Diphtheria is a contagious, sometimes fatal infection of the upper respiratory tract caused by the gram-positive, rod-shaped bacteria (see figure How Bacteria Shape Up) Corynebacterium diphtheriae. Some types of Corynebacterium diphtheriae release a potent toxin that can damage the heart, kidneys, and nervous system.
Diphtheria is caused by a bacterial infection that is now rare in countries where immunization is widespread.
Typical symptoms include a sore throat, general feeling of illness, and fever, sometimes with swollen lymph nodes, and a tough, gray pseudomembrane that forms in the throat.
The diagnosis is based on symptoms, particularly a sore throat and the pseudomembrane, and the results of a culture.
People are hospitalized and given antibiotics to eliminate the infection.
Vaccination can help prevent this infection.
(See also Overview of Bacteria.)
Years ago, diphtheria was one of the leading causes of death among children. Today, diphtheria is rare in high-resource countries, primarily because of widespread childhood vaccination. Fewer than five cases occur in the United States each year, but diphtheria bacteria still exist in the world and can cause outbreaks if vaccination is inadequate.
Diphtheria is common in many countries in Asia, the South Pacific, the Middle East, Eastern Europe, Venezuela, Haiti, and the Dominican Republic. Outbreaks in Indonesia, Thailand, Vietnam, Laos, South Africa, Sudan, and Pakistan have occurred since 2011 (travel information about diphtheria is available at the Centers for Disease Control and Prevention [CDC] web site).
Did You Know...
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The bacteria that cause diphtheria are usually spread in droplets of moisture coughed into the air. Usually, the bacteria multiply on or near the surface of the mucous membranes of the mouth or throat, where they cause inflammation. This form of diphtheria is called respiratory diphtheria.
Some types of Corynebacterium diphtheriae release a potent toxin, which can damage the heart, kidneys, and nervous system.
A milder form of diphtheria affects only the skin and occurs mainly in adults. This form is more common among people with poor hygiene (for example, people who are homeless). It spreads through contact with infected skin sores.
Symptoms of Diphtheria
The illness typically begins a few days (an average of 5 days) after exposure to the bacteria. Diphtheria symptoms then begin over a few days, with sore throat, painful swallowing, hoarseness, a general feeling of illness (malaise), a low-grade fever (about 100.4 to 102° F, or 38 to 38.9° C), and a fast heart rate. Children may also have nausea, vomiting, chills, and a headache.
The lymph nodes in the neck may swell (called bull neck). The inflammation may make the throat swell, narrowing the airway and making breathing extremely difficult.
A pseudomembrane forms near the tonsils or other parts of the throat. This membrane is a tough, gray sheet of material made by the bacteria that coats a surface, in this case, the throat. It is composed of dead white blood cells, bacteria, and other substances. The pseudomembrane narrows the airway. The roof of the mouth may be paralyzed. When inhaling, the pseudomembrane may cause people to make a noisy gasping sound. Also, the pseudomembrane may extend into the windpipe or airway or suddenly become detached and block the airway completely. As a result, people may be unable to breathe.
The toxin produced by certain types of diphtheria bacteria sometimes affects certain nerves, particularly those to the muscles of the face, throat, arms, and legs, causing symptoms such as difficulty swallowing or moving the eyes, arms, or legs. The diaphragm (the most important muscle used for inhaling) may become paralyzed, sometimes causing respiratory failure. These symptoms take weeks to resolve. Toxin effects on nerves can result in rapid heart rate, an abnormal heart rhythm, and low blood pressure. The bacterial toxin may also cause inflammation of the heart muscle (myocarditis), sometimes leading to abnormal heart rhythms, heart failure, and death.
Severe infection can also damage the kidneys.
If diphtheria affects only the skin, it causes what look like scrapes (abrasions) and sores that vary in appearance. These sores appear on the arms and legs and resemble other skin disorders, such as eczema, psoriasis, and impetigo. A few people have open sores that do not heal. Sores may be painful and red and may ooze.
