The signs and symptoms typically presents within the first 2 to 5 days from infection. The symptomatology of the disease includes the following:

• Pseudomembrane formation (gray membrane covering the throat and tonsils) [8]
• Odynophagia (painful swallowing)
• Hoarseness of voice
• Adenopahty of the neck lymph nodes
• Dyspnea or tachypnea
• Oropharyngeal discharges
• Fever and chills
• Malaise
• Skin ulcers covered by a gray membrane

• Chills

  Constitutional signs of fever and chills can also be present. Diagnosis The diagnosis of diphtheria is done with the use of a detailed medical history and the careful physical examination of the throat. [symptoma.com]

  Symptoms of diphtheria also include: a high temperature (fever) of 38C (100.4F) or above chills fatigue (extreme tiredness) sore throat hoarse voice cough headache difficulty swallowing or pain when swallowing difficulty breathing foul-smelling, bloodstained [web.archive.org]

  Meanwhile, during screening in the health camp at Gopanpally, the doctors referred five children to the Fever Hospital who had typical symptoms of Diphtheria including sore throat, fever and chills. [thehindu.com]

  Signs and Symptoms Diphtheria can cause a mild fever, a sore throat, and chills a few days after infection with the bacteria. A nasal discharge, fatigue, and a thick gray membrane covering the throat may develop as well. [healthychildren.org]

• Streptococcal Pharyngitis

  The membrane bleeds when swabbed, unlike that in typical streptococcal pharyngitis or infectious mononucleosis. The onset is insidious, with early symptoms of malaise, sore throat, anorexia and low-grade fever (rarely 39.1 C). [www2.health.vic.gov.au]

  Mild cases resemble streptococcal pharyngitis. The pseudo-membrane may be absent, especially in vaccinated cases. The severity of the disease depends on the toxigenicity of C. diphtheriae. [health.nsw.gov.au]

  Milder infections resemble streptococcal pharyngitis and the pseudomembrane may not develop, particularly where there has been previous vaccination. Carriers do not usually have any symptoms. [patient.info]

  In addition to person-person spread of streptococcal infections including scarlet fever, contaminated milk was also shown to produce explosive epidemics of very acute streptococcal pharyngitis with high mortality. [doi.org]

• Sore Throat

  Her father revealed that she had a fever and sore throat for the last four days and was not immunised for diphtheria. Characteristic gross and microscopic pathology of respiratory diphtheria and microbiological findings were observed. [ncbi.nlm.nih.gov]

  Formerly known in England as the Boulogne sore throat, since it spread from France. [web.archive.org]

• Hoarseness

  We report a case of a 7-year-old unimmunized child who presented with a 2 week history of nasal quality speech, hoarseness of the voice, regurgitation of feeds, and unstable gait. [ncbi.nlm.nih.gov]

  Symptoms of diphtheria also include: a high temperature (fever) of 38C (100.4F) or above chills fatigue (extreme tiredness) sore throat hoarse voice cough headache difficulty swallowing or pain when swallowing difficulty breathing foul-smelling, bloodstained [web.archive.org]

  Symptoms usually occur 1 to 7 days after the bacteria enter your body: Fever and chills Sore throat, hoarseness Painful swallowing Croup-like (barking) cough Drooling (suggests airway blockage is about to occur) Bluish coloration of the skin Bloody, watery [nlm.nih.gov]

  The symptomatology of the disease includes the following: Pseudomembrane formation (gray membrane covering the throat and tonsils) Odynophagia (painful swallowing) Hoarseness of voice Adenopahty of the neck lymph nodes Dyspnea or tachypnea Oropharyngeal [symptoma.com]

  Hoarseness, paralysis of the palate, or stridor (high-pitched breathing sound) are also clues. [medicalnewstoday.com]

• Stridor

  The primary distinction: stridor is a sign of airway obstruction, whereas croup is a syndrome that can cause stridor. [web.archive.org]

  Other manifestations include cervical lymphadenopathy, soft tissue swelling of the neck, stridor, and/or difficulty breathing as a result of partial airway obstruction. [amboss.com]

  […] swallowing Croup-like (barking) cough Drooling (suggests airway blockage is about to occur) Bluish coloration of the skin Bloody, watery drainage from nose Breathing problems, including difficulty breathing, fast breathing, high-pitched breathing sound (stridor [nlm.nih.gov]

