Diphtheria

Symptoms Of Diphtheria

The symptoms of diphtheria depend upon the part of the body affected by the bacteria. It usually infects the respiratory tract and skin involving tonsils, throat, nose, and/or skin. The signs and symptoms can be mild or severe. The incubation period is generally 2 to 5 days. Even asymptomatic patients,  if not treated with antibiotics, can pass the infection to another person for up to 4 weeks. 

The bacteria attaches to the lining of the respiratory tract and cause symptoms such as: 

• Weakness

• Sore throat

• Runny nose

• Hoarseness

• Chills

• Painful swallowing

• Low grade fever (about 100.4 to 102° F)

• Generally feeling unwell (malaise)

• Swollen lymph nodes in the neck

• Cervical lymphadenopathy (enlargement of lymph nodes in the head and neck)

• Swelling of the palate (roof of the mouth)

• Loss of appetite

• Tiredness/fatigue

In children, symptoms may also include:

• Rapid heart rate

• Nausea

• Vomiting

• Headache

The bacteria can also affect skin (cutaneous/skin diphtheria) and cause symptoms such as open sores and ulcers. These sores appear on the arms and legs, sometimes resemble other skin conditions such as eczema, psoriasis, and impetigo. The bacteria can also cause painful, red and swollen lesions on the skin. 

Formation of pseudomembrane

The diphtheria bacteria makes a thick and gray coating in the respiratory system near tonsils or other parts of the throat which is called pseudomembrane. The pseudomembrane may narrow and block the airway. It can also paralyze the roof of the mouth. All these manifestations can be experienced in the following symptoms: 

• Difficulty in breathing

• Difficult in swallowing 

• Gasping sound while inhaling

In severe cases the toxin produced by the bacteria can damage nerves of the face, throat, arms, and legs and cause:

• Sudden Movements of the eyes, arms and legs

• Respiratory failure

• Rapid heart rate

• Irregular heart rhythm

• Low blood pressure

• Myocarditis 

• Heart failure

Causes Of Diphtheria

Diphtheria is caused by a bacteria known as Corynebacterium diphtheria which can enter the body through nose, mouth or broken skin. The bacteria produces a toxin that can travel via the bloodstream and lymph vessels. This toxin can damage the heart, kidney, and nervous system. 

Transmission

It is a highly contagious disease and can spread through close contact with the discharge from an infected person's eyes, nose, throat or skin. It can transmit through: 

• Coughing, sneezing, or speaking via respiratory droplets

• Touching infected sores or ulcers

• Touching contaminated clothes or objects through a break in the skin 

Types Of Diphtheria

There are several types of diphtheria according to the part of the body affected. It can be categorized as: 

Respiratory diphtheria

In this, the bacteria affects the part of the respiratory tract that includes the nose, larynx, and tonsils. It is of following types: 

Nasal diphtheria: In this, the pseudomembrane formed by the bacteria appears inside the nostrils. This form is not dangerous as almost no toxins are absorbed from this location. The chances of systemic complications are also rare in nasal diphtheria. 

Faucial diphtheria: It is the most common form of diphtheria in which the effect of the toxin is generally limited to the tonsils. People generally recovered well from this form with early treatment.

Nasopharyngeal: As the name suggests, here infection spreads to nose and pharynx. It is the most fatal form of diphtheria as infection can spread to blood. This can lead to septicemia which refers to blood poisoning. 

Laryngeal diphtheria: This form of diphtheria can block the airway as infection spreads downward from the nasopharynx to the larynx. 

Cutaneous diphtheria

In this, the skin is affected by the bacteria which can cause symptoms like open sores, lesions and ulcers on the skin. 

