diphtheria

Definition

Diphtheria is a potentially fatal, contagious disease that usually involves the nose, throat, and air passages, but may also infect the skin. Its most striking feature is the formation of a grayish membrane covering the tonsils and upper part of the throat.

Description

Like many other upper respiratory diseases, diphtheria is most likely to break out during the winter months. At one time it was a major childhood killer, but it is now rare in developed countries because of widespread immunization. Since 1988, all confirmed cases in the United States have involved visitors or immigrants. In countries that do not have routine immunization against this infection, the mortality rate varies from 1.5–25%.

Persons who have not been immunized may get diphtheria at any age. The disease is spread most often by droplets from the coughing or sneezing of an infected person or carrier. The incubation period is two to seven days, with an average of three days. It is vital to seek medical help at once when diphtheria is suspected, because treatment requires emergency measures for adults as well as children.

— Rebecca J. Frey

An acute infectious disease caused by the bacillus Corynebacterium diphtheriae, characterized by the production of a systemic toxin and the formation of a false membrane on the lining of the mucous membrane of the throat and other respiratory passages, causing difficulty in breathing, high fever, and weakness. The toxin is particularly harmful to the tissues of the heart and central nervous system.

[New Latin diphthēria, from French diphthérie, from Greek diphtherā, piece of hide, leather. See letter.]

An acute infectious disease of humans caused by Corynebacterium diphtheriae. Classically, the disease is characterized by low-grade fever, sore throat, and a pseudomembrane covering the tonsils and pharynx. Complications such as inflammation of the heart, paralysis, and even death may occur due to exotoxins elaborated by toxigenic strains of the bacteria. The upper respiratory tract is the most common portal of entry for C. diphtheriae. It can also invade the skin and, more rarely, the genitalia, eye, or middle ear. The disease has an insidious onset after a usual incubation period of 2–5 days.

The only specific therapy is diphtheria antitoxin, administered in doses proportional to the severity of the disease. Antitoxin is produced by hyperimmunizing horses with diphtheria toxoid and toxin. It is effective only if administered prior to the binding of circulating toxin to target cells. Antibiotics do not alter the course, the incidence of complications, or the outcome of diphtheria, but are used to eliminate the organism from the patient.

Persons with protective antitoxin titers may become infected with diphtheria but do not develop severe disease. Since the 1920s, active immunization with diphtheria toxoid has proved safe and effective in preventing diphtheria in many countries. Diphtheria toxoid is produced by incubating the toxin with formalin. Active immunization requires a primary series of four doses, usually at 2, 4, 6, and 18 months of age, followed by a booster at school entry. See also Immunity; Medical bacteriology; Toxin; Vaccination.

An acute disease caused by Corynebacterium diphtheriae resulting in swelling of the pharynx and larynx with fever.

Definition

Diphtheria is a potentially fatal, contagious disease that usually involves the nose, throat, and air passages but may also infect the skin. Its most striking feature is the formation of a grayish membrane covering the tonsils and upper part of the throat.

Description

Like many other upper respiratory diseases, diphtheria is most likely to break out during the winter months. At one time it was a major childhood killer, but in the early 2000s it is rare in developed countries because of widespread immunization.

Persons who have not been immunized may get diphtheria at any age. The disease is spread most often by droplets from the coughing or sneezing of an infected person or carrier. The incubation period is two to seven days, with an average of three days. It is vital to seek medical help at once when diphtheria is suspected, because treatment requires emergency measures for adults as well as children.

Demographics

Diphtheria is a reportable disease in many countries in the world. Since 1988, all confirmed cases in the United States involved visitors or immigrants. In countries that do not have routine immunization against this infection, the mortality rate varies from 1.5 to 25 percent.

Causes and Symptoms

The symptoms of diphtheria are caused by toxins produced by the diphtheria bacillus, Corynebacterium diphtheriae (from the Greek for "rubber membrane"). In fact, toxin production is related to infections of the bacillus itself with a particular bacteria virus called a phage (from bacteriophage, a virus that infects bacteria). The intoxication destroys healthy tissue in the upper area of the throat around the tonsils or in open wounds in the skin. Fluid from the dying cells then coagulates to form the telltale gray or grayish green membrane. Inside the membrane, the bacteria produce an exotoxin, which is a poisonous secretion that causes the life-threatening symptoms of diphtheria. The exotoxin is carried throughout the body in the bloodstream, destroying healthy tissue in other parts of the body.

