Posts tagged Diphtheria

Oral manifestations of childhood illnesses 1. Oral thrush - Caused by the Candida fungus overgrowing on the mucous membranes of the mouth. Also known as candidiasis when it occurs elsewhere on the body (such as vaginal candidiasis).2. Varicella - Chicken pox. Have you ever had chicken pox in your mouth? It’s awful.3. Stomatitis herpetica or Aphthosa [Herpetic stomatitis] - Caused by the same herpes infection of the mouth that causes cold sores, but blisters and mild ulceration can occur. This condition usually occurs when the child first contracts Herpes simplex I.4. Stomatitis ulcerosa or Scorbutus - The oral manifestation of scurvy in children. The bone weakness, dry mouth, and immune dysfunction in scurvy often causes tooth weakening, loosening, and extreme gingivitis.5. Follicular tonsillitis - The “standard” childhood tonsillitis, with infection of the palatine tonsils. If the infection doesn’t subside, removal of the tonsils is still the most common treatment.6. Diphtheria - There are many oral manifestations of diphtheria, including “pseudo-membranes” covering the trachea, severely impairing breathing. The exotoxins exuded by Corynebacterium diphtherium can also cause thick, thrush-like patches in the pharyngotrachea. Pediatrics: The Hygienic and and Medical Treatment of Children. Thomas Morgan Rotch, 1901.

Oral manifestations of childhood illnesses

1. Oral thrush - Caused by the Candida fungus overgrowing on the mucous membranes of the mouth. Also known as candidiasis when it occurs elsewhere on the body (such as vaginal candidiasis).
2. Varicella - Chicken pox. Have you ever had chicken pox in your mouth? It’s awful.
3. Stomatitis herpetica or Aphthosa [Herpetic stomatitis] - Caused by the same herpes infection of the mouth that causes cold sores, but blisters and mild ulceration can occur. This condition usually occurs when the child first contracts Herpes simplex I.
4. Stomatitis ulcerosa or Scorbutus - The oral manifestation of scurvy in children. The bone weakness, dry mouth, and immune dysfunction in scurvy often causes tooth weakening, loosening, and extreme gingivitis.
5. Follicular tonsillitis - The “standard” childhood tonsillitis, with infection of the palatine tonsils. If the infection doesn’t subside, removal of the tonsils is still the most common treatment.
6. Diphtheria - There are many oral manifestations of diphtheria, including “pseudo-membranes” covering the trachea, severely impairing breathing. The exotoxins exuded by Corynebacterium diphtherium can also cause thick, thrush-like patches in the pharyngotrachea.

Pediatrics: The Hygienic and and Medical Treatment of Children. Thomas Morgan Rotch, 1901.

While we’re at it… If you want a “hero” from the Great Race of Mercy that wasn’t the native teams, here’s Togo and his handler, Leonhard Seppala. “Balto” was a farce. Usurping amateur who did little work compared to Togo. And to boot, the statue of Balto in Central Park is modeled after the real Balto, but every color and medal he wears was awarded to Togo. Officials and historians honored and knew Togo to be the real pack leader, who really deserved the praise. Roald Amundsen (of South Pole Expedition fame) even personally gave Togo a gold medal at Madison Square Gardens. But that’s not what people see these days. Togo’s silent honor was easily overshadowed by a fame-hungry musher who couldn’t wait to be in photoshoot after tour stop after film after headlines. Balto’s owner/musher, Gunnar Kaasen, knew how to exploit this opportunity to its fullest. After the rescue run, he and his team toured around the country with Balto at the forefront, and told heroic tales of “Balto’s” triumphs, the majority of which were what Togo led his team through, and which Kaasen had overheard Seppala speak about. Of course, none of that was Balto’s fault, and I feel sorry for the dog. Not only was he an amateur who wasn’t ready to lead a team in tough conditions up north, he was actually sold to a circus after Kaasen couldn’t milk anything else out of his appearances. He was malnourished and treated horribly there, before the children of Cleveland, OH found out, and had a fundraiser to bring Balto and his team to the local Zoo to live out their retirement. Here’s a source or two on the topic, but most of this is from old newspapers and accounts, as well as the Iditarod Museum.

While we’re at it…

If you want a “hero” from the Great Race of Mercy that wasn’t the native teams, here’s Togo and his handler, Leonhard Seppala.

“Balto” was a farce. Usurping amateur who did little work compared to Togo.

And to boot, the statue of Balto in Central Park is modeled after the real Balto, but every color and medal he wears was awarded to Togo. Officials and historians honored and knew Togo to be the real pack leader, who really deserved the praise. Roald Amundsen (of South Pole Expedition fame) even personally gave Togo a gold medal at Madison Square Gardens.

But that’s not what people see these days. Togo’s silent honor was easily overshadowed by a fame-hungry musher who couldn’t wait to be in photoshoot after tour stop after film after headlines. Balto’s owner/musher, Gunnar Kaasen, knew how to exploit this opportunity to its fullest. After the rescue run, he and his team toured around the country with Balto at the forefront, and told heroic tales of “Balto’s” triumphs, the majority of which were what Togo led his team through, and which Kaasen had overheard Seppala speak about.

