Difterite: sintomi, diagnosi e terapia
Definizione
La difterite è una malattia contagiosa acuta, causata dal patogeno Corynebacterium diphtheriae. Il germe non invade tutto l’organismo ma rimane localizzato spesso nella faringe, nelle vie respiratorie superiori dove produce l’esotossina che si diffonde in tutto l’organismo attraverso la circolazione; l’esotossina provoca un’iperemia generalizzata dei visceri e delle lesioni a distanza. Le lesioni primitive sono caratteristiche: la mucosa respiratoria localmente distrutta è sostituita da una falsa membrana, costituita da essudato coagulato, leucociti e cellule epiteliali necrotizzate. Le lesioni a distanza si osservano nelle fibre miocardiche, nei reni e nelle surrenali. In caso di paralisi difterica si ha degenerazione dei nervi periferici e lesione delle corna anteriori del midollo. Oggi, grazie all’avvento del vaccino e ai programmi vaccinali all’avanguardia, la difterite è molto meno diffusa rispetto a un tempo.
Eziologia
L’agente patogeno è il “Corynebacterium diphtheriae” o bacillo di Klebs-Löffler , che è un bastoncino sottile, immobile leggermente rigonfio ad una delle estremità, gram-positivo, ma che si decolora facilmente se si insiste. Colorato con il metodo Neisser presenta corpuscoli metacromatici caratteristici, mediante essicazione è possibile conservarlo per anni. L’esotossina difterica è distrutta a 100°, aggredisce soprattutto il miocardio e i nervi tramite il citocromo B.
Epidemiologia
La difterite colpisce soprattutto i bambini e i giovani adulti non immunizzati, con recrudescenza epidemiche di inverno nelle zone temperate. Nei paesi industrializzati, il vaccino ha fatto scomparire queste epidemie. Nelle zone tropicali, l’infezione spesso frusta e le forme cutanee sono frequenti. Il contagio è soprattutto diretto e si verifica tramite le secrezioni del naso e della bocca, disseminate dai malati e dai convalescenti, ma soprattutto dai portatori sani. La recettività è valutata mediante la reazione di Schick. L’habitat del bacillo è l’uomo.
Manifestazioni cliniche della difterite
L’incubazione va da 2 a 5 giorni ma talvolta è più lunga.
- Difterite nasale: questa è la forma più benigna e si manifesta con una coriza ( infiammazione acuta delle mucose nasali) sierosanguinolenta, spesso unilaterale, scolo nasale, erosione dei bordi delle narici, a volte epistassi, e pochi segnali e segni generali. I bambini non sembrano malati e diventano portatori di germi.
- Angina difterica: l’inizio è insidioso, con febbre poco elevata (più o meno 38°) angina rossa poi, dopo 2-3 giorni comparsa di false membrane, notevole adenopatia sottomascellare dolorosa e coriza spesso unilaterale. A questo stadio, disfagia discreta. Senza terapia, l’angina può aggravarsi, le false membrane diventano confluenti e possono invadere la faringe. Segni più o meno chiari di intossicazione possono comparire: pallore, tachicardia e albuminuria. Nelle forme maligne, tutti i segni si aggravano: estensione delle false membrane, aumento delle adenopatie, disfagia intensa e peggioramento dei segni di intossicazione (tachicardia, ipotensione, oliguria, albuminuria, diarrea, vomito, epatomegalia, porpora). Nelle forme ipertossiche la morte può sopravvenire per sincope in qualche giorno, malgrado la sieroterapia. Negli altri casi, la sieroterapia fa scomparire i segni locali in qualche giorno, ma i segni tossici regrediscono lentamente e recrudescenze brusche sono possibili dal settimo al quindicesimo giorno o verso il quarantesimo.
- Difterite laringea: quasi sempre secondaria a una difterite nasale o a un’angina difterica misconosciuta, evolve in tre fasi.
– Fase disfonica:” tosse rauca e voce spenta”.
– Fase dispnoica: dopo 2-3 giorni compaiono segni di stenosi della laringe, con accessi sempre più frequenti di dispnea inspiratoria, accompagnati da tirage, cornage, cianosi e polso paradosso.
–Fase asfittica: coma mortale se non si pratica una tracheotomia.
- Difterite cutanea: le localizzazioni cutanee della difterite sono a volte difficili da distinguere dall’impetigo; si possono osservare eritemi morbilliformi, scarlattiniformi o poliformi senza segni di intossicazione generale. La difterite cutanea si riscontra in zone insalubri sovrappopolate.
Diagnosi
- False membrane sulle tonsille, adenopatia sottomascellare e febbre poco elevata.
- Disfonia e dispnea (croup)
- Segni di miocardite
- Conferma con l’esame sul vetrino (immunofluorescenza) e coltura.
- L’esame batteriologico è essenziale per confermare la diagnosi, ma deve essere fatto molto precocemente; i risultati negativi non devono ritardare la terapia. L’esame sul vetrino permette una diagnosi rapida con la tecnica degli anticorpi fluorescenti. La coltura permette di identificare il bacillo.
Diagnosi differenziale
Angine banali, scarlattina, angina di Vincent, angina della mononucleosi infettiva o dell’agranulocitosi, sifilide secondaria e candidosi.
Terapia
Il paziente colpito dalla difterite deve essere posto in isolamento e trattato immediatamente con l’antitossina e antibiotici. I farmaci antibiotici più utilizzati sono la penicillina G e l’eritromicina, indicati sia per gli adulti che per i bambini (a dosaggi differenti). Le cefalosporine non sono raccomandate per la cura della difterite. La strategia più efficace contro la difterite resta la vaccinazione preventiva.
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