The most serious complications caused by the exotoxin are inflammations of the heart muscle (myocarditis) and damage to the nervous system. The risk of serious complications is increased as the time between onset of symptoms and the administration of antitoxin increases, and as the size of the membrane formed increases. The myocarditis may cause disturbances in the heart rhythm and may culminate in heart failure. The symptoms of nervous system involvement can include seeing double (diplopia), painful or difficult swallowing, and slurred speech or loss of voice, which are all indications of the exotoxin's effect on nerve functions. The exotoxin may also cause severe swelling in the neck ("bull neck").

The signs and symptoms of diphtheria vary according to the location of the infection.

Nasal

Nasal diphtheria produces few symptoms other than a watery or bloody discharge. On examination, there may be a small visible membrane in the nasal passages. Nasal infection rarely causes complications by itself, but it is a public health problem because it spreads the disease more rapidly than other forms of diphtheria.

Pharyngeal

Pharyngeal diphtheria gets its name from the pharynx, which is the part of the upper throat that connects the mouth and nasal passages with the voice box. This is the most common form of diphtheria, causing the characteristic throat membrane. The membrane often bleeds if it is scraped or cut. It is important not to try to remove the membrane because the trauma may increase the body's absorption of the exotoxin. Other signs and symptoms of pharyngeal diphtheria are mild sore throat, fever of 101–102°F (38.3–38.9°C), a rapid pulse, and general body weakness.

Laryngeal

Laryngeal diphtheria, which involves the voice box or larynx, is the form most likely to produce serious complications. The fever is usually higher in this form of diphtheria (103–104°F or 39.4–40°C) and the person is very weak. People may have a severe cough, have difficulty breathing, or lose their voice completely. The development of a bull neck indicates a high level of exotoxin in the bloodstream. Obstruction of the airway may result in respiratory compromise and death.

Skin

This form of diphtheria, which is sometimes called cutaneous diphtheria, accounts for about 33 percent of all diphtheria cases. It is found chiefly among people with poor hygiene. Any break in the skin can become infected with diphtheria. The infected tissue develops an ulcerated area, and a diphtheria membrane may form over the wound but is not always present. The wound or ulcer is slow to heal and may be numb or insensitive when touched.

When to Call the Doctor

A doctor should be called whenever a case of diphtheria is suspected.

Diagnosis

Because diphtheria must be treated as quickly as possible, doctors usually make the diagnosis on the basis of the visible symptoms without waiting for test results.

In making the diagnosis, the doctor examines the affected person's eyes, ears, nose, and throat in order to rule out other diseases that may cause fever and sore throat, such as infectious mononucleosis, a sinus infection, or strep throat. The most important single symptom that suggests diphtheria is the membrane. When a person develops skin infections during an outbreak of diphtheria, the doctor will consider the possibility of cutaneous diphtheria and take a smear to confirm the diagnosis.

Laboratory Tests

The diagnosis of diphtheria can be confirmed by the results of a culture obtained from the infected area. Material from the swab is put on a microscope slide and stained using a procedure called Gram's stain. The diphtheria bacillus is Gram-positive which means it holds the dye after the slide is rinsed with alcohol. Under the microscope, diphtheria bacilli look like beaded rod-shaped cells, grouped in patterns that resemble Chinese characters. Another laboratory test involves growing the diphtheria bacillus on a special material called Loeffler's medium.

Treatment

Diphtheria is a serious disease requiring hospital treatment in an intensive care unit if the person has developed respiratory symptoms. Treatment includes a combination of medications and supportive care.

