Vinnytsya National Pirogov Memorial Medical University
Department of Children Infectious Diseases
“Approved”
at sub-faculty meeting
“__”_____2012, protocol №_____
Head of Department
prof. _______I.I. Nezgoda
Study Guide for practical work of students
Topic: “Diphtheria, Infectious mononucleosis, Mumps”.
Course V
English-speaking Students’
Medical Faculty
Duration of the class-180min
Composed by assistant O.V. Bodnariuk
Vinnytsya
2012
I. The theme urgency
Diphtheria is an acute infectious disease caused by Corynebacterium
diphtheria and characterized by the appearance of a fibrinous membrane on the site of
pathogen invasion, which can spread on to the tonsils, larynx and pharynx, leading to
symptoms of toxemia and toxic lesions of the cardiovascular system, nervous system,
adrenal glands and kidneys.
Infectious mononucleosis (Filatov’s disease) is an acute feverish viral disease,
being spread by air-droplet route. It is characterized by polyadenitis (especially
cervical one), acute membranous tonsillitis, enlarged liver and spleen, leukocytosis,
limphocytosis, presence of atypical lymphocytes. The pathogen of the disease is
Epstein-Barr virus (EBV), which contains DNA. EBV is isolated in other diseases:
such as Burkitt’s lymphoma and nasopharyngeal carcinoma.
Mumps remains endemic in many countries throughout the world, and mumps
vaccine is used in only 57% of countries that belong to the World Health
Organization, predominantly in countries with more developed economies. As in the
prevaccine era, most cases of mumps are still in children ages 5 to 14, but the
proportion of young adults who become infected has been rising slowly over the last
two decades. Mumps infections are uncommon in children younger than 1 year old.
Death due to mumps is rare; more than half of the fatalities occur in persons older
than 19 years.
ІІ. Primary aims of the study
A student must know:
1. Etiology and properties of the cause and causing factors of diphtheria.
2. Epidemiology (source of infection, ways of transmission, age-old receptivity
and morbidity).
3. Pathogenesis of disease, pathomorphologic changes in the staggered organs.
4. Classification of clinical forms of diphtheria.
5. Clinic of typical form of diphtheria.
6. Clinic of rare form of diphtheria.
7. Classification of toxic (severe) forms of diphtheria.
8. Clinic of toxic (severe) forms of diphtheria.
9. Complication of diphtheria.
10.Methods of laboratory research.
11.Principles of therapy of diphtheria.
12.Measures of prophylaxis of diphtheria.
13.Etiology of infectious mononucleosis and mumps.
14.Epidemiology infectious mononucleosis and mumps.
15.Characteristic of Epstein-Barr virus (EBV) and mumps.
16.Pathogenesis of disease, pathomorphologic changes in the staggered organs
and blood cells.
17.Classification of clinical forms of infectious mononucleosis and mumps.
18.Clinic of infectious mononucleosis and mumps.
19.Clinic of acute form Epstein-Barr viral infection and mumps.
20.Clinic of chronic form Epstein-Barr viral infection and mumps .
21.Other clinical forms of Epstein-Barr viral infection and mumps
22.Hematologic disorders are typical for infectious mononucleosis and mumps.
23.Methods of laboratory research.
24.Principles of therapy of infectious mononucleosis and mumps .
25.Antiviral treatment of Epstein-Barr viral infection and mumps.
A student must be able:
1. 1.To follow the basic rules of work with a patient sick with diphtheria.
2. To take anamnesis with the estimation of epidemiology information (taking
into account seasonality, origin of febricities, polymorphism of clinical signs of
illness).
3. To examine a patient and reveal the basic clinical signs of illness.
4. To represent information of anamnesis and objective inspection in a hospital
chart and formulate the preliminary diagnosis.
5. To write a plan of examination.
6. To write a clinical diagnosis (form of disease, type, severity, course of
disease).
7. To prescribe the treatment taking into account age, severity of illness.
8. To write out a prescription.
9. To organize disease measures in the hearth of infection (to find out the source
of infection, fill an urgent report in SES, to set a quarantine, to define the circle
of contact persons, conduct them bacteriological inspection).
10.To write epicrisis with the estimation of development of illness, results of
inspection, efficiency of treatment, prognosis, by recommendations for a
subsequent supervision or treatment depending on the form of diphtheria.
11.11.To follow the basic rules of work with patients sick with infectious
mononucleosis and mumps.
12.To take anamnesis with the estimation of epidemiology information (taking
into account seasonality, origin of febricities, polymorphism of clinical signs of
illness).
13.To examine patients and reveal the basic clinical signs of illness.
14.To represent information of anamnesis and objective inspection in a hospital
chart and formulate the preliminary diagnosis.
15.To write a plan of examination.
16.To write a clinical diagnosis (form of disease, type, severity, course of
disease).
