Diphtheria: The “Forgotten Disease”

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Diphtheria is a serious and potentially life-threatening bacterial infection that was once widespread. In the early 20th century, thousands of people in Germany became infected every year, and mortality—especially among children—was high.

Today, widespread vaccination has drastically reduced cases, but the disease has not been eradicated and remains a risk, particularly in regions with low vaccination coverage. Therefore, immunization is still essential.

1. What Is Diphtheria?

Diphtheria is a contagious infectious disease caused primarily by the bacterium:

  • Corynebacterium diphtheriae

The main danger is not the bacteria itself, but a toxin (diphtheria toxin) produced by the bacteria. This toxin:

  • Destroys local tissue (especially in the throat)

  • Can spread through the bloodstream

  • Damages vital organs such as the heart and nervous system

2. Forms of Diphtheria

There are two main clinical forms:

Respiratory (Pharyngeal) Diphtheria

  • Affects the throat, nose, or larynx

  • Most dangerous form

  • Mortality rate: 5–10%

Cutaneous (Skin) Diphtheria

  • Occurs through minor wounds or insect bites

  • Associated with poor hygiene conditions

  • Less dangerous but still contagious

3. Transmission and Reservoir

Main Reservoir

  • Humans are the only reservoir for Corynebacterium diphtheriae

Modes of Transmission

Respiratory Transmission

  • Via droplets (coughing, sneezing, speaking)

  • Most common route

Contact Transmission

  • Through direct contact with infected wounds

  • Or contaminated objects (especially in poor hygiene conditions)

Zoonotic Transmission (Animal-related)

Other species can cause diphtheria-like illness:

  • Corynebacterium ulcerans

  • Corynebacterium pseudotuberculosis

These are transmitted from:

  • Dogs, cats, cattle, pigs, and wildlife

  • Through close contact or unpasteurized milk

4. Laryngeal Diphtheria and Airway Obstruction

Laryngeal diphtheria (also called “true croup”) is one of the most dangerous forms.

Why It Is So Dangerous

The bacteria produce toxin that leads to the formation of a:

  • Thick gray-white pseudomembrane

This membrane can:

  • Cover the tonsils, throat, and larynx

  • Block the airway

  • Cause severe breathing difficulties (dyspnea)

Historically, this form was known as the “strangling angel of children” because it often led to fatal suffocation.

5. Symptoms of Diphtheria

Early Symptoms

  • Fever (up to 39°C)

  • Sore throat

  • Difficulty swallowing

  • General flu-like symptoms

Respiratory and Laryngeal Symptoms

Airway and Breathing

  • Severe shortness of breath

  • Narrowed airways

  • Stridor (whistling breathing sound)

Voice and Larynx (Laryngitis)

  • Hoarseness (can progress to loss of voice)

  • Barking (croup-like) cough

  • Damage to the vocal cords

Local Findings

  • Gray-white coatings (pseudomembranes)

  • Later turning brown due to bleeding

  • Swollen lymph nodes

6. Complications (Toxic Diphtheria)

If the toxin enters the bloodstream, systemic (toxic) diphtheria can develop.

Possible Complications

  • Airway obstruction → suffocation

  • Pneumonia → respiratory failure

  • Myocarditis (heart muscle inflammation)

  • Nerve damage (polyneuropathy)

  • Paralysis

  • Coma

7. Diagnosis

Diagnosis is based on:

Clinical Examination

  • Typical throat findings (membranes, swelling)

Laboratory Confirmation

  • Throat or wound swab

  • Bacterial culture

  • PCR (detects bacterial DNA)

Important: Treatment begins immediately if diphtheria is suspected—before lab confirmation.

8. Treatment

Diphtheria is a medical emergency requiring hospital care.

1. Antitoxin (Antidote)

  • Neutralizes toxin not yet bound to cells

  • Must be given as early as possible

2. Antibiotics

  • Usually penicillin

  • Reduce bacterial load and transmission

3. Supportive Care

  • Airway monitoring

  • Isolation (infection control)

9. Prevention: Vaccination

Vaccination is the only reliable protection against diphtheria toxin.

Why Vaccination Is Essential

  • The disease can be transmitted by asymptomatic carriers

  • Prevents severe and fatal cases

  • Recommended especially for:

    • Children

    • Travelers to endemic regions

10. Epidemiology

  • Diphtheria is still endemic in parts of:

    • Asia

    • Africa

    • Eastern Europe

    • Latin America

  • In Germany:

    • 469 cases reported since 2001

    • 435 cases in the last decade (2014–2023)

  • The disease is notifiable by law (must be reported to health authorities)

Key Takeaways

  • Diphtheria is a toxin-mediated bacterial disease

  • The laryngeal form can cause life-threatening airway obstruction

  • Early treatment with antitoxin is critical

  • Vaccination remains the most important preventive measure

 

References Diphtherie in German: 

https://www-mayoclinic-org.translate.goog/diseases-conditions/diphtheria/symptoms-causes/syc-20351897?_x_tr_sl=en&_x_tr_tl=de&_x_tr_hl=de&_x_tr_pto=sge&_x_tr_hist=true

https://www.helios-gesundheit.de/magazin/news/03/diphtherie/#:~:text=Erreger%20und%20%C3%9Cbertragungswege%20Die%20Infektionskrankheit%20tritt%20in,Mensch%2Dzu%2DMensch%20%C3%9Cbertragung%20in%20Form%20einer%20Tr%C3%B6pfchen%2D%20oder

https://www.lgl.bayern.de/gesundheit/infektionsschutz/infektionskrankheiten_a_z/diphtherie/index.htm

https://gesund.bund.de/diphtherie#behandlung

References in English: 

Diphtheria: https://www-mayoclinic-org.translate.goog/diseases-conditions/diphtheria/symptoms-causes/syc-20351897?_x_tr_sl=en&_x_tr_tl=de&_x_tr_hl=de&_x_tr_pto=sge&_x_tr_hist=true

Diphtheria: https://my.clevelandclinic.org/health/diseases/17870-diphtheria 

WHO: https://www.who.int/news-room/fact-sheets/detail/diphtheria 

© 2000-2030 Sieglinde W. Alexander. All writings by Sieglinde W. Alexander have a fife year copy right. Library of Congress Card Number: LCN 00-192742 ISBN: 0-9703195-0-9 

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