Antitoxin

The most important step is prompt administration of diphtheria antitoxin, without waiting for laboratory results. The antitoxin is made from horse serum and works by neutralizing any circulating exotoxin. The doctor must first test people for sensitivity to animal serum. People who are sensitive (about 10%) must be desensitized with diluted antitoxin, since as of 2004 the antitoxin is the only specific substance that counteracts diphtheria exotoxin. No human antitoxin is available for the treatment of diphtheria.

The dose ranges from 20,000 to 100,000 units, depending on the severity and length of time of symptoms occurring before treatment. Diphtheria antitoxin is usually given intravenously.

Antibiotics

Antibiotics are given to wipe out the bacteria, to prevent the spread of the disease, and to protect people from developing pneumonia. They are not a substitute for treatment with antitoxin. Both adults and children may be given penicillin, ampicillin, or erythromycin. Erythromycin appears to be more effective than penicillin in treating people who are carriers because of better penetration into the infected area.

Cutaneous diphtheria is usually treated by cleansing the wound thoroughly with soap and water and giving an individual antibiotics for ten days.

Supportive Care

Persons with diphtheria require bed rest with intensive nursing care, including extra fluids, oxygenation, and monitoring for possible heart problems, airway blockage, or involvement of the nervous system. People with laryngeal diphtheria are kept in a croup tent or high-humidity environment; they may also need throat suctioning or emergency surgery if their airway is blocked.

People recovering from diphtheria should rest at home for a minimum of two to three weeks, especially if they have heart complications. In addition, persons should be immunized against diphtheria after recovery, because having the disease does not always induce antitoxin formation and protect them from reinfection.

Prevention of Complications

People with diphtheria who develop myocarditis may be treated with oxygen and with medications to prevent irregular heart rhythms. An artificial pacemaker may be needed. Persons with difficulty swallowing can be fed through a tube inserted into the stomach through the nose. Persons who cannot breathe are usually put on mechanical respirators.

Prognosis

The prognosis depends on the size and location of the membrane and on early treatment with antitoxin; the longer the delay, the higher the death rate. The most vulnerable persons are children under the age of 15 years and those who develop pneumonia or myocarditis. Nasal and cutaneous diphtheria are rarely fatal.

Prevention

Prevention of diphtheria has four aspects: immunization, isolation of infected persons, identification and treatment of contacts, and reporting cases to health authorities.

Immunization

Universal immunization is the most effective means of preventing diphtheria. The standard course of immunization for healthy children is three doses of DPT (diphtheria-tetanus-pertussis) preparation given between two months and six months of age, with booster doses given at 18 months and at entry into school. Adults should be immunized at ten-year intervals with Td (tetanus-diphtheria) toxoid. (A toxoid is a bacterial toxin that is treated to make it harmless but still can induce immunity to the disease.)

Isolation of Affected Persons

Individuals with diphtheria must be isolated for one to seven days or until two successive cultures show that the individuals are no longer contagious. Children placed in isolation are usually assigned a primary nurse for emotional support.

Identification and Treatment of Contacts

Because diphtheria is highly contagious and has a short incubation period, family members and other contacts of persons with diphtheria must be watched for symptoms and tested to see if they are carriers. They are usually given antibiotics for seven days and a booster shot of diphtheria/tetanus toxoid.

Reporting Cases to Public Health Authorities

Reporting is necessary for tracking potential epidemics, to help doctors identify the specific strain of diphtheria, and to see if resistance to penicillin or erythromycin has developed.

Parental Concerns

Parents in the United States should ensure that their children have full immunizations against diphtheria. Completion of the three-shot series initiates lifelong immunity from diphtheria.

Resources

Books

Diphtheria: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. San Diego, CA: ICON Health Publications, 2004.

Holmes, Randall K. "Diphtheria, Corynebacterial Infections and Anthrax." In Harrison's Principles of Internal Medicine, 15th ed. Edited by Eugene Braunwald et al. New York: McGraw-Hill, 2001, pp. 909–14.

Long, Sarah S. "Diphtheria (Corynebacterium diphtheriae)." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2003, pp. 886–9.

Miller, Debbie S. Great Serum Race: Blazing the Iditarod Trail. New York: Walker & Company, 2002.

Salisbury, Gay. The Cruelest Miles: The Heroic Story of Dogs and Men in a Race against an Epidemic. New York: Norton, 2003.