17.To prescribe the treatment taking into account age, severity of illness.
18.To write out a prescription.
19.To organize disease measures in the hearth of infection (to find out the source
of infection, fill an urgent report in SES, to set a quarantine, to define the circle
of contact persons).
20.To write epicrisis with the estimation of development of illness, results of
inspection, efficiency of treatment, prognosis, by recommendations for a
subsequent supervision or treatment depending on the form of infectious
mononucleosis and mumps.
III. Educational aims of the study
- forming the deontological presentations, skills of conduct with the patients
- to develop deontological presentations, be able to carry out deontology
approach to the patient
- to develop the presentations of influence of ecological and socio-economic
factors on the state of health
- to develop sense of responsibility for a time illness and loyalty of
professional actions
- to be able to set psychological contact with a patient and his family
IV. Control materials for the preliminary and final stage of the lesson
Tests and tasks
1. A 7 -year-old boy has been ill for 2 weeks, when coryza occured. Vaccination
terms were not kept to. Now he has difficulty of nasal breathing, sanioserous nasal
discharge, excoriations on the skin at the entrance into the nose and on the upper
lip.
Fibrinous membranes are discovered by rhinoscopy on the mucous membrane of
the nose. Mucous membrane of oropharynx is intact. What is your diagnosis?
a). nasal diphtheria
b). adenoviral infection
c). rhinoviral infection
d). allergic rhinitis
e). maxillary sinusitis
2. 5-year-old child. Complains on throat aches when swallowing, Т - 38,5°С. 2nd
day: Т- 37,8°С. Pharynx and tonsils are edematic, moderately hyperaemic,
covered with gray membranes, elivated over mucosa, hardly detached, mucosa is
cyanotic, hyperaemic, Submandibular lymphatic nodes are enlarged - 2 cm,
painless. What disease is most likely with those clinical features?
a). necrotic tonsillitis.
b). paratonsillar abscess.
c). infectious mononucleosis.
d). tonsils diphtheria
e). adenovirus infection.
3. Characterize diphtheria film
a) hardly to remove
b) easily to remove
c) white-yellowish color
e) creamy
4. What type is the most virulent?
a) mitis
b) gravis
c) intermedius
5. 12-year-old child. Complaints are fever Т - 38,9о С, sore throat. 3rd day: Т 39,2о С, pale, adynamic. Submandibular lymphatic nodes - 3 cm; Oedema of the
neck subcutaneous tissue up to the middle of the neck. The pharynx is oedematic,
hyperaemic with cyanosis, tonsils are enlarged, there is a grayish-white colour
thick membrane, firmly adherent on them and upon the uvula there’s. What is the
primary diagnosis?
1= Infectious mononucleosis
2=Epidemic parotitis (Mumps)
3=Toxic diphtheria of tonsils
4=Localized diphtheria of tonsils
5=Paratonsillar abscess
6. 10-year-old child. Complaints are fever - 38,2о С, sore throat while swallowing.
The 2nd day – fever - 37,6оС, the swollen tonsils are observed in the pharynx, all
over on the right tonsil extending to the palatoglossal arch, the upper and centre
part of the left tonsil there is a grayish-white membrane is found, which is firmly
adherent. The mucous around tonsils is hyperaemic, cyanotic; the submandibular
lymphatic nodes are enlarged, a little painful. Taking into consideration the
clinical features what medication is most sufficient for that patient?
1=Metronidazole
2=Biseptolum
3=Prednisolone
4=Antidiphtheric serum
5=Erythromycin
7. 2-year-old child. Complaints: cough, hoarseness, dyspnoe, Т - 37,4оС. The
condition gradually became worse. 3rd day of the disease: Т - 37,2оС, inspiratory
dyspnoe. Cough soundless, voice is aphonic cyanosis of the perioral area,
acrocyanosis. Cold sweat. Anxious. Resonant breath in the lungs. What is the
primary diagnosis:
1=Parainfluenza, stenotic laryngotracheobronchitis.
2=Larynx polyposis
3=Pertussis (spasmatic period)
4=Larynx diphtheria
5=Foreign body on the larynx
8. 12 -year-old child. Complains to sore throat. Т - 39°С. 3rd day: Т- 39,5°С,
pallor, hypodynamics. Submandibular lymphatic nodes are enlarged - 2 cm,
painless edema of cervical subcutaneous tissue up to the middle of the neck.
Mucus membrane of tonsils and the palatoglossal arch is hyperaemic with
cyanotic color, edemous. On the both tonsils, involving uvula from the left side
there is a concrete grayish-white membrane, bulged, hardly detached, bleed. Heart
sounds are muted. Your diagnosis?
1= Tonsils diphtheria, localized form.
2= Infectious mononucleosis.
3= Tonsils diphtheria, toxic form.
4= Mumps.
5= Necrotic tonsillitis.