  Local edema may cause a visibly swollen neck (bull neck), hoarseness, stridor, and dyspnea. The membrane may extend to the larynx, trachea, and bronchi and may partially obstruct the airway or suddenly detach, causing complete obstruction. [msdmanuals.com]

• Dyspnea

  The symptomatology of the disease includes the following: Pseudomembrane formation (gray membrane covering the throat and tonsils) Odynophagia (painful swallowing) Hoarseness of voice Adenopahty of the neck lymph nodes Dyspnea or tachypnea Oropharyngeal [symptoma.com]

  Oxygen is administered as necessary to relieve dyspnea and cyanosis. Cardiac complications are usually more severe in adults; thus the convalescent period is extended for these patients. Prevention. [medical-dictionary.thefreedictionary.com]

  Symptoms include formation of an inflammatory pseudomembrane, fever, sore throat, headaches, coughing, dysphagia, dyspnea, and prominently swollen cervical lymph nodes. [orpha.net]

  Local edema may cause a visibly swollen neck (bull neck), hoarseness, stridor, and dyspnea. The membrane may extend to the larynx, trachea, and bronchi and may partially obstruct the airway or suddenly detach, causing complete obstruction. [msdmanuals.com]

• Vomiting

  These can be followed by difficulties in breathing and swallowing, and vomiting. Immunization: The diphtheria vaccine utilizes an inactivated diphtheria toxin that enables the body to neutralize the poison. [unicef.org]

  Severe symptoms can include choking, vomiting, or brain damage; infection can even lead to death. How is it spread? Whooping cough is spread by coughing or sneezing. [immunize.ca]

  In respiratory tract infections, the main symptoms are sore throat and fever, sometimes accompanied by nausea, vomiting, headache, and swelling of the neck. [redplanet.travel]

  ‘Possible reactions to immunisation against diphtheria and tetanus and pertussis include fever, vomiting, and listlessness.’ [en.oxforddictionaries.com]

• Nausea

  In respiratory tract infections, the main symptoms are sore throat and fever, sometimes accompanied by nausea, vomiting, headache, and swelling of the neck. [redplanet.travel]

  […] treatment Responses to combined vaccines (DTaP, Td, Tdap) Common responses Decreased appetite Vomiting or diarrhoea Irritability, restlessness Unusual crying Limb swelling after the 4th or 5th vaccine dose Muscle or joint stiffness or pain Headache or nausea [immune.org.nz]

  Mild side effects of Tdap may include : Pain, redness, or swelling in the arm where the shot was given Mild fever Headache Tiredness Stomach upset, including nausea, vomiting, or diarrhea Muscle aches and pains Swollen glands Continued Mild side effects [webmd.com]

• Tonsillar Ulcer

  Hippocrates had recognized the unfavorable implications of a sort of spiderweb (or membrane) in patients with tonsillar ulcers (2), and both Bard's 1771 contribution and the introduction of tracheostomy for laryngeal diphtheria in France in the 1820s [doi.org]

• Eczema

  […] months — — Tonsillitis, adenoids (post-operative) 2 months — — Tuberculosis (active or inactive with positive Mantoux test results) With specialist's approval — — Chronic lung suppuration — — Allergies (anaphylaxis, serum sickness, bronchial asthma, eczema [doi.org]

  The infection can coexist with other infections and skin conditions and may look no different from eczema, psoriasis, or impetigo. [medicalnewstoday.com]

  Skin lesions usually occur on the extremities and are varied in appearance, often indistinguishable from chronic skin conditions (eg, eczema, psoriasis, impetigo). [msdmanuals.com]

  Signs of Diphtheria on Physical Examination Skin infection Skin lesions usually occur on the extremities and are varied in appearance, often indistinguishable from chronic skin conditions (eg, eczema, psoriasis, impetigo). [merckmanuals.com]

  In a diphtheria outbreak in the Russian Federation in the 1990s, additional significant contributing factors included exposure to skin lesions and a history of eczema, sharing a bed, sharing glasses and cups, and taking a bath less often than weekly. [nvic.org]