Of course, none of that was Balto’s fault, and I feel sorry for the dog. Not only was he an amateur who wasn’t ready to lead a team in tough conditions up north, he was actually sold to a circus after Kaasen couldn’t milk anything else out of his appearances. He was malnourished and treated horribly there, before the children of Cleveland, OH found out, and had a fundraiser to bring Balto and his team to the local Zoo to live out their retirement.

Here’s a source or two on the topic, but most of this is from old newspapers and accounts, as well as the Iditarod Museum.

Top: Incision for inferior tracheotomy

Bottom: Tracheal anatomy and surrounding structures

In diphtheria patients with a significant formation of leathery pseudo-membrane, providing a way to breathe is paramount. Since the putrid pus that hardened into the membrane would be pushed into the bronchi if regular intubation was used, a technique that allowed air in below the upper pharynx (where most of the membrane formed) was needed. The concept of the tracheotomy has been around for hundreds of years, but it wasn’t until the 18th century that more than a handful of patients survived the procedure when it came to diphtheria and other membranous croups. Well, if you consider 25% to be “more than a handful”.

By the point a patient would need a tracheotomy, the procedure would need to be done quickly and accurately, but because of the relative size of veins, arteries, nerves, and tendons surrounding a child’s trachea, it would be incredibly difficult to do this successfully. However, once the medical schools began teaching this as a standard procedure in the mid-1800s, the success rate (meaning the survival of the patient, not just the procedure being done correctly) increased to around 45%. Given how sick someone with advanced pseudo-membranous laryngeal diphtheria is, that’s not bad at all.

Atlas and Epitome of Operative Surgery. Otto Zuckerkandel, translated by J. Chalmers DaCosta, 1902.

A Treatise on Diphtheria including Croup, Tracheotomy, and Intubation. Henry Z. Gill, 1887.

Diphtheria Antitoxin - 1895 Diphtheria is a killer by the toxins it excretes, which can cause necrosis, myocarditis, and, most dangerously, the putrid-smelling pseudo-membrane that can line the pharynx and trachea, preventing breathing. Antitoxins were the first solution to these toxins. Antibodies against the toxin were taken from the serum of large animals (horses) who were inoculated with the toxin produced by the C. diphtheriae bacteria. The amount of toxin was small enough that it only produced an immune reaction in the animal, and did not poison them. When someone contracted diphtheria, the antitoxin could be injected, and this inactivated the circulating toxin created by the bacteria. While it did not kill the bacteria itself, the immune system was capable of doing that on its own when it wasn’t busy being dissolved and ripped apart by the toxins. Unfortunately, the antitoxin could not inactivate toxins created by bacteria that were already bound to tissues, so the earlier it was administered, the better. Combined with the refinement of the tracheotomy (so that patients could breathe, even with a pseudo-membrane covering their airway), the antitoxin dropped the mortality rate of diphtheria from 40-45% down to around 12-15%.  Image: Production of antitoxin by inoculation of horses. One of the first bottles of antitoxin produced at the Hygienic Lab, later known as the National Institutes of Health.

Diphtheria Antitoxin - 1895

Diphtheria is a killer by the toxins it excretes, which can cause necrosis, myocarditis, and, most dangerously, the putrid-smelling pseudo-membrane that can line the pharynx and trachea, preventing breathing.

Antitoxins were the first solution to these toxins. Antibodies against the toxin were taken from the serum of large animals (horses) who were inoculated with the toxin produced by the C. diphtheriae bacteria. The amount of toxin was small enough that it only produced an immune reaction in the animal, and did not poison them.

When someone contracted diphtheria, the antitoxin could be injected, and this inactivated the circulating toxin created by the bacteria. While it did not kill the bacteria itself, the immune system was capable of doing that on its own when it wasn’t busy being dissolved and ripped apart by the toxins. Unfortunately, the antitoxin could not inactivate toxins created by bacteria that were already bound to tissues, so the earlier it was administered, the better.

Combined with the refinement of the tracheotomy (so that patients could breathe, even with a pseudo-membrane covering their airway), the antitoxin dropped the mortality rate of diphtheria from 40-45% down to around 12-15%. 

