed and entering the body will also be relatively low, as a result of which the body temperature will rarely rise above 38 - 38.5 degrees.
• General malaise. Symptoms of general intoxication result from activation of the immune system and the development of infectious and inflammatory processes in the body. This can be manifested by general weakness, increased fatigue, headaches, muscle pain, drowsiness, and decreased appetite.
• Swollen lymph nodes in the neck. Lymph nodes are collections of lymphocytes that are located in many tissues and organs. They filter the lymphatic fluid flowing from the tissues, preventing the spread of infectious agents or their toxins throughout the body. However, with the local form of the disease, the amount of toxin formed is relatively small, as a result of which the regional lymph nodes may be normal or slightly enlarged, but painless on palpation ( probing).

Catarrhal diphtheria

This is atypical ( rare) a form of diphtheria of the oropharynx, in which the classical clinical manifestations of the disease are absent. The only symptom of catarrhal diphtheria may be swelling and hyperemia of the mucous membrane of the palatine tonsils ( that is, its redness as a result of the expansion of blood vessels and their overflow with blood). In this case, the patient may be disturbed by minor pain in the throat, aggravated by swallowing, but symptoms of general intoxication are usually absent.

It should be noted that, without timely treatment, catarrhal diphtheria is prone to progression and transition to more severe forms of the disease.

Common diphtheria

The main distinguishing feature of this form of the disease is the spread of plaque and films outside the palatine tonsils, on the mucous membrane of the palatine arches, uvula and posterior pharyngeal wall.

Other manifestations of widespread pharyngeal diphtheria can be:

• Symptoms of general intoxication - can be more pronounced than with a localized form of the disease ( patients are lethargic, drowsy, may refuse to eat and complain of severe headaches and muscle pain).
• Sore throat - more pronounced than in the localized form.
• Increased body temperature - up to 39 degrees and more.
• Swollen cervical lymph nodes - they may be slightly painful to palpation.

Toxic diphtheria

The toxic form of diphtheria develops as a result of the excessively rapid multiplication of corynebacteria and the entry of a large amount of toxins into the systemic circulation, as well as due to the pronounced activation of the immune system.

Toxic diphtheria is characterized by:

• A pronounced increase in temperature. From the first days of illness, the patient's body temperature can rise to 40 degrees or more.
• General intoxication. Patients are pale, lethargic, drowsy, complain of severe headaches and aches throughout the body, severe general and muscle weakness. Lack of appetite is often noted.
• Extensive lesion of the oropharynx. From the first hours of the disease, the mucous membrane of the tonsils, oropharynx and uvula is sharply hyperemic and edematous. Edema of the palatine tonsils can be so pronounced that they can come into contact with each other, almost completely blocking the entrance to the pharynx ( thereby disrupting the processes of swallowing, breathing and speech). By the end of the first - second day, a grayish plaque appears on the mucous membrane, which is relatively easy to remove, but then re-forms. After another 2 - 3 days, the plaque turns into a rather dense film that covers almost the entire visible mucous membrane. At the same time, the tongue and lips of the patient are dry, there is an unpleasant odor from the mouth.
• Sore throat. Severe stabbing or cutting pains can torment the patient even at rest.
• Swollen lymph nodes. Absolutely all groups of cervical lymph nodes are enlarged, elastic and sharply painful on palpation, when turning the head or during any other movements.
• Swelling of the cervical tissue. With the progression of the disease, the diphtheria toxin spreads to neighboring tissues. Damage to the blood vessels of the neck leads to the development of pronounced edema of the subcutaneous tissue in this area, which significantly complicates breathing. At any attempt to move the head, the patient experiences severe pain.
• An increase in heart rate ( Heart rate). Normally, the heart rate of a healthy person ranges from 60 to 90 beats per minute ( in children, the heart rate is slightly higher). The cause of tachycardia ( increase heart rate) in patients with diphtheria is an increase in temperature ( with an increase in body temperature by 1 degree, heart rate increases by 10 beats per minute). It should be noted that the direct toxic effect of diphtheria toxin on the heart in this form of the disease is rare.

Hypertoxic ( fulminant) diphtheria

This is an extremely severe form of the disease, which is characterized by a lightning-fast course and, without timely medical intervention, leads to the death of the patient within 2 to 3 days.

Hypertoxic diphtheria is characterized by:

• Increased body temperature ( up to 41 degrees and more).
• The development of seizures. Seizures are involuntary, persistent, and extremely painful muscle contractions. The occurrence of seizures in hypertoxic diphtheria is due to a pronounced increase in temperature. This leads to disruption of the functioning of nerve cells in the brain, as a result of which they begin to send uncontrolled impulses to various muscles throughout the body.
• Impaired consciousness. From the first day, the patient's consciousness is impaired to varying degrees ( from drowsiness or dullness to coma).
• Collapse. Collapse is a life-threatening condition characterized by a marked decrease in blood pressure in the vessels. The development of collapse occurs mainly due to the entry into the bloodstream of a large amount of diphtheria toxin and the associated expansion of blood vessels. With a critical decrease in blood pressure ( less than 50 - 60 mm Hg) the blood supply to vital organs is disrupted ( including the brain) and the work of the heart muscle, which can lead to the death of the patient.
• The defeat of the oropharynx. The mucous membrane is extremely edematous, covered with dense gray films. It should be noted that with this form of the disease, systemic toxic effects appear earlier than local manifestations.
• Decreased amount of urine. Under normal conditions, a healthy adult excretes about 1,000 to 1,500 milliliters of urine per day. The formation of urine occurs in the kidneys as a result of ultrafiltration of the blood. This process depends on the value of blood pressure and stops when it drops below 60 mm Hg, which is observed during the development of collapse.

