Corynebacterium

diphtheriae
A paradigm of the toxigenic
infectious diseases

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Edwin Klebs

In 1883, Klebs demonstrated that

Corynebacterium diphtheriae was the

agent of diphtheria
 Introduction

Alexandre Yersin Pierre Paul Émile Roux

By 1888, Roux and Yersin showed that animals injected with sterile filtrates

of C diphtheriae developed symptoms similar to that of human diphtheria;

this demonstrated that a potent exotoxin was the major virulence factor.
 General Characters

• It is also known as the Klebs-Löffler bacillus

• Gram-positive, highly pleomorphic organisms with no particular arrangement

• Special stains like Albert’s stain and Ponder's stain are used to demonstrate the

metachromatic granules formed in the polar regions

 General Characters

• It is also known as the Klebs-Löffler bacillus

• Gram-positive, highly pleomorphic organisms with no particular arrangement

• Special stains like Albert’s stain and Ponder's stain are used to demonstrate the

metachromatic granules formed in the polar regions

 General Characters
• Corynebacterium diphtheriae is a nonmotile, noncapsulated, club-shaped, gram-positive

bacillus

• Toxigenic strains are lysogenic for one of a family of corynebacteriophages that carry the

structural gene for diphtheria toxin, tox

• Corynebacterium diphtheriae is classified into biotypes (mitis, intermedius, and gravis)

according to colony morphology on tellurite containing media, as well as into lysotypes

based upon corynebacteriophage sensitivity

 Classification

• Long Rods
• Short Rods • Long-barred forms,
• curved shaped
• Uniform Staining clubbed end
• pleomorphic
• Few or no granules • Poor Granulation
• Prominent granules
• May be pleomorphic • Very pleomorphic
• greyish black, opaque
• gray colony, dark center • gray, opaque glossy,
colonies
shining smooth surface, poached
• Glycogen and starch
• Non-hemolytic egg colonies,
fermentation
• Hemorrhagic and epidemic • Obstructive and Endemic
• Paralytic and epidemic
 DIphtheria
• Diphtheria is most commonly an infection of the
upper respiratory tract and causes

• Fever

• sore throat

• malaise

• A thick, gray-green fibrin membrane, the

pseudomembrane, often forms over the site(s) of
infection as a result of the combined effects of

• bacterial growth

• toxin production

• necrosis of underlying tissue

• host immune response

 Diseases
There are two types of clinical diphtheria: nasopharyngeal and cutaneous.

• Symptoms of pharyngeal diphtheria vary • The skin lesions in cutaneous diphtheria are

from mild pharyngitis to hypoxia due to usually covered by a gray-brown

airway obstruction by the pseudomembrane pseudomembrane

• The involvement of cervical lymph nodes may • Life-threatening systemic complications,

cause swelling of the neck (bull neck principally loss of motor function (e.g.,

diphtheria), and the patient may have a fever difficulty in swallowing) and congestive heart

(≥ 103 °F) failure, may develop as a result of the action

of diphtheria toxin on peripheral motor

neurons and the myocardium.

 Pathogenesis

The pathogenesis of diphtheria is based upon two primary determinants:

1. the ability of a given strain of C diphtheriae to colonize in the nasopharyngeal cavity and/or

on the skin

2. its ability to produce diphtheria toxin

Pathogenesis
• The structural gene for diphtheria toxin, tox, is

carried by a family of closely related

corynebacteriophages

• The regulation of diphtheria tox expression is

mediated by an iron-activated repressor, DtxR,

which is encoded on the C diphtheriae genome

• When iron become the growth limiting

diphtheria toxin is synthesized and secreted at

maximal rates
 Pathogenesis
• Diphtheria toxin is extraordinarily potent: as little as 100 to 150 ng/kg of body weight is

lethal

• Diphtheria toxin is composed of a single polypeptide chain of 535 amino acids

• Intoxication of a single eukaryotic cell by diphtheria toxin can lead to complete irreversible

inhibition of protein synthesis (by binding to elongation factor – 2, EF-2)

 Diagnosis
• laboratory confirmation of toxigenic C diphtheriae in throat or lesion cultures

• Sterile cotton-tipped applicators are used to swab the pharyngeal tonsils or their beds.