• Diplopia

  The symptoms of nervous system involvement can include seeing double (diplopia), painful or difficult swallowing, and slurred speech or loss of voice, which are all indications of the exotoxin's effect on nerve functions. [medical-dictionary.thefreedictionary.com]

• Neck Swelling

  Symptoms may include: A moderate to severe sore throat Swollen and sore lymph nodes in the neck Swelling of the neck Heart and nervous system complications Diphtheria in your skin can cause lesions (damaged skin tissue or sores). [bccdc.ca]

  Neck swelling is usually present in severe disease. Cutaneous diphtheria presents as infected skin lesions which lack a characteristic appearance. Etiologic Agent Toxin-producing strains of Corynebacterium diphtheriae. [meningitis-angels.org]

  However, there are certain symptoms and conditions which should warrant a visit to your health-care provide for further evaluation should they develop: Severe sore throat or the inability to swallow Neck swelling Difficulty breathing Chest pain Extreme [emedicinehealth.com]

Patients can be easily diagnosed clinically with the aid of a detailed medical history and the demonstration of the throat signs like the pseudomembrane formation and the neck adenopathy. A throat swab can be performed for culture and sensitivity purposes where a specialized culture media is used to grow Corynebacterium diptheriae. In cases of cutaneous diphtheria, a skin sample is biopsied and processed to demonstrate the infecting bacillus in culture. Diphtheria which complicates to myocarditis can be assessed using serum troponin I levels to determine its severity [9].

• Right Bundle Branch Block

  The ECG changes seen were sinus tachycardia (68.3%), T wave inversion (20%), ST segment depression (13.3%), right bundle branch block (5%), multiple atrial ectopics (3.3%). The case fatality rate in our study was 25% (15 patients). [ncbi.nlm.nih.gov]

• T Wave Inversion

  The ECG changes seen were sinus tachycardia (68.3%), T wave inversion (20%), ST segment depression (13.3%), right bundle branch block (5%), multiple atrial ectopics (3.3%). The case fatality rate in our study was 25% (15 patients). [ncbi.nlm.nih.gov]

Diphtheria is a potentially fatal disease that warrants immediate medical care and treatment. Patients are promptly given diphtheria antitoxins intravenously or intramuscularly to neutralize the circulating diphtheria toxin in the body. Due care and diligence must be observed in the introduction of the antitoxin because this can cause a life-threatening hypersensitivity reaction among susceptible patients. Antibiotics like penicillin and erythromycin are also being used in the treatment of diphtheria infections [10]. The antibiotic therapy clears up the bacterial load of the infections and shortens its infective stage.

The international mortality rate for all forms of diphtheria is 5% to 10%. Mortality increases beyond 20% among children below 5 years or age and adults beyond 40 years of age. Toxigenic forms of the diphtheria bacteria are associated with increased mortality and morbidity among patients. Regions of the world with high immunization patterns have lower mortality ratings than those with low immunization coverage. Diphtheria in its aggressive bacteremia phase may carry a poorer prognosis and could reach a mortality rate of up to 40% [7].

Diphtheria is brought about by the gram positive aerobic bacillus Corynebacterium diphtheria. The aerobic bacterium propagates near the surface of the throat’s mucous membrane. The pathogen can be spread via airborne droplet through sneezing and coughing. There are less common ways of diphtheria transmission like the inadvertent contact with personal belongings and household items (i.e. towels, toys, and tissue papers).

In the United States, diphtheria occured in at least 200,000 patients annually before the advent of the vaccination in the 1920’s [4]. Effective preventive measures and mass immunizations have eradicated the disease, and limited the incidence of diphtheria infections to 1,000 cases per annum at the maximum. Sporadic occurrence of diphtheria has been noted among the Native American population, alcoholics, homeless people, and those in the low socioeconomic group [5]. In the international arena, the World Health Organizations has continually regarded diphtheria as a public health threat in the poor and developing nations.

Large epidemics were recorded in the Russian federation and the Baltic states during the periods 1990 to 1995. Moreover, diphtheria outbreaks in small pockets were documented in the regions of the sub-Saharan Africa, France, and India [6]. After the development of the vaccine, mortality rate of diphtheria in United States has gone down to 1 case per 100 million population. There is no sexual and racial predilection to the diphtheria infection.

