Diptheria (For Undergraduates) by Dr Fatima Shahid PGT -ENT HFH

3. OBJECTIVES
• Introduction
• Epidemiology
• Transmission
• Pathogenesis
• Clinical presentation & Classification
• Complications
• Diagnosis
• Differential Diagnosis
• Treatment
• Prevention and Control

4. INTRODUCTION
• Diphtheria is an infectious disease caused by the
bacterium Corynebacterium diphtheria, which primarily
infects the throat and upper airways, and produces a toxin
affecting other organs. The illness has an acute onset and
the main characteristics are sore throat, low fever and
swollen glands in the neck, and the toxin may, in severe
cases, cause myocarditis or peripheral neuropathy.

5. INTRODUCTION (Continued)
• It spreads by droplet infection
• Incubation periodis 2 to 6 days
• Clinically,it can vary from an asymptomatic carrier
state to a rapidly fatal toxic disease

6. DIPHTHERIA IN PAKISTAN
• There are at least four biotypes of Corynebacterium
diphtheriae: gravis, intermedius, mitis, and belfanti. All
biotypes have been associated with both endemic and
epidemic diphtheria, although, in general, mitis strains are
less toxigenic and cause less severe disease

7. DIPHTHERIA IN PAKISTAN(Contd...)
• Vaccination against diphtheria has reduced the mortality
and morbidity of diphtheria dramatically, however
diphtheria is still a significant child health problem in
countries with poor EPI coverage. In countries endemic
for diphtheria, the disease occurs mostly as sporadic
cases or in small outbreaks. Diphtheria is fatal in 5 - 10%
of cases, with a higher mortality rate in young children

8. DIPHTHERIA IN PAKISTAN(Contd...)
• In Pakistan because of incomplete vaccination program of
diphtheria multiple cases of outbreaks have been seen in
the previous years.
• According to the latest WHO data published in 2017
Diphtheria Deaths in Pakistan reached 41 in number. The
age adjusted Death Rate is 0.02 per 100,000 of
population ranks Pakistan #33 in the world.

11. TRANSMISSION
• Diphtheria is spread (transmitted) from person to person,
usually through respiratory droplets, like from coughing
or sneezing
• Can also be transmitted directly to susceptible person
from infected cutaneous lesions

12. PATHOGENESIS
• Asymptomatic nasopharyngeal carriage is common in
regions where diphtheria is endemic. In susceptible
individuals, toxigenic strains cause disease by multiplying
and secreting diphtheria toxin in either nasopharyngeal or
skin lesions. The diphtheritic lesion is often covered by a
pseudomembrane composed of fibrin, bacteria, and
inflammatory cells.

13. CORYNEBACTERIUM DIPHTHERIA:
• Gram Positive.
• Non – Motile Organism
• Contains Metachromatic granules.
• Survives in dust, freezing & Drying atmosphere.
• Has no invasive power but produces powerful
exotoxins (Toxin Mediated Disease)

14. CLASSIFICATION & CLINICAL
PRESENTATION
• Tonsillopharyngeal, laryngeal,nasal & tracheobronchial
involvement.
• The average incubation period is 2 to 6 days
• Symptoms initially are general and nonspecific, often
resembling a typical viral upper respiratory infection (URI).
Respiratory involvement typically begins with sore throat
and mild pharyngeal inflammation associated with
dysphagia,rhinorrhea and coughing.Called catarrhal stage
• Low grade fever associated with tachycardia.

15. CLASSIFICATION & CLINICAL
PRESENTATION (Contd…)
• The diagnostic feature is
the “wash leather”
elevated greyish green
pseudo-membrane on
the tonsils(bleeds on
attempt to remove).It is
firm,adherent and
surrounded by a zone of
inflammation.

16. CLASSIFICATION & CLINICAL
PRESENTATION (Contd…)
• There may be swelling of the neck(bull neck) and tender
enlargment of lymph nodes.

17. CLASSIFICATION
Based on site of infection :
• Pharyngeal and tonsillar
• Anterior nasal
• Laryngeal
• Cutaneous
• Ocular
• genital

18. COMPLICATIONS
Local or toxic mediated
• Respiratory arrest
• Myocarditis leading to arrhythmia and/or heart
failure.Seen after 2 weeks of infection
• Polyneuritis(proximal to distal weakness and
paresthesia).spontaneous recovery occurs.Seen after 2-3
weeks of infection
• Pneumonia

19. DIAGNOSIS
• The diagnosis of diphtheria must be made on clinical
grounds and cannot await evidence of culture.
ROUTINE INVESTIGATION;
• Leukocytosis,neutrophils dominant
• Low platelet count
SPECIFIC INVESTIGATION:
• Specimen is taken from nose,throat or specific lesion.
• Gram stain : shows beaded rods in typical arrangemnt
• Culture: inoculated on loeffler agar or tinsdale tellurite
agar

20. DIFFERENTIAL DIAGNOSIS
• Streptococcal tonsillitis
• Infectious Mononucleousis
• Leukaemia
• Agranulocytosis

21. TREATMENT
• Antibiotics:
• Controls local infection and helps inprevention of
further toxic production and spread
• Penicillin 1.2g intravenous 6 hourly for 2 weeks.
• Erythromycin 40-50mg/kg/day orally or intravenously
for 2 weeks.

22. TREATMENT (Contd…)
Anti Toxins:
Produced from horse serum
• In MILD cases 20,000 to 40,000U
• In MODERATE cases 40,000 to 60,000U
• In SEVERE cases 80,000 to 1,00,000U

23. TREATMENT OF COMPLICATIONS
• For airway obstruction tracheostomy is
done.Endotracheal tube is not passed to avoid spread of
toxins into the lungs.

24. PREVENTION
• Active immunization should be done in all the children
• If diphtheria occurs in closed community,contact should
be given erythromycin.
• Diphtheria toxoid or booster dose (in already immunized
people) should be given to the effected population.

25. PREVENTION (Contd…) :
• Vaccine:
• Diphtheria vaccine is a bacterial
toxoid, ie. a toxin whose toxicity
has been inactivated. The vaccine
is normally given in combination
with other vaccines as
DTwP/DTaP vaccine or
pentavalent vaccine. For
adolescents and adults the
diphtheria toxoid is frequently
combined with tetanus toxoid in
lower concentration (Td vaccine).

26. PREVENTION (Contd…)
• WHO recommends a 3-dose primary vaccination series
with diphtheria containing vaccine followed by 3 booster
doses. The primary series should begin as early as 6-
week of age with subsequent doses given with a minimum
interval of 4 weeks between doses. The 3 booster doses
should preferably be given during the second year of life
(12-23 months), at 4-7 years and at 9-15 years of age.
Ideally, there should be at least 4 years between booster
doses.