DEFINITION

Diphtheria is a serious bacterial infection that affects the mucous membranes of the throat and

nose. Although it spreads easily from one person to another, diphtheria can be prevented through the

use of vaccines

Diphtheria is an infectious disease caused by the bacterial microorganism known as

Corynebacterium diphtheriae. Other Corynebacterium species can be responsible, but this is rare.

Some strains of this bacterium produce a toxin, and it is this toxin that causes the most serious

complications of diphtheria. The bacteria produce a toxin because they themselves are infected by a

certain type of virus called a phage.

The toxin that is released:

 inhibits the production of proteins by cells

 destroys the tissue at the site of the infection

 leads to membrane formation

 gets taken up into the bloodstream and distributed around the body's tissues

 causes inflammation of the heart and nerve damage

 can cause low platelet counts, or thrombocytopenia, and produce protein in the urine in a

condition called proteinuria

Diphtheria is an infection spread only among humans. It is contagious by direct physical contact with:

 droplets breathed out into the air

 secretions from the nose and throat, such as mucus and saliva
  infected skin lesions

 objects, such as bedding or clothes an infected person has used, in rare cases

The infection can spread from an infected patient to any mucous membrane in a new person, but the

toxic infection most often attacks the lining of the nose and throat.

CLINICAL MANIFESTATION

Patient Presentation

A 9-year-old boy was referred to the hospital with a low-grade fever, cough and sore throat for 5

days. On the first day of illness he had been taken to a rural clinic and diagnosed with pharyngitis. The

patient was prescribed an unknown oral antibiotic and acetaminophen. By the third day of illness his fever

had gradually declined and the sore throat had resolved. However, he subsequently became worse and

experienced neck swelling, dyspnoea and dysphagia. He also had a harsh breathing sound.

Examination

 His vital signs showed a blood pressure of 110/90 mm Hg, heart rate of 153 bpm, temperature of

37.5 °C, respiratory rate of 22 breaths/min and room air oxygen saturation

 His tonsils were inflamed and had white patches, and he had inspiratory stridor and poor air entry

but no adventitious sounds. He was subsequently endotracheally intubated at the local hospital

and had copious amounts of white as well as bloody secretions suctioned from the tube. A

nasogastric tube was placed and revealed 20 mL of fresh blood and a substantial amount of coffee

ground emesis. He was given a bolus dose of normal saline (20 mL/kg) and 2 g of ceftriaxone

before referral to our hospital. The laboratory results from the local hospital were significant for

a leucocytosis of 30 300 cells/mm3 and a high creatinine level of 1.7 mg/dL.

respiratory rate (20 breaths/min) and normal blood pressure (106/74 mm Hg). His weight was 22

kg (10th centile) and his height was 130 cm (50th centile).

 He was fully alert. He was also able to follow commands, move all his extremities equally well and

open his eyes spontaneously. His pupils were equal, round and reactive to light with normal

accommodation.

 The examination revealed bilateral neck tissue swelling that was soft, tender and without

fluctuation or rash (figure 1). His tonsils were enlarged, bleeding and had white patches on them.

His lungs were bilaterally clear to auscultation.

Figure 1

Signs and Symptoms

 A thick, gray membrane covering your throat and tonsils

 A sore throat and hoarseness

 Swollen glands (enlarged lymph nodes) in your neck

 Difficulty breathing or rapid breathing

 Nasal discharge

 Fever and chills

 Malaise
ANATOMY AND PHYSIOLOGY

 Heart

 Nose and throat

PATHOPHYSIOLOGY

The toxin is a single polypeptide with an active (A) domain, a binding (B), and a hydrophobic

segment known as the T domain, which helps release the active part of the polypeptide into the

cytoplasm. The toxin is responsible for many of the clinical manifestations of the disease.

