Diphtheria is a nasopharyngeal and skin infection caused by Corynebacterium diphtheriae. Toxigenic strains of C. diphtheriae produce a protein toxin that causes systemic toxicity, myocarditis, and polyneuropathy.

Etiology
C. diphtheriae is a gram-positive, unencapsulated, nonmotile, nonsporulating bacillus.

Epidemiology
C. diphtheriae is transmitted via the aerosol route, primarily during close contact. There are no significant reservoirs other than humans. The incubation period for respiratory diphtheria is 2-5 days; however, disease can develop as long as 10 days after exposure.

Cutaneous diphtheria is usually a secondary infection that follows a primary skin lesion due to trauma, allergy, or autoimmunity. Most often, isolates from cases of cutaneous disease lack the toxic gene and therefore do not express diphtheria toxin.

Pathogenesis and Immunology
Diphtheria toxin, produced by toxigenic strains of C. diphtheriae, is the primary virulence factor in clinical disease.
The toxin is produced in the pseudomembranous lesion and is taken up into the bloodstream, through which it is distributed to all organ systems.

Characteristic pathologic findings of diphtheria include mucosal ulcers with a pseudomembranous coating composed of an inner band of fibrin and a luminal band of neutrophils.

Initially white and firmly adherent, in advanced diphtheria the pseudomembranes turn gray and even green or black as necrosis progresses.

Expanding and sloughing membranes may result in fatal airway obstruction.

Clinical Manifestations
Respiratory Diphtheria
The clinical diagnosis of diphtheria is based on the constellation of sore throat, adherent tonsillar, pharyngeal, or nasal pseudo membranous lesions, and low-grade fever.

Occasionally, weakness, dysphagia, headache, and voice change are the initial manifestations. Neck edema and difficulty breathing are seen in more advanced cases and carry a poor prognosis.

The pseudo membranous lesion is most often located in the tonsillo pharyngeal region. Less commonly, the lesions are detected in the larynx, nares, and trachea or bronchial passages. Large pseudo membranes are associated with severe disease and a poor prognosis.

A few patients develop massive swelling of the tonsils and present with “bull-neck” diphtheria, which results from massive edema of the sub mandibular and para tracheal region and is further characterized by foul breath, thick speech, and stridorous breathing.

Cutaneous Diphtheria
This is a variable dermatosis most often characterized by punched-out ulcerative lesions with necrotic sloughing or pseudo membrane formation ,non healing or enlarging skin ulcers, which may be associated with a preexisting wound or dermatoses such as eczema, psoriasis, and venous stasis disease. The lesions rarely exceed 5 cm.

Complications
Airway obstruction poses a significant early risk in patients presenting with advanced diphtheria. Pseudo membranes may slough and obstruct the airway or may advance to the larynx or into the tracheo bronchial tree. Children are particularly prone to obstruction because of their small airways.

Polyneuropathy and myocarditis are late toxic manifestations of diphtheria.

Other complications of diphtheria include
1. Pneumonia
2. Renal failure
3. Encephalitis
4. Cerebral infarction
5. Pulmonary embolism

Management
Patients in whom diphtheria is suspected should be hospitalized in respiratory isolation rooms, with close monitoring of cardiac and respiratory function. A cardiac workup is recommended to assess the possibility of myocarditis.

Prognosis
Fatal pseudo membranous diphtheria typically occurs in patients with non protective antibody titers and in unimmunized patients.

Prevention
Vaccination
Vaccination of all infants along with vaccines for tetanus and pertussis

Homoeopathic approach:
Arsenicum alb:
It is mainly a remedy indicated by its general symptoms, such as low fever, prostration, restlessness, thirst, foetid Breath.

It is most
useful in the later stage of the disease when indicated by these very symptoms.

The throat will be much swollen inside and out, the membrane will be dark, and there will be much foetor, and there will be present considerable oedema.

It may correspond to the prodromal stage also, with the tired-out feeling, thirst and feverish flush.

Phytolacca:

Pain in the back and limbs, a general aching all over with great prostration are general characteristics of this remedy

Highly-inflamed throat, which is much swollen, so sore and sensitive that deglutition is almost impossible, pain shooting to ears, thick-coated tongue, foetid breath, swollen glands, high, rapid and weak pulse and a grayish membrane.

Great burning in the throat is also an indication, and chilliness as the disease commences.

Nitric acid:

Excoriating discharges are characteristic of this remedy.

There is much distress and uneasiness at the stomach and vomiting of all food; with there is prostration and a membrane in the nose and throat.

A remedy in nasal diphtheria, with a white deposit in the nose and ulcerative conditions which are sensitive.

Muriatic acid:

The most characteristic symptom calling for this remedy is the extreme weakness; nose bleed of dark and putrid blood is also a prominent symptom.

There is a foetid breath and oedematous uvula, a yellowish-gray deposit on fauces, tonsils, uvula and posterior pharyngeal wall; excoriating thin discharge from nose; pulse intermittent and patient weak; tongue dry, lips dry and cracked.

It is a remedy decidedly applicable to low, poisoned states of the blood.

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