Diphtheria in Emergency Medicine Workup

  • Author: Allysia M Guy, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Feb 14, 2011
 

Laboratory Studies

To establish the diagnosis of C diphtheriae, it is vital to both isolate C diphtheriae in culture media and to identify the presence of toxin production.[2]

Bacteriologic testing

Gram stain shows club-shaped, nonencapsulated, nonmotile bacilli found in clusters.

Immunofluorescent staining of 4-hour cultures or methylene blue–stained specimen may sometimes allow for a speedy identification.

Cultures

Inoculation of tellurite or Loeffler media with swabs taken from the nose, pseudomembrane, tonsillar crypts, any ulcerations, or discolorations. Identification is accomplished through observation of colony morphology, microscopic appearance, and fermentation reactions. Any diphtheria bacilli isolated must be tested for toxin production.

Obtain throat and pharyngeal swabs from all close contacts.[9]

Toxigenicity

Toxigenicity testing is aimed to determine the presence of toxin production.

Elek test detects the development of an immunoprecipitin band on a filter paper impregnated with antitoxin and then is laid over an agar culture of the organism being tested.[10]

Polymerase chain reaction (PCR) assays for detection of DNA sequence encoding the A subunit of tox+ strain are both rapid and sensitive.

Once diphtheria infection has been established, the Centers for Disease Control and Prevention (CDC) should be contacted, and further testing may be requested.

Other laboratory studies

CBC may show moderate leukocytosis.

Urinalysis (UA) may demonstrate transient proteinuria.

Serum antibodies to diphtheria toxin prior to administration of antitoxin: Low levels cannot exclude the possibility of the disease; high levels may protect against severe illness (concentrations of 0.1 to 0.01 IU are thought to confer protection).[9]

Serum troponin I levels seem to correlate with the severity of myocarditis.[21]

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Imaging Studies

  • Chest radiograph and soft tissue neck radiography/CT or ultrasonography may show prevertebral soft tissue swelling, enlarged epiglottis, and narrowing of the subglottic region.
  • Echocardiography may demonstrate valvular vegetations; however, this systemic manifestation of diphtheria is rare.[22, 21]
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Other Tests

  • ECG may show ST-T wave changes, variable heart block, and dysrhythmia.
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Procedures

  • Endotracheal intubation
  • Surgical airway - Cricothyroidotomy or tracheostomy
  • Laryngoscopy, bronchoscopy as indicated in intubated patients
  • Electrical pacing for high-grade conduction disturbances
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Contributor Information and Disclosures
Author

Allysia M Guy, MD  Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, MMB, FACEP  Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center

Mark A Silverberg, MD, MMB, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Steven A Conrad, MD, PhD  Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center

Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Barry J Sheridan, DO  Chief Warrior in Transition Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Elzbieta Pilat, MD, Lorenzo Paladino, MD, and Malini K Singh, MD, to the development and writing of this article.

The authors and editors of eMedicine gratefully acknowledge the medical review of this article by Joseph U Becker, MD.

References

  1. Chen RT, Broome CV, Weinstein RA. Diphtheria in the United States, 1971-81. Am J Public Health. Dec 1985;75(12):1393-7. [Medline].

  2. Dass J FP, Deepika V. Implications from predictions of HLA-DRB1 binding peptides in the membrane proteins of Corynebacterium diphtheriae. Bioinformation. 2008;3(3):111-3. [Medline].

  3. Dale DC, ed. 16 Infections Due to Gram-Positive Bacilli. In: Infectious Diseases: The Clinician's Guide to Diagnosis, Treatment, and Prevention. WebMD Corporation; 2007.

  4. Mattos-Guaraldi AL, Sampaio JL, Santos CS, Pimenta FP, Pereira GA, Pacheco LG, et al. First detection of Corynebacterium ulcerans producing a diphtheria-like toxin in a case of human with pulmonary infection in the Rio de Janeiro metropolitan area, Brazil. Mem Inst Oswaldo Cruz. Jun 2008;103(4):396-400. [Medline]. [Full Text].