9. 6,5-year-old child. Complains on difficulty breathing, pallor, Т - 38,2°С,
soundless cough. Child didn’t have vaccinations. 4th day of the disease: sits, bents
onward, pale, face is edematic, respiration is noisy, aspiratory dyspnoe, 48 per
min, cough soundless. Throat mucosa is pale and cyanotic. Severe tachycardia.
About what disease do you think?
1= Infectious mononucleosis.
2= Larynx diphtheria, croup.
3= Mumps.
4= Adenovirus infection.
5=Parainfluenza, stenotic laryngotracheobronchitis
10. Driving part in pathogenesis of diphtherias is:
1=Homeostasis violation
2=Bacteremia
3=Sensitization
4=Toxemia
5=Immunity violation
11. Disease of the 5 years old child started acutely with high temperature, single
vomiting. On the second day of disease sore throat, a hoarseness voice has
appeared, tonsils are greatly increased, pruinose dirty - gray color. During
examination of the pharynx the unpleasant ordor is sensed. Submaxillary and
cervical lymph nodes are increased, painful at palpation. Edema of cervical
subcutaneous tissue of the neck. What is the most probable diagnosis?
1=Scarlatina
2=Phlegmonic paratonsillitis
3=Infectious mononucleosis
4=Lacunary quinsy
5=Toxic form of a diphtheria tonsil
12. Disease of 5 years old child began acutely with a high temperature, single
vomiting. For the second day of disease the throat is sore, hoarseness of voice has
appeared, tonsil are greatly increased of pruinose dirty - grey color. During
examination of the pharynx the unpleasant ordor is sensed. Submaxillary and
cervical lymph nodes are increased, painful at palpation. Edema of cervical
subcutaneous tissue of the neck. What from the listed attributes is the basic at
diagnostics of the toxic form of a diphtheria tonsil?
1=Hoarseness voices
2=Patch on tonsils
3=Stagnant hiperemia tonsils
4=Impossibility to open a mouth
5=Edema hypodermic cellular tissue necks
13. Child of 3 years old the diagnosis is a diphtheria of tonsils, the toxic form is
established. Has been sick for 2 weeks. What is most severe complication can
develop at the patient with the current of disease?
1=Violation of brain blood circulation
2=Paresis of the soft sky
3=Polyradiculoneuritis
4=Glomerylonefritis
5=Myocarditis
14. Child 6,5 years. Т – 38,2С. 4-th day of the disease. Sits, having bent forward,
pale. The person bloated. Inspiration is superficial, 48 per minute, aphonic, silent
cough. Mucous membranes are pale cyanotic. The tachycardia is expressed.
Diagnose:
1=Diphteria throats, croup.
2=Foreign a body of a throat.
3=Whooping cough pneumonia.
4=Adenovirus an infection, croup.
5=Parainfluenzia groats.
15. How to prevent development of the diphteriae?
a) Antitoxin
b) Antidiphtheric serum
c) DTP-vaccine
d) Anatoxin
16. Name the method of introduction of antidiphtheric serum
a) after Urbah method
b) after Bezredko method
c) per os
g) after Tsuverkalov
17. A 3-year-old girl has had fever, difficulty of nasal breathing, enlarged cervical
lymph nodes. Fever up to 38,3oC, lacunar tonsillitis, maculopapular rash on the
skin, enlarged liver and spleen had occured on the 3rd day of illness. Blood count
contained leucocytosis, limphomonocytosis, atypical mononuclear cells - 20 % .
What is your diagnosis?
A. Measles
B. Rubella
C. Infectious mononucleosis
D. Scarlet fever
E. Adenoviral infection
18. A 6 -year-old child has infectious mononucleosis.
Which blood cells may confirm the diagnosis?
A. Polymorphonuclear cells
B. Basophilic leukocyties
C. Atypical mononuclear cells
D. Eosinophils
E. Erythrocytes
Task 1.
An eight-month baby had an acute onset of a disease. Among the symptoms
are: a moderate temperature 37,80 C; barking cough; hoarseness.
Dyspnea and aphonia appeared on the third day of the disease. From the
anamnesis: the baby wasn’t vaccinated completely because she had only one dose
APDT-vaccine. The mother of the baby has angina now.
The child was taken to the hospital.
Physical Examination: temperature 37,40 C; harsh and loud breathing; chest
retraction while resting; nostrils inflation; breathing rate – 66\min; anxious and
restless condition of the baby; acrocyanosis; tachycardia – 180 beats/min; dropped
pulse during breathing.
Questions:
1. Figure out the diagnosis according to the classification.
2. Prescribe correct treatment.
3. Prescribe urgent pathogenetic therapy.
4. Point out the prophylaxis measures in this case.
Task 2.
During the prophylactic examination at the boarding school one boy had in his
fauces a toxigenic diphtheritic bacterium – strain gravis (in the swab).
