MUMPS,
DIPHTERIA,
TETANUS AND
PERTUSIS
Prof. Dr. Ayça
VİTRİNEL
MUMPS
 Mumps virus RNA virus of the genus
paramyxovirus in the family paramixoviridae which also includes parainfluenza
viruses.
 Spread from human reservoir by direct
contact, airborne droplets fomites
contaminated by saliva and possibly urine.
 Peak age: 5-9 yr (before vaccinatum)
MUMPS
 Virus has been isolated from as long as 6
days up to 9 days after appereance of
salivary gland swelling.
 Isolated from urine from the 1st –14th day
after the onset of salivary gland swelling .
 Transmission doesn’t seen to occur more
than 24 hr before the appereance of the
swelling or later than 3 days after it has
subsided.
MUMPS
 Clinical Manifestations:
 Incubation period 14-24 days
 Prodrome : rare
 Salivary glands: Pain and swelling in one
/both parotid glands
 Swollen tissues push the ear lobe upward
and outward
MUMPS
 Angle of the mandible is no longer visible
 Swelling subsides within 3-7 days
 Swollen area is tender and painful  pain being
elicited especially by tasting sour liquids such as
lemon juice or vinegar
 Redness and swelling about the opening of the
Stenon duct are common
 Edema over the manibrium and upper chest wall
may occur  lymphatic obstruction.
MUMPS
 Swelling of submandibular glands occur
frequently and usually accompany the
parotid gland.
 Least commonly the sublingual glands are
infected.
MUMPS
 Diagnosis:
 Clinical symptoms
 Physical appereance
 Laboratory : leukopenia (lymphocytosis)
elevations of serum amylase
Serology: IgM (in the first days) and IgG
Culture: saliva, CSF, blood, urine.
MUMPS




Treatment: no spesific antiviral treatment
Supportive
Complications:
Meningoencephalomyelitis: most frequently
complication. Male/female: 3/1
 Primary infection of nerves at the same time or
before primer parotitis
 Postinfectious encephalitis with demyelination
follows parotitis by an avarage of 10 days
MUMPS
 Orchitis and epididymitis : adolescent and adults.
Follows parotitis within 8 days.
 Oophoritis
 Pancreatitis
 Thyroiditis
 Myocarditis
 Deafness
 Ocular complication
 Arthritis
 Prevention: mumps vaccine.
TETANUS
 Acute spastic paralytic illness caused by
tetanus toxin (tetanospasmin) a neurotoxin
 C.tetani Gr (+), spore forming, obligate
anaerobe. Natural habitat is soil, dust,
alimentary tracts of various animals
drumstic/tennis racket appereance microscopically.
TETANUS
 1) Neonatal
 2) Nonneonatal travmatic injury,
penetrating injury infected by a dirty object
use of contaminated suture material
 Tetanus toxin binds at the neuromusculer
junction  endocytosed by the motor
nerve  axonal transport  cytoplasm of
motor neuron  prevents neurotransmitter
release
TETANUS
 Blocks the normal inhibition of antagonistic muscles {basis of voluntary coordinated
movement} : affected muscles sustain
maximal contraction.
 Clinical manifestations:
 1) Localized
 2) generalized: more common
TETANUS
 Incubation period: 2-14 days
 Trismus (masseter muscle spasm: lockjaw)
is presenting symptom
 Headache, restlessness, irritability 
stiffness, difficulty chewing, disphagia,
sardonic smile
 Opistotonos : arched posture, neck muscle
spasm
 Laringeal and respiratory muscle spasm :
airway obstruction
TETANUS
 Patient remains conscious (tetanus toxin
doesn’t affect sensory nerves or cortical
function)
 Smallest disturbance by slight sound, touch
: trigger a tetanic spasm
 Dysuria, urinary retention, forced
defecation
 Fever
TETANUS
 Tachycardia, arythmics
 Labile hypertension
 Tetanic paralysis more severe in the 1st
week  stabilizes in the 2nd week
 Localized: painful spasm of muscles
adjacent to the wound site
TETANUS
 Cephalic tetanus: Rare form of localized
tetanus involving the bulbar musculature
that occurs with wound or foreign bodies
in the head, nostrils or face.
 Association with chronic otitis media.
 Retracted eyelids + trismus + risus sardonicus + spastic paralysis of tongue and
pharyngeal musculature.