• Swabs may be inserted through both nares to collect nasopharyngeal samples for culture. Since

diphtheritic lesions are often covered with a pseudomembrane, the surface of the lesion may

have to be carefully exposed before swabbing

• The most common in vitro assay for toxigenicity is the Elek immunodiffusion test

• This test is based on the double diffusion of diphtheria toxin and antitoxin in an agar medium.

• A sterile, antitoxin-saturated filter paper strip is embedded in the culture medium, and C

diphtheriae isolates are streak-inoculated at a 90° angle to the filter paper

• The production of diphtheria toxin can be detected within 18 to 48 hours by the formation of a

toxin-antitoxin precipitin band in the agar

 Elek immunodiffusion test

• Sterile filter paper impregnated with diphtheria antitoxin is imbedded in agar culture

medium. Isolates of C diphtheriae are then streaked across the plate at an angle of 90° to

the antitoxin strip. Toxigenic C diphtheriae is detected because secreted toxin diffuses from

the area of growth and reacts with antitoxin to form lines of precipitin.
 Signs and symptoms
• The symptoms of diphtheria usually begin two to seven days after infection

• fever of 38 °C (100.4 °F) or above, chills, fatigue, bluish skin coloration (cyanosis), sore
throat, hoarseness, cough, headache, difficulty swallowing, painful swallowing, difficulty
breathing, rapid breathing, foul-smelling and bloodstained nasal discharge, and
lymphadenopathy

• Within two to three days, diphtheria may destroy healthy tissues in the respiratory system

• Dead tissue forms a thick, gray coating that can build up in the throat or nose. This thick
gray coating is called a “pseudomembrane.”

• It can cover tissues in the nose, tonsils, voice box, and throat, making it very hard to
breathe and swallow.

• Symptoms can also include cardiac arrhythmias, myocarditis, and cranial and peripheral
nerve palsies
 Signs and symptoms

Diphtheria can cause a An adherent, dense, A diphtheria skin lesion

swollen neck, sometimes grey on the leg
referred to as a bull neck pseudomembrane
covering the tonsils is
classically seen in
diphtheria.
 Control
• The control of diphtheria depends upon adequate immunization with diphtheria toxoid:

ormaldehyde-inactivated diphtheria toxin that remains antigenically intact

• Immunization against diphtheria should begin in the second month of life with a series of

three primary doses spaced 4 to 8 weeks apart, followed by a fourth dose approximately 1

year after the last primary inoculation

• Diphtheria toxoid is widely used as a component in the DPT (diphtheria, pertussis, tetanus)

vaccine.

• Diphtheria vaccine is usually combined at least with tetanus vaccine (Td) and often with

pertussis (DTP, DTaP, TdaP) vaccines, as well.

• The adult population should be reimmunized with diphtheria toxoid every 10 years
 Control
• Although antibiotics (e.g., penicillin and erythromycin) are used as part of the treatment of

patients who present with diphtheria, prompt passive immunization with diphtherial

antitoxin is most effective in reducing the fatality rate

• The long half-life of specific antitoxin in the circulation is an important factor in ensuring

effective neutralization of diphtheria toxin; however, to be effective, the antitoxin must

react with the toxin before it becomes internalized into the cell.

• Metronidazole, Erythromycin, Procaine penicillin G, rifampin or clindamycin

• diphtheria toxin spreads through the blood and can lead to potentially life-threatening

complications that affect other organs, such as the heart and kidneys. Damage to the heart

caused by the toxin affects the heart's ability to pump blood or the kidneys' ability to

clear wastes. It can also cause nerve damage, eventually leading to paralysis.
Immunization coverage
How did they make diphtheria antitoxin?