During physical examination there were no acute inflammation processes on
the mucous membranes of the fauces.
Questions:
1.
Figure out the clinical diagnosis.
2.
The doctor’s tactics according to the boy.
3.
Prescribe the antibacterial therapy.
4.
When can the boy be allowed to the school?
Task 3.
The doctor pointed the diagnosis “follicular angina” on the second day of a
disease. The patient was a boy of 15. Also the swab (from the fauces) was taken the
same day. Three days later a diphtheritic bacterium – the toxigenic strain is
determined.
During the second examination there were not any signs of the disease. There
were no membranous films on the tonsils, the temperature of the body was normal.
The vaccination plan: at the age of 3 mo – APDT I, 4 mo – APDT II, 5 mo –
APDT III. The revaccination: at the age of 2 years 3 mo – APDT I, at the age of 6,5 –
ADT II.
Questions:
1. Figure out the clinical diagnosis.
2. Estimate the vaccination plan in this case.
3. Prescribe the specific treatment.
4. When can the boy be allowed to the school?
TASK 4
A thirteen-year child has an acute onset of the disease. Among the symptoms
are: the temperature increases to 38,40C; tonsillitis; the lymphatic nodes enlarge;
splenomegaly and mild hepatomegaly. The findings on the blood tests are as follows:
leucocytes – 13,0x109\l, b - 2 %; s – 38 %; l – 40 %; m – 10 %; at. m. – 10 % .
Questions:
1. What is your diagnosis?
2. Give the examination scheme.
3. Prescribe the treatment.
4. What antibiotic is not used at this disease? Why?
TASK 5
A thirteen-year child has an acute onset of the disease. Among the symptoms
are: the temperature increases to 38,70C; tonsillitis; the lymphatic nodes enlarge;
splenomegaly and mild hepatomegaly. The findings on the blood tests are as follows:
leucocytes – 15,8x109\l; b - 2 %; s – 28 %; l – 40 %; m – 10 %; at. m. – 20 % .
Questions:
1. What is your diagnosis?
2. Give the examination scheme.
3. Prescribe the treatment.
4. What group does this disease belong to?
Mumps
Tests
1. A 4-year-old boy complains of fewer up to 38,9 C, pain in chewing and opening
the mouth, headache. Right parotis gland is enlarged and painful in palpation. The
skin over the parotis gland is without change. On the affected side the salivary
duct is reddened and edematous. What is your diagnosis?
A. Infectious mononucleosis
B. Mumps
C. Rubella
D. Cervical lymphadenitis
E. Sialoademitis
2. A 7-year-old boy fell ill abruptly: fever up to 39C, headache, recurrent
vomiting. Positive meningeal signs are present. The boy had been in contact with
patient with mumps. He is not vaccinated against mumps. What is the probable
diagnosis?
A. Mumps meningitis
B. Meningococcal meningitis
C. Pneumococcal meningitis
D. Staphylococcal meningitis
E. Tuberculosis meningitis
3. A 10-year-old boy had mumps. On the 5th day of illness the child's general
condition become worse. Abdominal pain, nausea, anorexia and then vomiting
occurred. The amylase in the blood and diastase in the urine increased highly.
What is the diagnosis?
A. Appendicitis
B. Pancreatitis
C. Mesadenitis
D. Cholecystitis
E. Gastritis
TASK №1
A child of 6 years old is diagnosed epidemic parotitis, the 7-th day of the
disease. Today the body temperature has raised up to 38.5°С, there is a intensive
headache and repeated vomiting. Positive meningeal signs are revealed. Spinal
punition was prescribed. Liquor is transparent, flows under the increased pressure;
pleocytosis is 600 cells in 1mcl, with prevalence of lymphocytes, a level of protein is
slightly increased, a level of glucose is 3.2 mmol/l.
Questions:
1. Formulate the clinical diagnosis.
2. What diseases is it necessary to make differential diagnosis with?
3. Administer the therapy.
TASK №2
In a 10-year-old girl having mumps with fever, recurrent vomiting and severe
surrounding pain in upper part of her abdomen occurred on the 4th day of illness.
Questions:
1.
Make the preliminary diagnosis.
2.
What laboratory examinations should be administered?
3.
Make the plan of treatment of the patient.
V. Literature
1. Mikhailova A.M., Minkov I.P., Savchuk A.I. Infection diseases in children.Odessa, 2003.- 236 p.
2. Nelson Textbook of Pediatrics. / Edited by Richard E. Behrman, Robert,
M.Kliegman, Ann M. Arvin.; senior editor, Waldo E. Nelson. – 1996.
3. Kuznetsov S.V., Olchovskaya O.N., Tatarkina A.N. Selected lectures in
children’s infectious diseases.- Kharkiv, 2006.- 164 p.