- 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. In tropical countries, there is also a cutaneous form of diphtheria without systemic manifestations. Cutaneous diphtheria manifests as a scaly erythematous rash and/or a deep punched-out ulcer following direct entry of C. diphtheriae into skin.. 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
- C. diphtheriae colonizes the mucous membrane of the respiratory tract (respiratory diphtheria) and, less commonly, pre-existing skin lesions (cutaneous diphtheria)
C. diphtheriae has both toxigenic and non-toxigenic strains; toxigenic strains contain a prophage gene called tox, which encodes the diphtheria toxin, an exotoxin that inhibits protein synthesis by ADP-ribosylation and deactivation of EF-2
- Local effects of the toxin: destruction of the respiratory epithelium → inflammatory response →
- Systemic effects of the toxin
- Incubation period: 2–5 days
- The patient presents initially with prodromal symptoms: fever, malaise, and sore throat
4–5 days after the onset of prodromal symptoms, symptoms due to the local and systemic effects of the toxin occur
- Anterior nasal diphtheria: bloody rhinorrhea
Tonsillar and pharyngeal diphtheria
- A grayish white pseudomembrane over the posterior pharyngeal wall, and/or tonsils
- Any attempt to scrape off the pseudomembrane exposes the underlying capillaries and results in heavy bleeding.
- Bull neck, which may result in airway obstruction
- Foul mouth odor
- Laryngeal diphtheria: difficulty breathing, inspiratory stridor
- Systemic features
- Local features
- Cutaneous diphtheria is the result of direct inoculation of C. diphtheriae into skin (e.g., skin abrasions) or pre-existing skin lesions.
- Cutaneous diphtheria is usually seen in tropical regions, where it is more common than respiratory diphtheria.
- Patients present with scaly erythematous rash, impetigo, or deep, punched-out ulcers
- Cutaneous diphtheria does not result in systemic effects.
Cultures of pharyngeal swabs are used to confirm the diagnosis
- Microscopic examination of pharyngeal swabs or culture isolates reveals multiple C. diphtheriae clustered together. , follow-up recommended
- Culture media of choice are cystine-tellurite agar or Löffler medium
- Once the culture reveals C. diphtheriae, one or both of the following tests are used to identify whether the strain is toxigenic:
- Test for myocarditis: Conduct multiple ECGs and serial measurement of cardiac markers.
Therapy should be started immediately upon clinical suspicion, even before diagnostic confirmation of diphtheria!
- The patient should be isolated as soon as diphtheria is suspected.
- Antibiotic therapy; : IM injections of Penicillin G (< 10 kg: 300,000 IU/day; > 10 kg: 600,000 IU/day) or oral/IV erythromycin (40 mg/kg/day) for 14 days
Immediate administration of diphtheria antitoxin The antitoxin is not commercially available and can only be obtained from the CDC. Antitoxin therapy is not needed in the case of cutaneous diphtheria.
- Laryngeal/pharyngeal diphtheria lasting < 48 hours: 20,000–40,000 units IV over 60 minutes
- Nasopharyngeal diphtheria: 40,000–60,000 units IV over 60 minutes
- Bull neck or diphtheria lasting > 3 days: 80,000–120,000 units IV over 60 minutes
- Airway support
Post-exposure prophylaxis is indicated for close personal contacts and caretakers of a patient with diphtheria.
- Erythromycin; (400 mg PO Q.I.D. for 7–10 days) or a single dose of benzathine penicillin (< 6 years: 600,000 units IM; ≥ 6 years: 1,200,000 units IM)
- Complete immunization schedule if vaccinations are not up-to-date.
Diphtheria is a notifiable disease!