• Clinical science



Diphtheria is an infectious disease caused by Corynebacterium diphtheriae, which is usually transmitted via respiratory droplets. The clinical features of diphtheria are caused by a toxin produced by C. diphtheriae after it colonizes the upper respiratory tract. Patients initially present with fever, malaise, and sore throat. Within a few days, a grayish white pseudomembrane develops over the tonsils, posterior pharyngeal wall, and/or larynx. Other manifestations include cervical lymphadenopathy, soft tissue swelling of the neck, stridor, and/or difficulty breathing as a result of partial airway obstruction. Systemic absorption of the toxin can result in myocarditis, acute tubular necrosis, and/or polyneuropathy. Even before culture reports come back positive, patients should be promptly treated with penicillin and antitoxins, as untreated diphtheria is associated with a high mortality rate. Since the introduction of routine immunization against diphtheria in the 1920s, the incidence of disease has decreased dramatically in the US.


  • Incidence: 0–5 cases/year
  • Most cases occur in patients 20 years of age or older.

Epidemiological data refers to the US, unless otherwise specified.


  • Pathogen: Corynebacterium diphtheriae
    • A gram-positive, non-sporulating, club-shaped bacillus, containing metachromatic granules (AKA volutin granules).
  • Route of infection
    • Droplet transmission
    • Less commonly through direct or indirect contact with open lesions (see extra information for more details on cutaneous diphtheria)
  • Infectious period: variable




Clinical features

Respiratory diphtheria

Cutaneous diphtheria



Therapy should be started immediately upon clinical suspicion, even before diagnostic confirmation of diphtheria!

Differential diagnoses

The differential diagnoses listed here are not exhaustive.


  • The patient should be isolated as soon as diphtheria is suspected.
  • Antibiotic therapy; : IM injections of Penicillin G or oral/IV erythromycin for 14 days
  • Immediate administration of diphtheria antitoxin: The antitoxin can only neutralize unbound toxin and should therefore be administered early in the course of the disease.
  • Airway support

Administration of the antitoxin is a critical part of treatment, as the clinical features of diphtheria are not caused by the pathogen itself but rather by the exotoxin that C. diphtheriae produces!



Pre-exposure prophylaxis

Post-exposure prophylaxis

Post-exposure prophylaxis is indicated for close personal contacts and caretakers of a patient with diphtheria.

Diphtheria is a notifiable disease!