Total Loss of Function Is Rare, and Sensation Is Unimpaired
Sensation Unimpaired Redness in spite of the presence of a significant degree of edema;
(1) the appearance of the characteristic membrane in the tonsillar area; and
(2) moderate pyrexia.
Sensation Unimpaired In severe cases, significant systemic manifestations occur; in mild cases, however, the patient may feel well throughout, and the throat may appear comparatively innocuous. The laboratory diagnosis depends upon the isolation and identification of the causative organism from the lesion. The throat or wound swab should be taken by an experienced person and sent to the laboratory without delay. Here a Loffier's slant, a tellurite plate, and a blood agar plate should be inoculated promptly. Although experienced workers can recognize the organism in a fair percentage of cases by smears made directly from the wound or throat swab, this procedure is not recommended for the average laboratory. The inoculated cultures may be inspected at the end of 16 to 24 hours and a presumptive diagnosis made on the basis= of characteristic colony formation and cellular morphology.
Confirmatory evidence may be obtained by a study of fermentation reactions, and, whenever indicated, virulence tests should be carried out. Other laboratory findings include moderate leukocytosis and transient albuminuria in all but the mildest cases. Streptococcal tonsillitis and pharyngitis are most often confused with diphtheria. In the former conditions, the throat is usually a fiery red, the tonsillar exudate is thinner and lighter colored, the fever is higher, and swallowing is painful. Frequently the follicles in the faucial area are prominent. Upon occasion, it may be impossible to differentiate the two infections without resort to laboratory means. Rarely a concomitant streptococcal infection may mask the underlying diphtheritic process.
Sensation Unimpaired Other conditions that must be considered in the differential diagnosis are Vincent's angina, agranulocytic angina, infectious mononucleosis, post-tonsillectomy throat, and exudative pharyngitis, caused by an adenovirus. Complications. The most important complications are related to the myocardium and the nervous system. Signs of myocarditis may appear as early as the second week of the disease, although the usual time of onset is somewhat later. They are characteristically associated with the more severe forms of respiratory diphtheria. In general, those patients showing early myocardial involvement tend to run a graver course.
The onset may be insidious, with a rising pulse of poor quality, distant heart sounds, premature contractions, and gradual cardiac enlargement. Less often, cardiac failure may appear with little warning. Pallor, epigastric pain, vomiting, and circulatory collapse are the usual signs and symptoms. -Inversion of the T waves, delayed conduction time, bundle branch block, and terminally ventricular flutter or fibrillation are the most common electrocardiographic changes noted. Occasionally peripheral circulatory collapse occurs in the absence of demonstrable cardiac damage. Recovery, when it takes place, is usually complete.
Postdiphtheritic paralysis affecting the cr or peripheral nerves is a relatively freq complication. The most common fourth cr nerve palsy is paralysis of the soft palate. makes its appearance in the third to the fifth week of the disease, and is ushered in by the development of a nasal twang in the voice and regurgitant of fluid through the nose upon attempted swallowing. Although the course is usually mild, occasional ally tube feeding may be required. The condition tends to clear up completely in the course of; week or ten days. Ocular paralysis may occur I the fourth to sixth week of the disease.
The ts' most common types are oculomotor, affecting the external rectus muscle of one or both sides, thus resulting in a convergent squint, and ciliary, I which the power of accommodation is weakened or lost. Spontaneous recovery in the course of a week is the general rule. Rarer forms of the crate: ° nerve palsies are facial, pharyngeal, and laryngeal paralysis. The prognosis in these forms is good unless there is concomitant involvement of the respiratory muscles. Paralysis of the peripheral nerves appears somewhat later than do the cranial nerve palsies; the usual time of occurrence for the former is between the fifth and eighth week of the disease.
The most common form is polyneuritis of the lower extremities, as evidenced by weakness or paralysis of certain muscle groups. Total loss of function is rare, and sensation is unimpaired. Complete recovery over a period of a few weeks is the general rule. Less commonly, the upper extremities, the neck, and the trunk may be involved. Again, in general, the prognosis is good; if, however, the intercostal muscles are involved there is a danger of serious respiratory embarrassment, particularly in the presence of diaphrag-matic weakness or paralysis. It must be emphasized that polyneuritis of diphtheritic origin may occur in the absence of faucial manifestations of the disease. For example, generalized polyneuritis can follow cutaneous diphtheria. During World War II, it represented the most important sequela of so-called “wound diphtheria.” Treatment.
Laboratory studies and clinical experience have demonstrated the importance of administering antitoxin as early as possible in the course of the disease. Presumably, the union between toxin and cell is a stable one that cannot be broken down by any practicable amount of antitoxin; the role of the latter is con-fined therefore to neutralizing unbound toxin circulating in the blood and other body fluids, thereby protecting the undamaged cells that have not come into intimate contact with the toxin as yet. Antitoxin should be administered as soon as diphtheria is suspected on clinical grounds, without waiting for confirmation from the lab-• oratory. Assurance of prompt and vigorous treatment of the actual case of diphtheria is well ace& the price of occasionally administering antitazia.