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Diphtheria

Last updated: November 26, 2020

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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 the skin. Since the introduction of routine immunization against diphtheria in the 1920s, the incidence of the disease has decreased dramatically in the US.

  • Incidence: 0–2 cases/year [1]
  • Most cases occur in patients 20 years of age or older.

Epidemiological data refers to the US, unless otherwise specified.

References:[2]

ABCDEFG of C. diphtheria: ADP-ribosylation, Beta-prophage, Club-shaped, Diphtheria, Elongation Factor 2, metachromatic Granules.

References:[2][3][4]

Respiratory diphtheria

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.

Cutaneous diphtheria

References:[3]

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

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 the unbound toxin and should therefore be administered early in the course of the disease.
    • 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

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.

References:[2][5]

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.

References:[5][6][7][8][9][10]

  1. Diphteria.
  2. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. McGraw-Hill Education ; 2015
  3. Barroso LF, Pegram PS. Clinical manifestations, diagnosis, and treatment of diphtheria. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-treatment-of-diphtheria.Last updated: October 4, 2016. Accessed: March 13, 2017.
  4. Immunization Schedules: Catch-up Schedule. https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html. Updated: February 6, 2017. Accessed: March 13, 2017.
  5. Immunization Schedules: Child and Adolescent Schedule. https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. Updated: February 6, 2017. Accessed: March 13, 2017.
  6. Drutz JE. Diphtheria, Tetanus, and Pertussis Immunization in Children 7 Through 18 Years of Age. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/diphtheria-tetanus-and-pertussis-immunization-in-children-7-through-18-years-of-age.Last updated: February 28, 2017. Accessed: March 13, 2017.
  7. Drutz JE. Diphtheria, Tetanus, and Pertussis Immunization in Infants and Children 0 Through 6 Years of Age. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/diphtheria-tetanus-and-pertussis-immunization-in-infants-and-children-0-through-6-years-of-age.Last updated: October 4, 2016. Accessed: March 13, 2017.
  8. Immunization Schedules: Adult Immunization Schedule. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html. Updated: February 6, 2017. Accessed: March 13, 2017.
  9. Vaccine-preventable diseases: monitoring system. 2020 global summary. https://apps.who.int/immunization_monitoring/globalsummary/incidences?c=USA. Updated: July 15, 2020. Accessed: November 15, 2020.
  10. Kumar V, Abbas AK, Aster JC. Robbins & Cotran Pathologic Basis of Disease. Elsevier Saunders ; 2014
  11. Herold G. Internal Medicine. Herold G ; 2014