In most cases, C. diphtheria infection grows locally and elicits toxin rather than spreading

hematogenously. The characteristic membrane of diphtheria is thick, leathery, grayish-blue or white and

composed of bacteria, necrotic epithelium, macrophages, and fibrin. The membrane firmly adheres to the

underlying mucosa; forceful removal of this membrane causes bleeding. The membrane can spread down

the bronchial tree, causing respiratory tract obstruction and dyspnea.

DIAGNOSTIC TEST

Complete blood count for:

 haemoglobin (11.4g/dL)

 Haematocrit (31.4%)

 White cell count of 22 600 cells/mm3 (neutrophils 74%, lymphocytes 12% and monocytes 11%)

 Platelet count of 80 000/mm3.

 Blood urea nitrogen (40 mg/dL) and creatinine (1.0 mg/dL) were elevated at admission

 Liver function tests and erythrocyte sedimentation rate were within normal limits.

 Urinalysis showed 5-10 red blood cells per high-power field, 10-20 white cells count per high-

power field, 2+ albumin and trace glucose.

 The troponin T level was 74 ng/mL (normal <14)

 Pro-brain natriuretic peptide was 1236 ng/L (normal <355 ng/L for age 8-13 years)

 A throat swab Gram stain showed Gram-positive bacilli (figure 2). A throat swab culture showed

Corynebacterium diphtheriae. The Elek test for detection of toxigenic Corynebacterium strain was

positive.

Figure 2

 A chest radiograph showed bilateral neck swelling and patchy right lower lobe infiltration. The

ECG on the first day of admission was unremarkable showing a normal sinus rhythm at 90 bpm

without significant ST segment changes, a left ventricular ejection fraction of 55% (within normal

range), cardiac output of 2 L/min, cardiac index of 2.5 L/min/m 2, mild tricuspid regurgitation, no

chamber enlargement and no pericardial effusion.

MEDICAL MANAGMENT

Nursing Management

 The aims of treatment are to inactivate toxin, to kill the organism, and to prevent respiratory

obstruction.

1. Strict bed rest, strict isolation

2. Cleansing throat gargle may be ordered

3. Liquid or soft diet or parenteral fluid

4. Observe for respiratory obstruction (tracheotomy).

5. Suction as needed

6. Oxygen therapy
 7. Antitoxin is given against toxin

8. Toxoid is given to immunized contact

9. Broad spectrum antibiotic is given against diphtheria bacilli.

Management and Prevention

 Place patients with suspected or confirmed diphtheria in isolation room.

 Apply standard precautions, including hand hygiene at all times.

 In addition, also apply droplet and contact precautions. Wearing gown, gloves and mask are also

very important to prevent spread of infection.

 The disease is usually not contagious 48 hours after treatment.

After discharge, restrict contact with others until completion of antibiotic therapy.

 People with diphtheria need to be kept in isolation until they are certified to be free of the disease

by SA Health's Communicable Disease Control Branch (CDCB).

 Contacts of people with diphtheria need to be investigated for the disease, receive antibiotics and

receive vaccination if required.

 Family or household contact with diphtheria should be excluded from childcare, preschool, school

and work until cleared to return by the CDCB.

 Contacts whose work involves food handling or caring for unimmunised children are excluded

from work until they certified to be free of the disease by the CDCB.

 Widespread immunisation against diphtheria is the only effective control.

 People travelling to countries where diphtheria is common should have received a full course of

immunisation and consider a booster dose of vaccine in discussion.

 Diphtheria: Causes, symptoms, and treatment - Medical News Today (2018).

https://www.medicalnewstoday.com/articles/159534.php

 Washington, C. H., Issaranggoon Na Ayuthaya S., Makonkawkeyoon, K., and Oberdorfer P. (2014).

A 9-year-old boy with severe diphtheria infection and cardiac complications..

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4244344#__ffn_sectitle

 WHO | Diphtheria - World Health Organization (2018).

https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.who.int/immunization

/diseases/diphtheria/en/&ved=2ahUKEwjimdTIgP7gAhVKso8KHTxFDqoQFjAEegQIDRAZ&usg=A

OvVaw22QWSn72WQ_f4gld4d0WeS