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Diphtheria

Diphtheria is a serious bacterial infection caused by Corynebacterium diphtheriae. While rare in countries with widespread vaccination, it remains a threat in areas with low immunization rates. The disease primarily affects the respiratory system but can also manifest on the skin. Its hallmark feature is the formation of a thick grayish-white membrane in the throat, which can block the airway.

Why It Matters:

  • Historically, diphtheria caused widespread deaths, particularly in children.
  • It is preventable but can cause severe complications, including heart and nerve damage, if untreated.


Etiology & Pathophysiology

Causative Agent:

Corynebacterium diphtheriae is a Gram-positive bacterium shaped like a club. Some strains produce the diphtheria toxin, which is responsible for the disease's severity.

How It Works:

The toxin stops protein production in human cells by inactivating EF-2 (elongation factor-2), leading to cell death. This results in the formation of a pseudomembrane (a layer of dead tissue) in the throat or on the skin.

How It Spreads:

  • Respiratory droplets: Sneezing or coughing by an infected person.
  • Contact with sores: Touching infected wounds.
  • Contaminated objects (fomites): Rare but possible.


Types of Diphtheria

  1. Respiratory Diphtheria:

    • The most recognized form, it affects the throat and airways.
    • Can lead to breathing difficulties, heart issues, and nerve damage.

  2. Cutaneous Diphtheria:

    • Causes chronic skin ulcers, especially in tropical climates.
    • Less severe but can spread bacteria to others.

  3. Other Rare Forms:

    • Nasal diphtheria involves mild nasal discharge.
    • Ocular or genital diphtheria is extremely uncommon.


Clinical Features

1. Respiratory Diphtheria:

Symptoms usually begin 2–5 days after exposure.

  • Early signs:

    • Sore throat, mild fever, and general fatigue.
    • Swollen lymph nodes, causing a “bull neck” appearance in severe cases.

  • Hallmark sign:
    A grayish-white pseudomembrane forms in the throat and can obstruct breathing.

  • Complications:

    • Airway obstruction: Can cause suffocation.
    • Myocarditis: Inflammation of the heart muscle.
    • Neuropathy: Weakness or paralysis, starting with cranial nerves.

2. Cutaneous Diphtheria:

  • Non-healing skin ulcers with a grayish covering.
  • Often painless but may get infected with other bacteria.


Clinical features of diphtheria 


Diagnosis

1. Clinical Clues:

The presence of a pseudomembrane in the throat and bull neck swelling is highly suggestive.


Pseudomembrane


2. Lab Tests:

  • Culture and Staining: Identifies the bacteria from throat swabs or skin lesions.
  • Toxin Detection:
    • Elek test: Confirms toxin production.
    • PCR: Detects the toxin gene.

3. Additional Tests for Complications:

  • ECG to monitor for heart damage.
  • Nerve conduction studies if neuropathy is suspected.


Treatment & Management

1. Antitoxin Therapy (Diphtheria Antitoxin - DAT):

  • The antitoxin neutralizes the diphtheria toxin before it binds to tissues.
  • Must be administered early to be effective.

2. Antibiotics:

  • Erythromycin or Penicillin is used to kill the bacteria.
  • Helps prevent the spread of infection to others.

3. Supportive Care:

  • Airway support: Intubation may be necessary for severe cases.
  • Cardiac monitoring: For signs of myocarditis.

4. Isolation:

  • Infected patients should be isolated to prevent transmission.
  • Release from isolation requires two negative throat cultures after completing antibiotics.


Prevention & Vaccination

Vaccination is Key:

The diphtheria vaccine is part of routine childhood immunizations:

  • DTaP series: Protects infants and children.
  • Tdap booster: For adolescents and adults every 10 years.

Post-exposure Prophylaxis:

  • Close contacts of an infected person should receive:
    • A Tdap booster (if not up-to-date).
    • Antibiotics to clear any asymptomatic infection.


Complications & Prognosis

Major Complications:

  • Airway Blockage: From the pseudomembrane.
  • Myocarditis: Can lead to arrhythmias or heart failure.
  • Nerve Damage: Starting in the throat muscles, progressing to peripheral nerves.

Prognosis:

  • With prompt treatment, most patients recover.
  • Without treatment, the mortality rate is 5–10% and higher in children.


Conclusion

Diphtheria is a preventable but potentially deadly disease. Vaccination and early recognition are critical to managing cases and preventing outbreaks. Public health measures, including high vaccination coverage, remain the most effective way to protect communities.


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