Hemorrhagic diphtheria

It is characterized by the development of many bleeding in the area of \u200b\u200bthe mucous membrane of the oropharynx ( the films are soaked in blood), at the injection sites. There may also be nosebleeds, bleeding gums, gastrointestinal bleeding, and skin hemorrhages. These manifestations appear 4 to 5 days after the onset of the disease, usually against the background of symptoms characteristic of the toxic form of diphtheria.

The cause of bleeding is a violation of the blood coagulation system. This is due to the toxic effect of diphtheria toxin on platelets ( blood cells responsible for stopping bleeding and the normal functioning of the vascular wall), as well as the expansion of blood vessels, increased permeability and fragility of the vascular walls. As a result, small vessels are easily damaged at the slightest physical impact and blood cells are released into the surrounding tissues.

With this form of the disease, signs of myocarditis develop quite quickly ( inflammatory lesion of the heart muscle), which can cause death of the patient.

Symptoms and signs of other types of diphtheria

As mentioned earlier, it is extremely rare that diphtheria can affect the mucous membranes of the respiratory tract, eyes, genitals and skin. However, these types of the disease can also be severe and pose a risk to the patient's health.

Diphtheria of the larynx and respiratory tract ( diphtheria croup)

The defeat of the larynx and respiratory tract with diphtheria is characterized by the development of a necrotic process at the site of introduction of the pathogen, as a result of which edema of the mucous membrane occurs and characteristic diphtheria films are formed. However, if, with a lesion of the oropharynx, these changes affect the breathing process insignificantly, damage to the upper respiratory tract can significantly complicate external respiration, posing a threat to the patient's life. This is explained by the fact that the formation of diphtheria films in narrow airways can lead to their partial overlap, thereby disrupting the process of oxygen delivery to the lungs. This, in turn, leads to a decrease in the concentration of oxygen in the blood and insufficient supply of oxygen to vital organs and tissues, which causes the clinical manifestations of the disease.

Diphtheria of the nose

It develops if, during inhalation, the causative agent of diphtheria lingers on the mucous membrane of the nasal passages and does not penetrate into the pharynx. This form of the disease is characterized by a slow progression of symptoms and mild general manifestations. Diphtheria of the nose can pose a serious threat only if corynebacteria spread to the mucous membrane of the pharynx or larynx, followed by the development of the manifestations described above.

Diphtheria of the nose can manifest itself:

• An increase in body temperature to 37 - 37.5 degrees. It should be noted that quite often the temperature remains normal throughout the entire period of the disease.
• Violation of nasal breathing. The development of this symptom is associated with swelling of the nasal mucosa, which leads to a narrowing of the lumen of the nasal passages.
• Pathological nasal discharge. At first, the discharge may be slimy. In the future, there may be a periodic discharge of pus or blood, and, in some cases, only from one nostril.
• Damage to the skin around the nose. It is associated with the negative effects of pathological secretions and can manifest itself as redness, peeling or even ulceration of the skin in the area of \u200b\u200bthe nasolabial triangle and upper lip.

Diphtheria of the eye

It is rare, and in the vast majority of cases, only one eye is affected by the pathological process. Local manifestations of the disease come to the fore, and signs of general intoxication are usually completely absent ( extremely rarely, there can be an increase in temperature of no more than 37.5 degrees and slight weakness).

Diphtheria of the eye is manifested:

• Fibrin bloom on the conjunctiva of the eye. Plaque grayish or yellowish, poorly separated. Sometimes the pathological process can spread to the eyeball itself.
• The defeat of the eyelids. The defeat of the eyelids is associated with the development of an infectious and inflammatory process and the expansion of the blood vessels in them. The eyelids on the affected side are swollen, dense and painful on palpation. At the same time, the eye gap is narrowed.
• Pathological discharge from the eye. Initially, they are slimy, and then bloody or purulent.

Diphtheria of the skin and genitals

Diphtheria do not penetrate through normal, intact skin. The place of their introduction can be wounds, scratches, cracks, sores or ulcerations, bedsores and other pathological processes associated with a violation of the protective function of the skin. The developing symptoms are local in nature, and systemic manifestations are extremely rare.

The main manifestation of skin diphtheria is the formation of a dense grayish fibrin film that covers the wound surface. It is separated with difficulty, and after removal it quickly recovers. At the same time, the skin around the wound itself is swollen and painful to touch.

The defeat of the mucous membranes of the external genital organs can be noted in girls or women. The surface of the mucous membrane at the site of the introduction of corynebacteria becomes inflamed, swollen and becomes sharply painful. Over time, an ulcerative defect may form at the site of the edema, which becomes covered with a dense, gray, hard-to-remove plaque.

Ear diphtheria

Ear lesion in diphtheria is rarely the initial form of the disease and usually develops with the progression of pharyngeal diphtheria. From the pharynx into the middle ear cavity, corynebacteria can enter through the Eustachian tubes, the mucous membrane-covered canals that connect the middle ear to the pharynx, which is necessary for the normal functioning of the hearing aid.

The spread of corynebacteria and their toxins into the tympanic cavity can lead to the development of a purulent-inflammatory process, perforation of the eardrum and hearing impairment. Clinically, diphtheria of the ear can manifest itself as pain and hearing loss on the affected side, sometimes patients may complain of tinnitus. When the tympanic membrane breaks out, purulent-bloody masses are released from the external auditory canal, and during examination, grayish-brown films can be detected.

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