Image: Production of antitoxin by inoculation of horses. One of the first bottles of antitoxin produced at the Hygienic Lab, later known as the National Institutes of Health.

biomedicalephemera: Diphtheria is known for creating a slimy/sticky/smelly exudate in the throat and mouth, but there are quite a few variations on its etiology and presentation. A. Common type of diphtheria. Child three years old, seen on fourth day of illness. Exudate covering pharynx, tonsils, and uvula. Received 16,000 units of antitoxin. Throat clear on sixth day. Discharged cured. B. Follicular type of diphtheria. Child seven years old, seen on second day of illness. The membrane involved the lacunae of the tonsils. Resembles follicular tonsillitis. Received 6,000 units of antitoxin total. C. Hemorrhagic type of diphtheria. Child seven-and-a-half years old, seen on sixth day of illness. Tonsillar and post-pharyngeal exudate. Severe nasal and post-pharyngeal hemorrhages during exfoliation of membrane. Received in all 15,000 units of antitoxin. Throat clear on ninth day of illness. Myocarditis developed. Case discharged cured four weeks after admission.  D. Septic type of diphtheria. Child eight years old, seen on fifth day of illness. The pseudo-membrane in this case covered the hard palate and extended in one large mass down the pharynx, completely hiding the tonsils. Diseases of Infancy and Childhood. Louis Fischer, M.D., 1917.

biomedicalephemera:

Diphtheria is known for creating a slimy/sticky/smelly exudate in the throat and mouth, but there are quite a few variations on its etiology and presentation.

A. Common type of diphtheria. Child three years old, seen on fourth day of illness. Exudate covering pharynx, tonsils, and uvula. Received 16,000 units of antitoxin. Throat clear on sixth day. Discharged cured.

B. Follicular type of diphtheria. Child seven years old, seen on second day of illness. The membrane involved the lacunae of the tonsils. Resembles follicular tonsillitis. Received 6,000 units of antitoxin total.

C. Hemorrhagic type of diphtheria. Child seven-and-a-half years old, seen on sixth day of illness. Tonsillar and post-pharyngeal exudate. Severe nasal and post-pharyngeal hemorrhages during exfoliation of membrane. Received in all 15,000 units of antitoxin. Throat clear on ninth day of illness. Myocarditis developed. Case discharged cured four weeks after admission. 

D. Septic type of diphtheria. Child eight years old, seen on fifth day of illness. The pseudo-membrane in this case covered the hard palate and extended in one large mass down the pharynx, completely hiding the tonsils.

Diseases of Infancy and Childhood. Louis Fischer, M.D., 1917.

Necrotic stomatitis in a calf (also known as gangrenous stomatitis or calf diphtheria*). From the Special Report on Diseases of Cattle from the U.S. Department of Agriculture, 1912 *This disease is also found in pigs, despite the name “calf diphtheria”.

Necrotic stomatitis in a calf (also known as gangrenous stomatitis or calf diphtheria*).

From the Special Report on Diseases of Cattle from the U.S. Department of Agriculture, 1912

*This disease is also found in pigs, despite the name “calf diphtheria”.

Diphtheria case study in Diseases of Infancy and Childhood by Louis Fischer, M.D., 1917.

Diphtheria case study in Diseases of Infancy and Childhood by Louis Fischer, M.D., 1917.

Diphtheria is known for creating a slimy/sticky/smelly exudate in the throat and mouth, but there are quite a few variations on its etiology and presentation. A. Common type of diphtheria. Child three years old, seen on fourth day of illness. Exudate covering pharynx, tonsils, and uvula. Received 16,000 units of antitoxin. Throat clear on sixth day. Discharged cured. B. Follicular type of diphtheria. Child seven years old, seen on second day of illness. The membrane involved the lacunae of the tonsils. Resembles follicular tonsillitis. Received 6,000 units of antitoxin total. C. Hemorrhagic type of diphtheria. Child seven-and-a-half years old, seen on sixth day of illness. Tonsillar and post-pharyngeal exudate. Severe nasal and post-pharyngeal hemorrhages during exfoliation of membrane. Received in all 15,000 units of antitoxin. Throat clear on ninth day of illness. Myocarditis developed. Case discharged cured four weeks after admission.  D. Septic type of diphtheria. Child eight years old, seen on fifth day of illness. The pseudo-membrane in this case covered the hard palate and extended in one large mass down the pharynx, completely hiding the tonsils. Diseases of Infancy and Childhood. Louis Fischer, M.D., 1917.

Diphtheria is known for creating a slimy/sticky/smelly exudate in the throat and mouth, but there are quite a few variations on its etiology and presentation.

A. Common type of diphtheria. Child three years old, seen on fourth day of illness. Exudate covering pharynx, tonsils, and uvula. Received 16,000 units of antitoxin. Throat clear on sixth day. Discharged cured.

B. Follicular type of diphtheria. Child seven years old, seen on second day of illness. The membrane involved the lacunae of the tonsils. Resembles follicular tonsillitis. Received 6,000 units of antitoxin total.

C. Hemorrhagic type of diphtheria. Child seven-and-a-half years old, seen on sixth day of illness. Tonsillar and post-pharyngeal exudate. Severe nasal and post-pharyngeal hemorrhages during exfoliation of membrane. Received in all 15,000 units of antitoxin. Throat clear on ninth day of illness. Myocarditis developed. Case discharged cured four weeks after admission. 

D. Septic type of diphtheria. Child eight years old, seen on fifth day of illness. The pseudo-membrane in this case covered the hard palate and extended in one large mass down the pharynx, completely hiding the tonsils.

Diseases of Infancy and Childhood. Louis Fischer, M.D., 1917.