Periodicals

Bertuccini, L., et al. "Internalization of non-toxigenic Corynebacterium diphtheriae by cultured human respiratory epithelial cells." Microbial Pathogenesis 37, no. 3 (2004): 111–8.

Clarke, P., et al. "DTP immunization of steroid treated preterm infants." Archives of Disease in Childhood: Fetal and Neonatal Edition 89, no. 5 (2004): F468–9.

Colgrove, J. "The power of persuasion: Diphtheria immunization, advertising, and the rise of health education." Public Health Rep 119, no. 5 (2004): 506–9.

Netterlid, E, et al. "Persistent itching nodules after the fourth dose of diphtheria-tetanus toxoid vaccines without evidence of delayed hypersensitivity to aluminium." Vaccine 22, no. 27–28 (2004): 3698–706.

Organizations

American Public Health Association. 800 I Street, NW, Washington, DC 20001–3710. Web site: www.apha.org/.

Centers for Disease Control and Prevention. 1600 Clifton Road, Atlanta, GA 30333. Web site: www.cdc.gov.

Pan American Health Organization. 525 23rd St., NW, Washington, DC 20037. Web site: www.paho.org.

World Health Organization, Communicable Diseases. 20 Avenue Appia, 1211 Geneva 27, Switzerland. Web site: www.who.int/gtb/.

Web Sites

"Diphtheria." MedlinePlus. Available online at www.nlm.nih.gov/medlineplus/ency/article/001608.htm (accessed January 5, 2005).

"Diphtheria." World Health Organization. Available online at www.who.int/topics/diphtheria/en/ (accessed January 5, 2005).

"Diphtheria, Tetanus, and Pertussis." Centers for Disease Control and Prevention. Available online at www.cdc.gov/travel/diseases/dtp.htm (accessed January 5, 2005).

[Article by: L. Fleming Fallon, Jr., MD, DrPH]

Diphtheria is a communicable disease caused by infection with Corynebacterium diphtheriae, typically presenting as respiratory tract infection in temperate climates and as cutaneous infection in the tropics. Clinical manifestations include pseudomembrane formation in the respiratory tract and soft tissue swelling of the neck ("bull neck"). Serious complications, primarily damage to the heart muscle and certain nerves that activate muscles, are due to diphtheria toxin, a potent toxin. Nontoxigenic strains can produce respiratory tract illness with pseudomembrane. Clusters of cases of invasive disease due to nontoxigenic strains, predominantly among persons with antecedent injection use, have been reported recently from several countries.

Vaccines composed of inactivated diphtheria toxin—diphtheria toxic—were developed in the early twentieth century and have been widely used in most developed countries since the middle of the twentieth century. Prior to introduction of vaccination, diphtheria was a major cause of childhood mortality in the United States, but by the 1990s respiratory diphtheria has been virtually eliminated in the United States and in other countries with high levels of childhood vaccination for diphtheria. Nonetheless, the infection remains endemic in much of the developing world. In the 1990s, a massive resurgence of diphtheria occurred in the countries of the former Soviet Union. Factors contributing to the epidemic included low vaccination coverage among children, lack of routine adult booster vaccination, population movements, and multiple introductions from areas where diphtheria remained endemic.

In the World Health Organization's Expanded Programme on Immunization, diphtheria toxic is administered with tetanus toxic and pertussis vaccine (DTP) at 6, 10, and 14 weeks of age. Recommendations for subsequent doses vary among countries. In the United States, diphtheria toxic is routinely administered with tetanus toxic and acellular pertussis vaccine at 2, 4, and 6 months of age, with booster doses at 15 to 18 months and 4 to 6 years of age.

Diptheria antitoxin is the mainstay of treatment of diphtheria. Outcome improves with early diagnosis and treatment. Antimicrobial therapy with penicillin or erythromycin hastens elimination of the organism. Antimicrobial prophylaxis is recommended for those in close contact with diphtheria cases.

(SEE ALSO: Communicable Disease Control; Diphtheria Vaccine; Immunizations)

— MELINDA WHARTON; CHARLES VITEK

For more information on diphtheria, visit Britannica.com.