Risk Factors For Diphtheria

Diphtheria is a vaccine preventable disease. The complete vaccination provides a good way to prevent diphtheria and decreases the chances of developing it even in the presence of risk factors. The risk of getting diphtheria are high if you: 

• Are not vaccinated 

• Are inadequately vaccinated

• Are living in temperate region

• Are exposed to cold environments 

• Are a frequent traveler in the diphtheria contaminated zone

• Are in close contact with an infected person

• Have weak immune system

• Live in unhygienic and crowded condition

• Travel to particular areas that are known for diphtheria such as South-East Asia, Russia and surrounding countries, Baltic countries and Eastern European countries.

Diphtheria is common in children, however older people with some comorbidities are also at higher risk of developing diphtheria. People with low socioeconomic status also have higher chances of getting this infection. 

Diagnosis Of Diphtheria

Physical examination and medical history

Doctors generally decide if the patient has diphtheria by analyzing the symptoms and discussing the medical history including vaccination status and travel history. The throat is specifically examined for gray or green membrane which is a characteristic of diphtheria. The doctor also asks if the patient has come in contact with someone who has had diphtheria. 

Culture

The diagnosis is confirmed by taking a sample and sending it to a laboratory for testing the growth of bacteria. The samples are taken by swabbing the throat and wound in case of skin infection. This procedure takes time so the treatment is usually started after physical examination. 

Toxin testing

The test detects the toxin produced by the bacteria. It helps in the differentiation of toxigenic strain from non-toxigenic variants. This is done through: 

• Elek test

• PCR testing

• Enzyme immunoassay (EIA) test

Blood tests

Complete blood count: It helps to find out the level of infection by assessing several blood parameters. 



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Troponin I: It is a marker of cardiac (heart) injury. This helps in finding out the extent of the damage to the heart. 

Diphtheria antitoxoid antibody: This test measures the level of antibodies in the blood. The antibodies can be produced either through vaccination or previous infection. 

Imaging studies

Chest and neck x-ray: These imaging tests are used to detect swelling of the soft tissue structure around the pharynx, epiglottis, and chest.

Electrocardiography (ECG): ECG is done in case of suspected heart disorders.

Specialist To Visit

Diphtheria demands immediate medical attention because any delay in treatment can lead to systemic complications.  So, it is very necessary to consult the doctor as early as possible to get the best effective treatment and to avoid complications. 

You may consult doctors from these specialties such as:

• General physician

• ENT specialist

• Infectious disease specialist 

• Pulmonoligist

In case of heart complications, consult a cardiologist. You may consult a pediatrician in case your child is facing any such issues. 

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Prevention Of Diphtheria

Vaccination

Diphtheria is a vaccine preventable disease. Before the introduction of the diphtheria vaccine, it was one of the leading causes of hospitalization and death especially in infants and children. Getting adequately vaccinated is the best way to prevent diphtheria. The vaccination also reduces the chances of community spread. 

Types of diphtheria vaccines

• DTaP vaccine is for young children & provides protection from diphtheria, tetanus, and whooping cough

• DT vaccine protects young children from diphtheria and tetanus

• Tdap vaccine is for preteens, teens, and adults & provides protection from tetanus, diphtheria, and whooping cough

• Td vaccine protects preteens, teens, and adults from tetanus and diphtheria

Things to consider before vaccination

It is always advisable to tell your doctor if you: 

• are unwell on the day of vaccination

• have had a serious reaction to any vaccine in the past

• have had a severe allergy to anything

• are pregnant

Who should get vaccinated?

Babies and children: Babies and younger children need 3 and 2 shots of DTaP vaccine respectively to get the high protection against diphtheria, tetanus, and whooping cough (pertussis). These shots are given at the following ages: 

• 2 months

• 4 months

• 6 months

• 15 to 18 months

• 4 to 6 years

Pregnant women: TdaP vaccine is administered in the third trimester of every pregnancy, as part of the combination vaccine for diphtheria, tetanus and whooping cough. This provides protection to the baby for the initial few months.

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Preteens and teens: One shot of TdaP is given to the children between the age of 11 to 12 years to boost their immunity.