When the diphtheria bacillus attaches to the airway mucosal epithelium, the local endosomes consequently release exotoxins that cause a localized inflammation. This process causes cell destruction and necrosis of the epithelium. Toxins may be carried hematologically or lymphatically to distant sites and organs in the advent of the cell destruction. The diphtheria toxin may affect the myocardium, the nervous system, and the kidneys. The toxigenic strains of the diphtheria bacteria are the most insidious and invasive in terms of organ afflictions and complications.

The most effective way in preventing diphtheria is by active immunization during childhood. The protection developed from the initial immunization will fade in time and would render the host susceptible to diphtheria infection once again. Booster shots when the child reaches 12 years old and every 10 years henceforth will essentially boost the immune system against the diphtheria infection. Early detection and treatment is paramount in shortening its clinical course and preventing its spread and transmission.

Diphtheria is a serious infection of the upper airways which usually involves the mucous membrane of throat and nose. The hallmark sign of diphtheria is the pseudomembrane formation at the back of the throat accompanied by symptoms of sore throat, fever, and weakness. Primary diphtheria is easily controlled by antibacterial therapy while complicated cases may cause damage to the kidneys, heart and the nervous system [3].

Definition

Diphtheria is a potentially life-threatening infection of the upper respiratory airways caused by the aerobic bacillus Corynebacterium diphtheria.

Cause

The diphtheria infection is caused by the toxigenic type and the non-toxigenic type of Corynebacterium diphtheria.

Symptoms

Patients suffering from diphtheria typically present with a pseudomembrane formation over the throat and tonsils with bilateral lymph node enlargement. Cutaneous diphtheria presents as ulcers with a grayish membrane. Constitutional signs of fever and chills can also be present.

Diagnosis

The diagnosis of diphtheria is done with the use of a detailed medical history and the careful physical examination of the throat. Culture and sensitivity of the bacteria taken from throat swabs and skin ulcer scrapings may also elucidate the infecting bacteria.

Treatment and follow-up

Patients with diphtheria are injected with diphtheria antitoxin and given penicillin and erythromycin antibiotics to control the disease. Primary prevention with the use of active immunization with diphtheria is the best way to control the spread of the illness.

1. Chen RT, Broome CV, Weinstein RA. Diphtheria in the United States, 1971-81. Am J Public Health. Dec 1985; 75(12):1393-7.
2. Dass J FP, Deepika V. Implications from predictions of HLA-DRB1 binding peptides in the membrane proteins of Corynebacterium diphtheriae. Bioinformation. 2008; 3(3):111-3.
3. Havaldar PV, Sankpal MN, Doddannavar RP. Diphtheritic myocarditis: clinical and laboratory parameters of prognosis and fatal outcome. Ann Trop Paediatr. Sep 2000; 20(3):209-15.
4. CDC. Summary of notifiable diseases--United States, 2001. MMWR Morb Mortal Wkly Rep. May 2 2003; 50(53): i-xxiv, 1-108.
5. Harnisch JP, Tronca E, Nolan CM, Turck M, Holmes KK. Diphtheria among alcoholic urban adults. A decade of experience in Seattle. Ann Intern Med. Jul 1 1989; 111(1):71-82.
6. Dallman T, Neal S, Green J, Efstratiou A. Development of an online database for diphtheria molecular epidemiology under the remit of the DIPNET project. Euro Surveill. May 8 2008; 13(19).
7. Mattos-Guaraldi AL, Moreira LO, Damasco PV, Hirata Júnior R. Diphtheria remains a threat to health in the developing world--an overview. Mem Inst Oswaldo Cruz. Dec 2003; 98(8):987-93.
8. Mandell, Bennett, Dolin. Corynebacterium diphtheriae. Principles and Practice of Infectious Diseases. 2005; 2457-2464.
9. Lakkireddy DR, Kondur AK, Chediak EJ. Cardiac troponin I release in non-ischemic reversible myocardial injury from acute diphtheric myocarditis. Int J Cardiol. Feb 15 2005; 98(2):351-4.
10. Dale DC, ed. 16 Infections Due to Gram-Positive Bacilli. In: Infectious Diseases: The Clinician's Guide to Diagnosis, Treatment, and Prevention. WebMD Corporation; 2007.