An acute disease, and a contagious disease, caused by bacteria that invade mucous membranes in the body, especially those found in the throat. The bacteria produce toxic substances that can spread throughout the body.

Pertaining to features of the human disease, diphtheria.

• d. inflammation — an adherent membrane, consisting of necrosis of the superficial layers of the mucosa combined with inflammatory exudate, is formed on the mucosa.
• d. membrane — the peculiar membrane characteristic of diphtheria in humans and in other species. The term is used to describe membranes with a similar appearance in other disease conditions. See also diphtheritic inflammation.

Diphtheria
Classification and external resources
Diphtheria causes a characteristic swollen neck, sometimes referred to as “bull neck”.
ICD-10	A30.
ICD-9	032
DiseasesDB	3122
MedlinePlus	001608
eMedicine	emerg/138 med/459 oph/674 ped/596
MeSH	D004165

Diphtheria (Greek διφθερα (diphthera)—“pair of leather scrolls") is an upper respiratory tract illness characterized by sore throat, low fever, and an adherent membrane (a pseudomembrane) on the tonsils, pharynx, and/or nasal cavity.^[1] A milder form of diphtheria can be restricted to the skin. It is caused by Corynebacterium diphtheriae, an aerobic Gram-positive bacterium.^[2]

Diphtheria causes the progressive deterioration of myelin sheaths in the central and peripheral nervous system leading to degenerating motor control and loss of sensation. Diphtheria is a contagious disease spread by direct physical contact or breathing the aerosolized secretions of infected individuals. Historically quite common, diphtheria has largely been eradicated in industrialized nations through widespread vaccination. In the United States for example, there were 52 reported cases of diphtheria between 1980 and 2000; between 2000 and 2007 there were only three cases^[3] as the DPT (Diphtheria–Pertussis–Tetanus) vaccine is recommended for all school-age children. Boosters of the vaccine are recommended for adults since the benefits of the vaccine decrease with age without constant re-exposure; they are particularly recommended for those traveling to areas where the disease has not been eradicated.

Contents 1 History 2 Mechanism 3 Signs and symptoms 3.1 Diagnosis 3.1.1 Laboratory criteria 3.1.2 Clinical criteria 3.1.3 Case classification 4 Treatment 5 Epidemiology 6 References 7 Further reading

History

In 1878, Queen Victoria's daughter Princess Alice and her family became infected with it, causing two deaths, Princess Marie of Hesse and by Rhine and Princess Alice herself.

Around the same year a woman called Esther Cox was being plagued by a poltergeist, she got Diptheria and took bed, the hauntings ceased all of the time she had Dipthera (the ghost said it wanted her dead), however the ghost got more violent after she recovered. (see the Great Amherst Mystery).

In the 1920s there were an estimated 100,000 to 200,000 cases of diphtheria per year in the United States, causing 13,000 to 15,000 deaths per year.^[3] Children represented a large majority of these cases and fatalities. One of the most famous outbreaks of diphtheria was in Nome, Alaska; the 1925 serum run to Nome to deliver diphtheria antitoxin is now celebrated by the "Great Race of Mercy".

One of the first effective treatments for diphtheria was discovered in the 1880s by U.S. physician Joseph O'Dwyer (1841–1898). O'Dwyer developed tubes that were inserted into the throat, and prevented victims from suffocating due to the membrane sheath that grows over and obstructs airways. In the 1890s, the German physician Emil von Behring developed an antitoxin that did not kill the bacterium, but neutralized the toxic poisons that the bacterium releases into the body. Von Behring discovered that animal blood has antitoxins in it and so he took the blood, removed the clotting agents and injected it into human patients. Von Behring was awarded the first Nobel Prize in Medicine for his role in the discovery, and development of a serum therapy for diphtheria. (Americans William H. Park and Anna Wessels Williams; and Pasteur Institute scientists Emile Roux and Auguste Chaillou also independently developed diphtheria antitoxin in the 1890s.) The first successful vaccine for diphtheria was developed in 1913 by Behring. However, antibiotics against diphtheria were not available until the discovery and development of sulfa drugs.