Adults: Tdap can be given at any age to the adults, if the person has not received it in the past. The shot is followed by either a Td or Tdap every 10 years.

Most people think that vaccines are for adults. However, what many people are unaware of is the fact that an adult also needs to be vaccinated for several diseases. 

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The vaccine is also advised for: 

• People who are traveling overseas, who haven’t had a diphtheria vaccine in the past 10 years

• Laboratory workers who might have contact with the bacteria that causes diphtheria.

Who should not get these vaccines? 

Vaccines are generally safe and do not cause any severe reaction. Vaccines are not given in case a child had a: 

• Life-threatening allergic reaction after a dose vaccine

• Severe allergy to any component of the vaccine

Side effects of vaccination

Most people who get any of the diphtheria vaccines will not face any serious side effects. But, in some cases vaccines can cause milder side effects which can be easily managed. Most of the effects usually go away on their own. The common side effects can include: 

• Redness and swelling at the injection site

• Fever

• Loss of appetite

• Tiredness

• Vomiting

• Headache

• Chills

• Body aches

Managing the side effects

All the side effects are usually mild and occur for a short period of time. They generally occur in the first 1-2 days of vaccination and do not require any specific treatment. However, following measures can be taken to reduce that. 

• Consume fluids 

• Avoid overdressing the children

• Take paracetamol after consulting with doctor if the fever is high or to manage the swelling and pain at the injection site

Treatment Of Diphtheria

If diphtheria is suspected, the treatment usually begins before the confirmation of laboratory tests to avoid any complications. The symptoms, overall health, and age of the patient is considered before initiating the treatment.  The two main treatment options include: 

Diphtheria antitoxin (DAT)

The prompt administration (intravenous or intramuscular) of DAT is the most effective treatment for diphtheria. It aids in the neutralization of the unbound toxin produced by the bacteria in the blood. Antitoxin has no role in neutralizing the already bound toxin. Therefore, it is necessary to administer it as early as possible to avoid complications. 

Antibiotics

The treatment of antibiotics is usually effective before the bacteria starts releasing toxins in the blood. It offers benefits such as: 

• Reduces the amount of toxins released in the blood

• Fastens the recovery

• Prevents the spread of infection

The commonly used antibiotics in diphtheria infection are erythromycin and penicillin G. linezolid and vancomycin are also used in case of antibiotic resistance. A full course of antibiotics, as advised by the doctor should be followed by the patient to completely remove the bacteria from the system. 

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Diphtheria is a severe and a highly infectious disease. Apart from the basic treatment given, the procedure may also include:

• Hospitalization of the patient 

• Isolation to reduce the transmission

• Other medicines such as corticosteroids, adrenaline or antihistamines to reduce any severe reaction to the antitoxin given

• Tracheostomy (surgical insertion of a tube in the windpipe), in case of severe breathing difficulties

• Surgery to remove the gray membrane in the throat, if necessary

• Treatment of complications, for example medications to treat myocarditis (inflammation of the heart) 

• Bed rest for about one month or longer, for complete recovery

• Cleaning sores with soap and water, in case of skin diphtheria

Home-care For Diphtheria

Eat soft food diet

Diphtheria causes sore throat and difficulty in swallowing. It is better to consume soft foods and liquids.

Self isolation

Since diphtheria is a highly contagious disease, it is necessary to isolate the patients to reduce the spread of infection. 

Maintain hygiene

Strict hygiene should be maintained by the people who are caring for diphtheria patients. The precautionary measures such as washing hands, particularly before cooking food and handling the patient should be followed. 

Get vaccinated 

Vaccination is also necessary for the patient who has recovered from the diphtheria infection because it can occur again also. The care-takers and the people who are in close contact with the patient should also take a booster dose of vaccine. 

Take sufficient rest

The recovery of the patient is generally very slow, especially if the infection was severe. Such people are advised to take proper rest for a couple of weeks. The normal physical exertion may be harmful if the disease has affected the heart. 

