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Key Features

Essentials of Diagnosis

  • Tenacious gray membrane at portal of entry in pharynx

  • Sore throat, nasal discharge, hoarseness, malaise, fever

  • Myocarditis, neuropathy

  • Culture confirms the diagnosis

General Considerations

  • An acute infection with a toxin-producing strain of Corynebacterium diphtheriae

  • Usually attacks the respiratory tract but may involve any mucous membrane or skin wound

  • The organism is spread primarily by respiratory secretions

  • Exotoxin produced by the organism is responsible for myocarditis and neuropathy

Demographics

  • Rare in the United States and Western Europe

  • More likely to be encountered in persons from developing countries and those from the former Soviet Union, where vaccine programs are lacking or inadequate

Clinical Findings

Symptoms and Signs

  • Nasal, laryngeal, pharyngeal, and cutaneous forms of diphtheria occur

  • Nasal infection produces few symptoms other than a nasal discharge

  • Laryngeal infection may lead to upper airway and bronchial obstruction

  • In pharyngeal diphtheria, the most common form, a tenacious gray membrane covers the tonsils and pharynx

  • Mild sore throat, fever, and malaise are followed by toxemia and prostration

Differential Diagnosis

  • Streptococcal pharyngitis

  • Oral candidiasis

  • Infectious mononucleosis

  • Viral pharyngitis, eg, adenovirus, herpes simplex virus

  • Necrotizing gingivostomatitis (Vincent angina, trench mouth)

  • Arcanobacterium haemolyticum pharyngitis

  • Other causes of cranial nerve or motor neuropathy, eg, myasthenia gravis, botulism, Guillain-Barré syndrome

  • Myocarditis due to other causes

Diagnosis

Laboratory Tests

  • The diagnosis is made clinically but can be confirmed by culture of the organism

Treatment

Medications

  • Susceptible persons exposed to diphtheria should receive a booster dose of diphtheria toxoid plus active immunization if not previously immunized, as well as a course of penicillin or erythromycin

Antitoxin

  • Prepared from horse serum

  • Must be given in all cases when diphtheria is suspected

  • For mild early pharyngeal or laryngeal disease, dose of antitoxin is 20,000–40,000 units

  • For moderate nasopharyngeal disease, dose is 40,000–60,000 units

  • For severe, extensive, or late (3 days or more) disease, dose is 80,000–100,000 units

Antibiotics

  • Either penicillin, 250 mg four times daily orally, or erythromycin, 500 mg four times daily orally, for 14 days is effective, though erythromycin is slightly more effective in eliminating the carrier state

  • Azithromycin or clarithromycin may be as effective as erythromycin

Therapeutic Procedures

  • Removal of membrane by direct laryngoscopy or bronchoscopy may be necessary to prevent or alleviate airway obstruction

Outcome

Follow-Up

  • The patient should be isolated until three consecutive cultures at the completion of therapy have documented elimination of the organism from the oropharynx

Complications

  • Myocarditis ...

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