The Schick test, invented between 1910 and 1911, is a test used to determine whether or not a person is susceptible to diphtheria. It was named after its inventor, Béla Schick (1877–1967), a Hungarian-born American pediatrician. A massive five-year campaign was coordinated by Dr. Schick. As a part of the campaign, 85 million pieces of literature were distributed by the Metropolitan Life Insurance Company with an appeal to parents to "Save your child from diphtheria." A vaccine was developed in the next decade, and deaths began declining in earnest in 1924.^[4]

Mechanism

A diphtheria skin lesion on the leg.

Diphtheria toxin consists of a single polypeptide. Proteolysis yields two fragments (A and B) which are held together by a disulfide bond. The toxin binds to EGF-like domain of Heparin-binding EGF-like growth factor (HB-EGF) through fragment B and is internalized with HB-EGF by receptor-mediated endocytosis. The low pH in the late endosomes induce pore formation by fragment B as well as catalyses the release of catalytic fragment A into the cytosol. Diphtheria toxin catalyzes the ADP-ribosylation of, and inactivates, the elongation factor eEF-2.^[5] In this way, it acts to inhibit translation during eukaryotic protein synthesis. The toxin enters the host cell and is hydrolysed by a trypsin-like protease to give a fragment with enzymatic activity. The toxin then transfers an ADP-ribose from NAD⁺ to a diphthamide residue, a modified histidine (amino acid), which is found within the EF-2 protein. EF-2 is needed for translocation of tRNA from the A-site to the P-site of the ribosome during translation. The ADP-ribosylation is reversible by administering high concentrations of nicotinamide, one of the reaction products^[6].

Diphtheria toxin is only produced by C. diphtheriae when it is infected with a bacteriophage. The bacteriophage integrates a gene into the bacteria that causes the toxin to be produced.

Signs and symptoms

The respiratory form has an incubation period of 2–5 days. The onset of disease is usually gradual. Symptoms include fatigue, fever, a mild sore throat and problems swallowing. Children infected have symptoms that include nausea, vomiting, chills, and a high fever, although some do not show symptoms until the infection has progressed further. In 10% of cases, patients experience neck swelling, informally referred to as "bull neck." These cases are associated with a higher risk of death.

In addition to symptoms at the site of infection (sore throat), the patient may experience more generalized symptoms, such as listlessness, pallor, and fast heart rate. These symptoms are caused by the toxin released by the bacterium. Low blood pressure may develop in these patients. Longer-term effects of the diphtheria toxin include cardiomyopathy and peripheral neuropathy (sensory type).^[7]

The cutaneous form of diphtheria is often a secondary infection of a preexisting skin disease. Signs of cutaneous diphtheria infection develop an average of seven days after the appearance of the primary skin disease.

Diagnosis

The current definition of diphtheria used by the Centers for Disease Control and Prevention (CDC) is based on both laboratory and clinical criteria.

Laboratory criteria

• Isolation of Corynebacterium diphtheriae from a clinical specimen, or
• Histopathologic diagnosis of diphtheria

Clinical criteria

• Upper respiratory tract illness with sore throat
• high-grade fever, and
• An adherent pseudomembrane of the tonsil(s), pharynx, and/or nose.

Case classification

• Probable: a clinically compatible case that is not laboratory-confirmed and is not epidemiologically linked to a laboratory-confirmed case
• Confirmed: a clinically compatible case that is either laboratory-confirmed or epidemiologically linked to a laboratory-confirmed case

Empirical treatment should generally be started in a patient in whom suspicion of diphtheria is high.