Close contacts get tested

The people who are in close contact with the patient should go for the test of diphtheria. The treatment protocol is initiated in these people in case of any suspicion. This is required even in the people who have been vaccinated. 

Alternative Therapies For Diphtheria

Home remedies

Diphtheria is a severe respiratory illness. Doctors should be immediately consulted to avoid any life threatening complications. The treatment of diphtheria consists of antibiotics and antitoxin. However, some home remedies can be used as an adjunct to medical treatment. It is also advisable to consult the doctor before starting any home remedies: 

Garlic (Lehsun): Chewing a clove of garlic every three to four hours for a week helps to reduce fever associated with diphtheria. It also helps to soothe the throat.

Pineapple: Pineapple juice helps in removing the throat deposits. It contains bromelain that is effective in managing coughing. 

Basil leaves (tulsi): The antibacterial property of tulsi helps in reducing respiratory infections. It can be consumed as water infused with basil leaves.

Passion flower: This herb can help to alleviate symptoms of diphtheria. Add a tablespoon of the passion flower powder to a cup of boiling water. Strain and drink it at least twice a day. 

Castor leaves: It possesses anti-inflammatory and antimicrobial properties that help to manage the condition. Ground castor leaves can be taken orally. A paste of castor leaves, garlic juice and drumstick leaves can also be inhaled to clear the nasal passage. 

Complications Of Diphtheria

The pseudomembrane formed by the bacteria separates from the tissues in 7 to 10 days. The toxin produced by the bacteria can reach the heart, kidney, muscles, and liver which can cause various severe complications: 

Cardiac complications

The heart is usually the first organ to be affected. Diphtheria usually affects the heart in the second or third week. The patient can develop: 

• Myocarditis (inflammation of the heart muscle i.e, myocardium)

• Cardiac arrhythmia (irregular heartbeat)

• Circulatory collapse 

Neurological complications

The toxin can affect the nerves of the brain, extremities and muscles of the pharynx and soft palate causing:

• Neuritis (may lead to respiratory failure and pneumonia)

• Nerve weakness

• Encephalitis (rare in children) 

• Oculomotor nerve palsy (Involuntary movement of eyeball)

• Reflux of food through nose

Respiratory obstruction

In most of the cases, the pseudomembrane blocks the respiratory tract and can cause

suffocation. This requires immediate mechanical ventilation and intubation. 

Kidney damage

The toxin released in the blood can also damage the kidney, thereby affecting their ability to filter wastes from the blood. 

Living With Diphtheria

Here are a few simple tips which could help to deal better with diphtheria infection:

Choose food wisely

The patients of diphtheria usually find it hard to swallow food due to the development of an artificial membrane in the throat. Liquids and soft food items might help in this condition. The incorporation of healthy foods such as fresh fruits and vegetables in the form of juices and smoothies may also speed up the recovery process. 

Foods to be taken

• Fluids (juices)

• Milk

• Garlic

• Food in semi-solid form (ice creams)

• Fruits and vegetables

Foods to be avoided

• Spicy food

• Saturated oils and trans fats

Keep hydrated

Drinking enough water especially before bedtime helps in clearing the throat and loosening the mucus.

Take plenty of rest

Rest plays a very crucial role in complete recovery of the diphtheria patient. Avoid vigorous exercise and take sufficient rest as advised by the doctor. Avoid resuming physical activities early and give the body some time to heal completely from the effects of the bacteria. 

Sleep the right way

The patient should avoid sleeping on the back as it can trigger the accumulation of mucus in the throat. It is advised to use a thick pillow or use two pillows. This helps in elevating the trunk region, thus opening up the airways. 

Practice Yoga 

Do some breathing exercises such as pranayama. This will ease the breathing process. Some yoga such as sarvangasana and uttanasana relaxes the body and helps in sound sleep.