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| |    Diphtheria: Overview by Lynn Cates, M.D., F.A.A.P. reviewed by Laura Jana, M.D., F.A.A.P. Diphtheria is a potentially fatal bacterial infection that is preventable with routine immunizations. It can lead to serious complications, such as paralysis, heart failure, or suffocation. Before diphtheria vaccine became available in the United States in the 1920s, about 100,000 to 200,000 people got diphtheria each year, and about 10 percent of them died. Thanks to successful immunization programs with diphtheria toxoid vaccine, only 49 cases were reported in the United States over the 20-year period from 1980 to 1999 (about 2 or 3 cases per year). Countries with low immunization rates have not fared nearly as well. Recently, there have been epidemics of tens of thousands of cases in Eastern Europe and the independent states of the former Soviet Union. For more information about who gets diphtheria and how it is spread, see our article "Diphtheria: Who Gets It." What causes diphtheria? Diphtheria is caused by the bacterium Corynebacterium diphtheriae, which is spread from person to person. The symptoms are produced both by the infection and by a powerful toxin (poison) this bacterium produces during the course of the infection. The toxin spreads throughout the body via the bloodstream and affects many parts of the body, including the heart, nerves, and kidneys. When should you suspect diphtheria? Diphtheria often is mistaken for a routine viral respiratory infection because it usually starts with fever, tiredness, decreased appetite, sore throat, and a stuffy or runny nose. Within a couple of days, however, a thick whitish membrane forms in the back of the throat or in the nose, on the septum (the part that divides the two nostrils). The membrane then turns gray or green or, if there is bleeding, it may even turn black. It may spread down the back of the throat into the larynx (or voice box) and cause hoarseness and a barky cough. If the membrane is forcibly disturbed (for example, by trying to remove it), it bleeds. People with diphtheria also may develop a swollen neck, termed a bull neck, and many other complications. You should suspect diphtheria in anyone who has not been fully immunized and who develops a fever, swollen neck, and sore throat with a grayish membrane across the back of the throat or in the nose. In addition, the disease may cause sores on the skin. These sores are particularly common in the tropics, but they can be seen in developed countries as well, including the United States (most often in homeless people). For reasons that are unclear, only some of the kinds of Corynebacterium diphtheriae that cause skin infections release the toxins responsible for some of the serious complications of diphtheria. How is diphtheria diagnosed? The laboratory diagnosis of diphtheria is made by culturing the nose, throat, the region underneath the membrane, and any skin sores to look for Corynebacterium diphtheriae. If diphtheria is suspected based on a person's history (including whether or not he has been immunized) and physical examination, treatment should not be delayed while awaiting laboratory results because the disease can progress rapidly and a delay can increase the chance of complications or death. Treatment Diphtheria should always be treated by healthcare professionals. Treatment is two-pronged: Diphtheria antitoxin is needed to combat the effects of the toxin, and antibiotics (penicillin or erythromycin) are used to kill the bacteria themselves. Neither antitoxin nor antibiotic treatment alone is sufficient. Antibiotics generally are given for about 14 days. In addition to these measures, many people with diphtheria need sophisticated supportive care in an intensive care unit equipped with ventilators. What is the outcome of diphtheria? Most people who get diphtheria eventually recover, particularly if they receive good medical care promptly. However, this disease can cause many serious complications, resulting in death for about 5 to 10 percent of those afflicted (with rates as high as 20 percent for children under five years), and leaving many others with permanent health problems. Prevention You can prevent most cases of diphtheria by keeping up-to-date on diphtheria toxoid vaccine. This is almost always given with tetanus toxoid vaccine (TD or Td) or with both tetanus toxoid and acellular pertussis vaccines (DTaP). (Pertussis is commonly referred to as whooping cough.) Whenever someone is suspected of having diphtheria, it should be reported to local health officials. It is also particularly important to identify people who have been in close contact with the infected individual so that they can be given a diphtheria toxoid booster (the one that is appropriate for age) and antibiotics (penicillin or erythromycin for 7 to 10 days). Whenever someone is hospitalized with diphtheria, he should be isolated until he has been tested and found to be no longer contagious.
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