Treatment

The disease may remain manageable, but in more severe cases lymph nodes in the neck may swell, and breathing and swallowing will be more difficult. People in this stage should seek immediate medical attention, as obstruction in the throat may require intubation or a tracheotomy. Abnormal cardiac rhythms can occur early in the course of the illness or weeks later, and can lead to heart failure. Diphtheria can also cause paralysis in the eye, neck, throat, or respiratory muscles. Patients with severe cases will be put in a hospital intensive care unit (ICU) and be given a diphtheria anti-toxin. Since antitoxin does not neutralize toxin that is already bound to tissues, delaying its administration is associated with an increase in mortality risk. Therefore, the decision to administer diphtheria antitoxin is based on clinical diagnosis, and should not await laboratory confirmation.^[3]

Antibiotics have not been demonstrated to affect healing of local infection in diphtheria patients treated with antitoxin. Antibiotics are used in patients or carriers to eradicate C. diphtheriae and prevent its transmission to others. The CDC recommends^[8] either:

• Erythromycin (orally or by injection) for 14 days (40 mg/kg per day with a maximum of 2 g/d), or
• Procaine penicillin G given intramuscularly for 14 days (300,000 U/d for patients weighing <10 kg and 600,000 U/d for those weighing >10 kg). Patients with allergies to penicillin G or erythromycin can use rifampin or clindamycin.

In cases that progress beyond a throat infection, diphtheria toxin spreads through the bloodstream and can lead to potentially life-threatening complications that affect other organs of the body, such as the heart and kidneys. The toxin can cause damage to the heart that affects its ability to pump blood or the kidneys' ability to clear wastes. It can also cause nerve damage, eventually leading to paralysis. Up to 40% to 50% of those who don't get treated can die.

Epidemiology

Diphtheria cases reported to the World Health Organization between 1997 and 2006 (see description for legend).

Diphtheria is a serious disease, with fatality rates between 5% and 10%. In children under 5 years and adults over 40 years, the fatality rate may be as much as 20%.^[3] Outbreaks, though very rare, still occur worldwide, even in developed nations such as Germany and Canada. After the breakup of the former Soviet Union in the late 1980s, vaccination rates in its constituent countries fell so low that there was an explosion of diphtheria cases. In 1991 there were 2,000 cases of diphtheria in the USSR. By 1998, according to Red Cross estimates, there were as many as 200,000 cases in the Commonwealth of Independent States, with 5,000 deaths. This was so great an increase that diphtheria was cited in the Guinness Book of World Records as "most resurgent disease".

References

1. ^ Ryan KJ, Ray CG (editors) (2004). Sherris Medical Microbiology (4th ed.). McGraw Hill. pp. 299–302. ISBN 0838585299. 
2. ^ Office of Laboratory Security, Public Health Agency of Canada Corynebacterium diphtheriae Material Safety Data Sheet. January 2000.
3. ^ ^{a b c d} Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. (2007). Diphtheria. in: Epidemiology and Prevention of Vaccine-Preventable Diseases (The Pink Book) (10 ed.). Washington DC: Public Health Foundation. pp. 59–70. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/dip.pdf. 
4. ^ "United States mortality rate from measles, scarlet fever, typhoid, whooping cough, and diphtheria from 1900–1965". HealthSentinel.com. http://www.healthsentinel.com/graphs.php?id=14&event=graphs_print_list_item. Retrieved 2008-06-30. 
5. ^ Jørgensen R, Merrill AR. and Andersen GR. (2006). "The life and death of translation elongation factor 2". Biochem. Soc. Trans. 34 (1): 1–6. doi:10.1042/BST0340001. PMID 16246167. 
6. ^ http://www.textbookofbacteriology.net/diphtheria_3.html
7. ^ Toxic Neuropathies. Neuromuscular Disease Center Washington University, St. Louis, MO, USA.
8. ^ The first version of this article was adapted from the CDC document "Diphtheria - 1995 Case Definition" at http://www.cdc.gov/epo/dphsi/casedef/diphtheria_current.htm. As a work of an agency of the U.S. Government without any other copyright notice it should be available as a public domain resource.