  5. Bonmarin I, Guiso N, Le Fleche-Mateos A, Patey O, Patrick AD, Levy-Bruhl D. Diphtheria: a zoonotic disease in France?. Vaccine. Jun 24 2009;27(31):4196-200. [Medline].

  6. Harnisch JP, Tronca E, Nolan CM, Turck M, Holmes KK. Diphtheria among alcoholic urban adults. A decade of experience in Seattle. Ann Intern Med. Jul 1 1989;111(1):71-82. [Medline].

  7. Centers for Disease Control and Prevention. FDA approval of expanded age indication for a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR Morb Mortal Wkly Rep. Apr 17 2009;58(14):374-5. [Medline].

  8. Webb TR, Cross SH, McKie L, Edgar R, Vizor L, Harrison J, et al. Diphthamide modification of eEF2 requires a J-domain protein and is essential for normal development. J Cell Sci. Oct 1 2008;121:3140-5. [Medline].

  9. CDC. Summary of notifiable diseases--United States, 2001. MMWR Morb Mortal Wkly Rep. May 2 2003;50(53):i-xxiv, 1-108. [Medline].

  10. Mattos-Guaraldi AL, Moreira LO, Damasco PV, Hirata Júnior R. Diphtheria remains a threat to health in the developing world--an overview. Mem Inst Oswaldo Cruz. Dec 2003;98(8):987-93. [Medline]. [Full Text].

  11. Vitek CR, Wharton M. Diphtheria in the former Soviet Union: reemergence of a pandemic disease. Emerg Infect Dis. Oct-Dec 1998;4(4):539-50. [Medline].

  12. de Benoist AC, White JM, Efstratiou A, et al. Imported cutaneous diphtheria, United Kingdom. Emerg Infect Dis. Mar 2004;10(3):511-3. [Medline].

  13. Dallman T, Neal S, Green J, Efstratiou A. Development of an online database for diphtheria molecular epidemiology under the remit of the DIPNET project. Euro Surveill. May 8 2008;13(19):[Medline].

  14. Patel UV, Patel BH, Bhavsar BS. A Retrospective Study of Diphtheria Cases Rajkot, Gujarat. Indian Journal of Community Medicine. 2004;XXIX, No 4.

  15. Mandell, Bennett, Dolin. Corynebacterium diphtheriae. Principles and Practice of Infectious Diseases. 2005;2457-2464.

  16. Murphy TV, Slade BA, Broder KR, Kretsinger K, Tiwari T, Joyce PM, et al. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. May 30 2008;57:1-51. [Medline]. [Full Text].

  17. Centers for Disease Control and Prevention. FDA approval of expanded age indication for a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR Morb Mortal Wkly Rep. Apr 17 2009;58(14):374-5. [Medline]. [Full Text].

  18. Havaldar PV, Sankpal MN, Doddannavar RP. Diphtheritic myocarditis: clinical and laboratory parameters of prognosis and fatal outcome. Ann Trop Paediatr. Sep 2000;20(3):209-15. [Medline].

  19. Holmes RK. Diphtheria, other corynebacterial infections and Anthrax. Principles of Internal Medicine. 2001;1:909-912.

  20. Dittmann S, Wharton M, Vitek C, et al. Successful control of epidemic diphtheria in the states of the Former Union of Soviet Socialist Republics: lessons learned. J Infect Dis. Feb 2000;181 Suppl 1:S10-22. [Medline].

  21. Lakkireddy DR, Kondur AK, Chediak EJ. Cardiac troponin I release in non-ischemic reversible myocardial injury from acute diphtheric myocarditis. Int J Cardiol. Feb 15 2005;98(2):351-4. [Medline].

  22. Lumio JT, Groundstroem KW, Melnick OB, Huhtala H, Rakhmanova AG. Electrocardiographic abnormalities in patients with diphtheria: a prospective study. Am J Med. Jan 15 2004;116(2):78-83. [Medline].