TETANUS
 Neonatal tetanus: 3-12 days after birth
 Difficulty in feeding
 Paralysis or diminished movement
 Stiffness to the touch
 Diagnosis:
 Clinically
 CSF: NORMAL
TETANUS
 Differential diagnosis: acute encephalitis
 Rabies: CSF pleocytosis, hydrophobia
 Strychnine poisoning
 Hypocalsemia
 Retropharengeal, dental abscess: trismus
TETANUS
 Treatment: eradication of C. tetani
 Neutralization of all accessible tetanus
toxin
 Control of seizure
 Supportive care
 Prevention of recurrences
 TIG (longer half life): Neutralizes the toxin
in the circulation before binding [30006000 U IM recommended ]
TETANUS
 TAT: bovine derived 50.000 – 100.000 U
½ IM + ½ IV risk of serum sickness.
 IVIG: Contains 4-90 U/ml TIG  optimal
dosage is not known
 Antibiotics: Pen G : 100.000 U/kg/ 24 hr :
4-6 hr intervals 10-14 days
 Metronidazole: 500 mg of 8 hr  equally
effective
 Erythromycin and tetracycline are
alternative for penicillin allergic patients.
TETANUS
 Muscle relexants: diazepam: relexation and
seizure control [0,1-0,2 mg/kg every 3-6 hr
IV: 2-6 weeks] { 2yr  ; 8mg/kg/day }
 Baclofen : only in intensive care unit
 Neromuscular blocking agents  M.V.
 Phenobarbital and morphine may also be
used as an adjunctive therapy
TETANUS
 Prognosis: recovery in tetanus occurs
through regeneration of synapses, within
the spinal cord and restoration of muscle
relexation . Episode of tetanus doesn’t
result in the production of toxin
neutralizing Abs : active immunization
with tetanus toxoid at discharge
TETANUS
 Favorable prognosis: long incubation
period, absence of fever, localized disease
 Prevention: active immunization, maternal
immunization with at least 2 doses of
tetanus toxoid, tetanus prophylaxis in
wound management
Clean minor
wound
Other
wounds
Prior tetanus
doses
Td
TIG
Td
TIG
Uncertain or
3
Yes
No
Yes
Yes
Three or
more
No
No
No
No
Yes if  10 yr
since last
dose
Yes if  5 yr
since last
dose
DIPHTERIA
 Acute toxicoinfection caused by Corynebacterium diphteriae
 Gr (+) bacilli, aerobic
 Three biotypes mitis, gravis-least, intermediusmost common
 Spread by airborne respiratory droplets , direct
contact with respiratory droplets, direct contact
with respiratory secretions of symp individuals.
Exudate from infected skin lesions
 Asymtomatic respiratory tract carriers are
important in transmission.
DIPHTERIA
 Entry of C. Diphtheriae in nose/mouth 
localized on the mucosal surface of URT  toxin
is adsorbed to cell membrane  tissue necrosis
 patchy exudate initially be removed
 As the toxin production increases  the area of
infection widens and deepens and a fibrinous
exudate develops  tough adherent pseudomembrane is formed that varies from gray to
black attemps to remove it are followed by
bleeding.
DIPHTERIA
 Edema of the soft tissues  bull neck
appereance
 Clinical manifestations: depend on the site
of infection
 Incubation period: 1-6 days
 Nasal diphteria: mild rhinorrhea  nasal
discharge serosaguineous  mucopurulent
 excoriates the nares, upper lip
DIPHTERIA
 White membrane on the nasal septum
 Most often in infants
 Slow absorbtion of toxin  lack of
systemic symptoms
 Tonsillar and/or pharyngeal diphteria: most
common site of disease
 Anorexia, malaise, low grade fever, pharangitis [1-2 days] thin-gray membrane
DIPHTERIA
  adherent membrane may spread to cover
the tonsils and pharyngeal wall  may
progress [bleeding] in to the larynx and
trachea
 Cervical lymphadenitis : bull neck appereance
 Respiratory and circulatory collaps may
occur
 Palatal paralysis may occur
 Stuppor, coma, death : wihin 7-10 days
DIPHTERIA
 Laryngeal diphteria: represents a downward
extension of the membrane for the pharynx
 Occasionally only laryngeal involvement is
present
 Noisy breathing
 Progresive stridor, hoarseness
 Suprasternal, subcostal, supraclavicular
retractions
DIPHTERIA
 Cutaneous diphteria: an ulcer with a sharpy
defined border ,important source of person
to person transmission
 Conjunctival lesions: red, edematous,
membranaeous , corneal erosion
 Aural diphteria: otitis externa with a
persistenly purulent and frequently faul
smelling discharge
DIPHTERIA
 Diagnosis: isolation of C. diphteria (
Loeffler, tellurite and blood agar)
 WBC N/
 Anemia; result of rapid hemolysis
 Toxigenicity by inoculating 2 guinea pigs
ID suspension of microorganism (
antitoxin/no antitoxin)  24 hr inflamatory
lesion , 72 hr necrotic lesion
DIPHTERIA
 Complications: Myocarditis: 2nd week (1-6 wk)
ST-T changes 1st degree heart block, hearth
failure, myocardial enzymes 
 Neurologic complications: Bilateral, usually
resolve competely. Paralysis of the soft palate
and pharengeal muscles (1-3 wk ). Ocular muscle
and ciliar paralysis (5th wk). Paralysis of
diaphragm (5-7 wk). Paralysis of the limbs with
loss of deep tendon reflexes (2-7 wk)
 Elevation of CSF protein, pleocytosis
 Hypotension, cardiac failure, gastritis, hepatitis,
nephritis
DIPHTERIA
 Prevention: Immunization
 Contacts: Isolation of patient; three consecutive
(-) cultures. Cultures schould be taken from close
contacts, observed for 7 days  if C. diphteria is
recovered treatment schould be instituted
 Asymptomatic immune close contacts: receive a
booster of DT, Td, if they haven’t received
booster within 5 yr.