Further reading

Wikimedia Commons has media related to: Diphtheria

• Holmes RK, "Diphtheria and other corynebacterial infections". In Harrison's Principles of Internal Medicine, 16th Ed. (2005).
• "Antitoxin dars 1735 and 1740." The William and Mary Quarterly, 3rd Ser., Vol 6, No 2. p. 338.
• Shulman ST, "The History of Pediatric Infectious Diseases", Pediatric Research. Vol. 55, No. 1 (2004).

v • d • e Infectious diseases · Bacterial diseases: G+ (primarily A00–A79, 001–041, 080–109) Firmicutes/ (low-G+C) Bacilli Lactobacillales (Cat-) Streptococcus Alpha hemolytic optochin susceptible: S. pneumoniae (Pneumococcal infection) optochin resistant: S. viridans (S. mitis, S. mutans, S. oralis, S. sanguinis, S. sobrinus, milleri group) Beta hemolytic A, bacitracin susceptible: S. pyogenes (Scarlet fever, Erysipelas, Rheumatic fever, Streptococcal pharyngitis) B, bacitracin resistant, CAMP test+: S. agalactiae Gamma hemolytic D, BEA+: Streptococcus bovis Enterococcus BEA+: Enterococcus faecalis (Urinary tract infection) · Enterococcus faecium Bacillales (Cat+) Staphylococcus Cg+ S. aureus (Staphylococcal scalded skin syndrome, Toxic shock syndrome, MRSA) Cg- novobiocin susceptible (S. epidermidis) · novobiocin resistant (S. saprophyticus) Bacillus Bacillus anthracis (Anthrax) · Bacillus cereus (Food poisoning) Listeria Listeria monocytogenes (Listeriosis) Clostridia Clostridium (spore-forming) motile: Clostridium difficile (Pseudomembranous colitis) · Clostridium botulinum (Botulism) · Clostridium tetani (Tetanus) nonmotile: Clostridium perfringens (Gas gangrene, Clostridial necrotizing enteritis) Peptostreptococcus (non-spore forming) Peptostreptococcus magnus Mollicutes Mycoplasmataceae Ureaplasma urealyticum (Ureaplasma infection) · Mycoplasma genitalium · Mycoplasma pneumoniae (Mycoplasma pneumonia) Anaeroplasmatales Erysipelothrix rhusiopathiae (Erysipeloid) Actinobacteria/ (high-G+C) Actinomycineae Actinomycetaceae Actinomyces israelii (Actinomycosis) · Tropheryma whipplei (Whipple's disease) Propionibacteriaceae Propionibacterium acnes Corynebacterineae Mycobacteriaceae M. tuberculosis/M. bovis Tuberculosis: Ghon focus/Ghon's complex · Pott disease · brain (Meningitis, Rich focus) · cutaneous (Scrofula, Bazin disease, Lupus vulgaris, Prosector's wart) · Miliary · Tuberculous pericarditis M. leprae Leprosy Nontuberculous R1: M. kansasii · M. marinum R2: M. gordonae R3: M. avium complex (MAA, MAP, MAI, Lady Windermere syndrome) · M. ulcerans (Buruli ulcer) · M. haemophilum R4: M. fortuitum · M. chelonae Nocardiaceae Nocardia asteroides/Nocardia brasiliensis (Nocardiosis) · Rhodococcus equi Corynebacteriaceae Corynebacterium diphtheriae (Diphtheria) · Corynebacterium minutissimum (Erythrasma) · Corynebacterium jeikeium Bifidobacteriaceae Gardnerella vaginalis

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Dansk (Danish)
n. - difteritis

Nederlands (Dutch)
difterie

Français (French)
n. - diphtérie

Deutsch (German)
n. - Diphtherie

Ελληνική (Greek)
n. - (παθολ.) διφθερίτιδα

Italiano (Italian)
difterite

Português (Portuguese)
n. - difteria (f)

Русский (Russian)
дифтерия

Español (Spanish)
n. - difteria, garrotillo

Svenska (Swedish)
n. - difteri

中文（简体）(Chinese (Simplified))
白喉

中文（繁體）(Chinese (Traditional))
n. - 白喉

한국어 (Korean)
n. - 디프레리아

日本語 (Japanese)
n. - ジフテリア

العربيه (Arabic)
‏(الاسم) مرض الديفتيريا, مرض الخناق ( يصيب الحلق ويسبب صعوبه في التنفس)‏

עברית (Hebrew)
n. - ‮אסכרה, דיפתריה‬

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