This image shows a pseudomembrane (a sheet of material composed of dead white blood cells, bacteria, and other substances). It can form near the tonsils or other parts of the throat. The pseudomembrane narrows the airway and can make breathing difficult.
Image courtesy of the Centers for Disease Control and Prevention.
This image shows swollen lymph nodes in the neck (called bull neck) of a boy who has diphtheria.
Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention.
Diphtheria infection of the skin can look like a red, scraped area, as on this person's neck.
Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention.
Diphtheria infection of the skin can look like an open sore (ulcer), as on this person's leg.
Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention.
This image shows a pseudomembrane (a sheet of material composed of dead white blood cells, bacteria, and other substances). It can form near the tonsils or other parts of the throat. The pseudomembrane narrows the airway and can make breathing difficult.
Image courtesy of the Centers for Disease Control and Prevention.
This image shows swollen lymph nodes in the neck (called bull neck) of a boy who has diphtheria.
Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention.
Diphtheria infection of the skin can look like a red, scraped area, as on this person's neck.
Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention.
Diphtheria infection of the skin can look like an open sore (ulcer), as on this person's leg.
Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention.
Overall, about 3% of people with diphtheria die. The risk of dying is increased if
People delay going to the doctor.
Diphtheria affects the heart or kidneys.
Diphtheria develops in children under 15 years old or in people over 40 years old.
Diagnosis of Diphtheria
Culture of a sample of infected material
If doctors suspect the heart is affected, electrocardiography
A doctor suspects diphtheria in a sick person who has a sore throat with a pseudomembrane, particularly if the roof of the mouth is paralyzed and if the person was not vaccinated. The diagnosis is confirmed by sending a sample of material from the person's throat to a laboratory where bacteria can be grown (cultured).
If doctors suspect that the heart is affected, electrocardiography (ECG) is done.
Doctors suspect skin diphtheria when people develop sores during an outbreak of respiratory diphtheria. To confirm the diagnosis, doctors take a sample from a sore and send it to a laboratory to be cultured.
Treatment of Diphtheria
Diphtheria antitoxin
Antibiotics
People who have symptoms of respiratory diphtheria are typically hospitalized in an intensive care unit (ICU) and given antibodies (antitoxin) by injection to neutralize the diphtheria toxin.
For skin diphtheria, doctors thoroughly clean sores with soap and water, and people are given antibiotics for 10 days.
People who have recovered from diphtheria must be vaccinated because infection does not guarantee immunity. People can get this infection more than once.
People who have had a severe infection recover slowly. They are advised not to resume activities too soon. If the heart was affected, even normal physical exertion may be harmful.
Prevention of Diphtheria
Vaccination
For more information, see also Diphtheria-Tetanus-Pertussis Vaccine and the vaccine schedules for children and adults from the Centers for Disease Control and Prevention (CDC).
The diphtheria vaccine protects only against the effects of the diphtheria toxin; it does not prevent infection with diphtheria. The vaccine is given in combination with other vaccines. Which vaccine is given depends on the person's age:
Children under 7 years of age: The combination DTaP (diphtheria-tetanus-pertussis) vaccine is part of routine childhood vaccination.
Adolescents and adults: The combination Tdap (tetanus-diphtheria-pertussis) vaccine is given as a booster shot at age 11 or 12 and to people 13 years of age or older who have never received Tdap or who are unsure about whether they received it. A Td booster is given every 10 years after that.
After exposure to diphtheria
If people have close contact with a person who has diphtheria, they are tested for the infection and given antibiotics for 7 days.
Samples from their throat and nose are sent to a laboratory to be cultured. If diphtheria bacteria are identified in the samples, these people must take antibiotics for an additional 10 days (for a total of 17 days). This exposure regimen is done whether or not people have been vaccinated because vaccinated people can still become infected with diphtheria.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Centers for Disease Control and Prevention (CDC): Recommended vaccine schedule for children
CDC: Diphtheria: Information about diphtheria, including transmission, symptoms, and vaccine links
CDC: Travelers' Health: Diphtheria: Information about diphtheria specific to travelers, such as how to prevent it and who is at risk of infection