DIPHTERIA
 Asymptomatic close contact is not
immunized or the immunization status is
unknown. He/she should be closely
observed and started erythromicin (7 days)
or benzathine pen G : culture should be
obtained before and after treatment ,active
immunization should be given.
DIPHTERIA
 Treatment : Antitoxin must be administired
as early as posible by IV route and in a
dose sufficient to neutralize all free toxins
 Desensitization must be done
 20.000-40.000 U for pharyngeal/laryngeal
 40.000-60.000 U nasopharyngeal
 80.000-100.000 U extensive disease
DIPHTERIA
 Penicillin (procain 300.000/600.000 U IM)
erythromicin (40 mg/kg/day) 14 days
 End point of therapy : three consecutive
negative culture
 Bed rest 2-3 wk
 Hydration
 Laryngeal diphteria; tracheostomy
PERTUSIS = WHOOPING
COUGH
 Acute respiratory infection
 Bordetella pertusis (B. Parapertusis, B.
Bronchiseptica) Gr (-) cocobacils
 Recovered best in Bordet Gengou media
(glyserin, patato, blood agar)
 Humans are the only known host
 Spread occurs by direct contact, by
respiratory droplets
PERTUSIS
 Transplacental passage of maternal Ab
does not protect the NB
 Severe neonatal pertusis can be acquired
from a mildly symptomatic mother.
 Pathology: peribronchial lymphoid
hyperplasia  necrotizing process
 Bronchopneumonia develops with necrosis
and desquamation of superficial epithelium
of small bronchi.
PERTUSSIS
 Bronchiolar obstruction and atelectasis 
accumulation of mucus secretions
 Bronchiectasis may develop
 Microscobic or gross cerebral hemorrhages
may be seen, cortical atrophy has been
observed
 Fatty infiltration of the liver
 B. Pertussis produces many biologically
active factors that are responsible for
disease
PERTUSIS
 Pertussis toxin, filamentous hemaglutinin etc
 Clinical manifestations: inc period : 6-20 days
 1) catarhal stage: 1-2 wk rhinorhea, conjuctival
injection, lacrimation, mild cough, low grade
fever
 2) paroxysmal stage: 2-4 wk
 Repetitive series of 5-10 forceful cough during a
single expiration  sudden massive inspiratory
effort.
PERTUSIS
 Prominent during attack:
 Facial redness/cyanosis
 Bulging eyes
 Protrusion of tongue
 Lacrimation, salivation
 Distention of neck veins
PERTUSIS
 Attacks may be trigerred : yawning,
sneezing, eating, drinking
 Petechial/ conjuctival hemorrhages may be
noted on the head and neck
 Diagnosis: cough more than 2 wk duration
with posttussive emesis is an important
diagnostic clue.
PERTUSIS
 Leukocytosis (20.000-50.000 /mm³)
 Absolute lymphocytosis
 Chest roentgen: perihilar infiltrates,
atelectasis, emphysema
 Spesific diagnosis: recovery of the
organism  nasopharingeal swabs
 ELISA (IgM, IgG, IgA)
 PCR
PERTUSIS
 Complications:
 1) respiratory: pneumonia, atelectasis,
emphysema, pneumothorax, bronchiectasis, otitis
media, epistaxis
 2) pressure: intracranial hemmorhagea,
subconjuctival hemmorhagea, epistaxis, rupture
of diaphragma, umbical hernia, inguinal hernia,
rectal prolapsus
 3) other: convulsions, dehydration, nutritional dis
PERTUSIS
 Prevention: vaccination
 Erythromycin effective in preventing
pertusis.
 Close contacts of less than 7 yr of age who
have been immunized previously
 booster dose, erythromicin 14 days
 7yr , immunized  erthromycin 14 days
 Treatment: erythromycin 50 mg/kg/day
(d4) 14 day