  23. Centers for Disease Control and Prevention. Licensure of a diphtheria and tetanus toxoids and acellular pertussis adsorbed and inactivated poliovirus vaccine and guidance for use as a booster dose. MMWR Morb Mortal Wkly Rep. Oct 3 2008;57(39):1078-9. [Medline]. [Full Text].

  24. Centers for Disease Control and Prevention. National, state, and urban area vaccination coverage among children aged 19-35 months--United States, 2004. MMWR Morb Mortal Wkly Rep. Jul 29 2005;54(29):717-21. [Medline].

  25. Centers for Disease Control and Prevention. Vaccination coverage among adolescents aged 13-17 years - United States, 2007. MMWR Morb Mortal Wkly Rep. Oct 10 2008;57(40):1100-3. [Medline]. [Full Text].

  26. Dajani NA, Scheifele D. How long can we expect pertussis protection to last after the adolescent booster dose of tetanus-diphtheria-pertussis (Tdap) vaccines?. Paediatr Child Health. Dec 2007;12(10):873-4. [Medline].

  27. Bronson-Lowe D, Anderson SM. Effects of a minimum interval immunization schedule for diphtheria and tetanus toxoids and acellular pertussis vaccination during a pertussis outbreak. Arch Pediatr Adolesc Med. May 2009;163(5):417-21. [Medline].

  28. Farizo KM, Strebel PM, Chen RT, Kimbler A, Cleary TJ, Cochi SL. Fatal respiratory disease due to Corynebacterium diphtheriae: case report and review of guidelines for management, investigation, and control. Clin Infect Dis. Jan 1993;16(1):59-68. [Medline].

  29. Gruner E, Opravil M, Altwegg M, von Graevenitz A. Nontoxigenic Corynebacterium diphtheriae isolated from intravenous drug users. Clin Infect Dis. Jan 1994;18(1):94-6. [Medline].

  30. Jayashree M, Shruthi N, Singhi S. Predictors of outcome in patients with diphtheria receiving intensive care. Indian Pediatr. Feb 2006;43(2):155-60. [Medline].

  31. Lurie P, Stafford H, Tran P. Fatal respiratory diphtheria in a U.S. traveler to Haiti--Pennsylvania, 2003. MMWR Morb Mortal Wkly Rep. Jan 9 2004;52(53):1285-6. [Medline].

  32. Maksimova NM, Markina SS, Iatskovskii KA, Cherkasova VV, Lazikova GF, Koshkina NA. [Immunization of adult population of Russia against diphtheria in 2006-2007]. Zh Mikrobiol Epidemiol Immunobiol. Nov-Dec 2008;27-31. [Medline].

  33. Prasad KC, Karthik S, Prasad SC. A comprehensive study on lesions of the pinna. Am J Otolaryngol. Jan-Feb 2005;26(1):1-6. [Medline].

  34. Tiley SM, Kociuba KR, Heron LG, Munro R. Infective endocarditis due to nontoxigenic Corynebacterium diphtheriae: report of seven cases and review. Clin Infect Dis. Feb 1993;16(2):271-5. [Medline].

  35. Toxigenic Corynebacterium diphtheriae--Northern Plains Indian Community, August-October 1996. MMWR Morb Mortal Wkly Rep. Jun 6 1997;46(22):506-10. [Medline].

  36. Zasada AA, Zaleska M, Podlasin RB, Seferynska I. The first case of septicemia due to nontoxigenic Corynebacterium diphtheriae in Poland: case report. Ann Clin Microbiol Antimicrob. May 5 2005;4:8. [Medline].

 
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The characteristic thick membrane of diphtheria infection in the posterior pharynx.
Cervical edema and cervical lymphadenopathy from diphtheria infection produce a bull's neck appearance in this child. Source: Public Domain www.immunize.org/images/ca.d/ipcd1861/img0002.htm.
Photomicrograph depicts a number of gram-positive Corynebacterium diphtheriae bacteria, which had been stained using the methylene blue technique. The specimen was taken from a Pai's slant culture.
 
 
 
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