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 the 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 attach 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 the skin (cutaneous/skin diphtheria) and cause symptoms such as open sores and ulcers. These sores appear on the arms and legs and may 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 produce a thick gray coating in the respiratory system near the tonsils or other parts of the throat, known as pseudomembrane. The pseudomembrane may narrow and block the airway and 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 the nerves of the face, throat, arms, and legs, causing:

• Sudden movements of the eyes, arms, and legs
• Respiratory failure
• Rapid heart rate
• Irregular heart rhythm
• Low blood pressure
• Myocarditis
• Heart failure

Diphtheria is caused by a bacterium known as Corynebacterium diphtheriae, which can enter the body through the nose, mouth, or broken skin. The bacterium produces a toxin that can travel via the bloodstream and lymphatic vessels. This toxin can damage the heart, kidneys, 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. Transmission can occur through:

• Coughing, sneezing, or speaking via respiratory droplets
• Touching infected sores or ulcers
• Touching contaminated clothes or objects through a break in the skin

Diphtheria is a vaccine-preventable disease. Complete vaccination is an effective way to prevent diphtheria and reduces the chances of developing the disease even in the presence of risk factors. The risk of contracting diphtheria is higher if you:

• Are not vaccinated
• Are inadequately vaccinated
• Live in a temperate region
• Are exposed to cold environments
• Frequently travel to areas contaminated with diphtheria
• Are in close contact with an infected person
• Have a weakened immune system
• Live in unhygienic and crowded conditions
• Travel to specific regions known for diphtheria, such as Southeast Asia, Russia and surrounding countries, the Baltic countries, and Eastern European countries

Diphtheria is more common in children; however, older individuals with certain comorbidities are also at a higher risk of developing the disease. Additionally, people with low socioeconomic status have an increased likelihood of contracting this infection.

Diagnosis of Diphtheria

Physical Examination and Medical History

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

Culture

The diagnosis is confirmed by taking a sample and sending it to a laboratory to test for bacterial growth. Samples are collected by swabbing the throat and, in the case of skin infection, the wound. This procedure takes time, so treatment is usually initiated after the physical examination.

Toxin Testing

The test detects the toxin produced by the bacteria, helping to differentiate between toxigenic and non-toxigenic strains. This is performed through:

• Elek test
• PCR testing
• Enzyme immunoassay (EIA) test

Blood Tests

• Complete Blood Count: This test helps determine the level of infection by assessing several blood parameters.
• Troponin I: This marker indicates cardiac (heart) injury and helps assess the extent of damage to the heart.
• Diphtheria Antitoxoid Antibody: This test measures antibody levels in the blood, which can be produced through vaccination or previous infection.

Imaging Studies

• Chest and Neck X-ray: These imaging tests are used to detect swelling of the soft tissue structures around the pharynx, epiglottis, and chest.
• Electrocardiography (ECG): An ECG is performed if heart disorders are suspected.

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 and 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 and 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 the DTaP vaccine respectively to gain 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: The 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.

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

Adults: Tdap can be given at any age to adults if they have 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 children. However, many are unaware that adults also need to be vaccinated for several diseases.

The vaccine is also advised for:

• People who are traveling overseas and have not 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 reactions. Vaccines are not given if a child has had:

• a life-threatening allergic reaction after a dose of the vaccine,
• a severe allergy to any component of the vaccine.

Side effects of vaccination

Most people who receive any of the diphtheria vaccines will not experience serious side effects. However, in some cases, vaccines can cause milder side effects that can be easily managed. Most of the effects usually resolve on their own. Common side effects may include:

• Redness and swelling at the injection site,
• Fever,
• Loss of appetite,
• Tiredness,
• Vomiting,
• Headache,
• Chills,
• Body aches.

Managing the side effects

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

• Consume fluids,
• Avoid overdressing the children,
• Take paracetamol after consulting with a doctor if the fever is high or to manage the swelling and pain at the injection site.

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 are 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
  Antibiotics are usually effective before the bacteria start releasing toxins into the blood. They offer several benefits:
  • Reduces the amount of toxins released in the blood
  • Speeds up 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 cases 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.

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

• Hospitalization of the patient
• Isolation to reduce transmission
• Other medications 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

• Eat a soft food diet: Diphtheria causes sore throat and difficulty in swallowing. It is advisable to consume soft foods and liquids.
• Self-isolation: Since diphtheria is a highly contagious disease, it is essential to isolate patients to reduce the spread of infection.
• Maintain hygiene: Strict hygiene should be maintained by those caring for diphtheria patients. Precautionary measures such as washing hands, particularly before cooking and handling the patient, should be followed.
• Get vaccinated: Vaccination is necessary for patients who have recovered from diphtheria, as reinfection can occur. Caretakers and individuals in close contact with the patient should also receive a booster dose of the vaccine.
• Take sufficient rest: Recovery is generally slow, especially if the infection was severe. Patients are advised to take proper rest for a couple of weeks, as normal physical exertion may be harmful if the disease has affected the heart.
• Close contacts get tested: Individuals in close contact with the patient should undergo testing for diphtheria. Treatment protocols are initiated in these individuals if there is any suspicion, even in those who have been vaccinated.

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, kidneys, muscles, and liver, leading to various severe complications:

Cardiac Complications

The heart is usually the first organ to be affected. Diphtheria typically impacts the heart in the second or third week. The patient may 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 the eyeball)
• Reflux of food through the nose

Respiratory Obstruction

In most cases, the pseudomembrane blocks the respiratory tract, potentially causing suffocation. This requires immediate mechanical ventilation and intubation.

Kidney Damage

The toxin released into the blood can also damage the kidneys, affecting their ability to filter waste from the blood.

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 aids in removing throat deposits. It contains bromelain, which is effective in managing coughing.
• Basil leaves (Tulsi): The antibacterial properties of tulsi help reduce respiratory infections. It can be consumed as water infused with basil leaves.
• Passion flower: This herb can help alleviate symptoms of diphtheria. Add a tablespoon of passion flower powder to a cup of boiling water. Strain and drink it at least twice a day.
• Castor leaves: These possess anti-inflammatory and antimicrobial properties that help 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.

Here are a few simple tips that could help in managing diphtheria infection:

Choose Food Wisely

Patients with diphtheria often find it difficult to swallow food due to the formation of an artificial membrane in the throat. Liquids and soft food items may be beneficial in this condition. Incorporating healthy foods such as fresh fruits and vegetables in the form of juices and smoothies can also aid 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 clear the throat and loosen mucus.

Take Plenty of Rest

Rest plays a crucial role in the complete recovery of diphtheria patients. Avoid vigorous exercise and follow the doctor's advice regarding rest. It is important not to resume physical activities too early and to allow the body ample time to heal from the effects of the bacteria.

Sleep the Right Way

Patients should avoid sleeping on their backs, as this can lead to mucus accumulation in the throat. It is advisable to use a thick pillow or two pillows to elevate the trunk region, thereby opening up the airways.

Practice Yoga

Engaging in breathing exercises such as pranayama can ease the breathing process. Yoga poses like sarvangasana and uttanasana can help relax the body and promote sound sleep.