Al-Ameed University; College of Medicine

Corynebacterium
diphtheriae

Prof. Dr. Kareem Thamir Al-Kaabi

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 Objectives
1-To study the structure and classification of
this microorganism
2-To clarify the habitat and the mode of
transmission
3-To know the pathogenicity and virulence
factors
4-To mention the clinical features of different
infections caused by it
5-The different laboratory method for
diagnosis are mentioned
6-Prevention of infection by different methods
 Diphtheria

Greek diphtheria (leather hide) •

Caused by Aerobic Gram +ve rods •
Corynebacterium diphtheriae •
Exotoxin production only if infected by •
virus phage infected carrying toxin gene

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 Corynebacterium
Gram + Non Acid fast, Non motile, •
Irregularly stained with granules, •
swelling at one or both ends Club shaped •
so the name
Important Pathogen •
Corynebacterium diphtheria,
Diptheros meaning leather,

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 What is Diphtheria
An infection of •
local tissue of
URT with
production of
toxin which
causes systemic
effects on Heart
and Peripheral
tissues, 4
 Definition
It’s a localized infectious disease, •
which usually attacks the throat
and nose mucous membrane

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 Etiology
C. diphtheriae is an aerobic gram- •
positive bacillus.
– Pleomorphic, club-end
–Non-spore-forming
–Non-acid-fast
–Non-motile

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 Etiology
The major virulence determinant is •
an exotoxin, diphtheria toxin. After
binding to the host cells, the active
subunit will interrupt the protein
synthesis of the target host cell
and results in cell death.
Toxoid made from diphtheria toxin •
can be used as vaccine.
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 Etiology
are three biotypes — There •
gravis, Intermedius, and
mitis. The most severe
clinical type of this disease
is associated with the gravis
biotype, but any strain may
produce toxin.
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 Pathogenesis
Entry ------ the bacilli multiply locally in the •
throat and elaborate a powerful exotoxin -----
produce local and systemic symptoms.
Local lesions :
Exotoxin causes necrosis of the epithelial cells •
and liberates serous and fibrinous material
which forms a grayish white pseudo
membrane
The membrane bleeds on being dislodged •
Surrounding tissue is inflamed and edematous •
10 Dr.T.V.Rao MD
Typical Presentation of Bull Neck

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 Local manifestation
Depend on the site of Faucial
lesion: diphtheria :
Nasal diphtheria : Redness and •
• Unilateral or bilateral
serosanguineous ( blood and swelling over
serous fluid ) discharge from Fauces
the nose
• Excoriation of upper lip
Exudates on the •
• Toxemia is minimal tonsils coalesces to
form grayish white
pseudo membrane
Regional lymph •
nodes are inflamed
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Dr T.V.Rao MD
 Corynebacterium diphtheria
Slender rods •
Clubbing at both ends •
Pleomorphic •
Non capsulate / Acid fast Gram + •
Granules are composed of •
polymetapohosphate
Staining with Loffler's methylene blue •
show bluish purple metachromatic
granules. with polar bodies,
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 Staining methods
Grams method •
Albert's stain •
Neissers stain •
Ponders stain •
On staining seen as •
Pairs, Appear as v and L letters, resembling
Chinese letter pattern or also called
cuneiform arrangement.
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 Cultural characters
Need enrichment Media •
Contain •
• 37 c ph 7.4Blood, Serum or Egg
Aerobic/Facultative anaerobic. •
Commonly used medium •
• Loeffler serum slope,
• Tellurite Blood agar,

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Gram +ve Bacilli and Colonies

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 Culturing
Selective & differential medium •
Corynebacterium are resistant to •
tellurite
Reduced to tellurium –
Forms deposit in colonies •
Colonies appear dark –
Biotypes •
gravis, Intermedius, mitis –

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 Growing on Culture Plates
Loffler serum slope •
Grows rapidly in
6 -8 hours,
Small white
disksopaque
Turns to yellow
Tellurite blood agar
Mac Modified
Leod
Hoyles medium.
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 Commonly used medium

Tellurite blood agar •

Contains tellurite
0.04 tellurite
Inhibits other
bacteria
Produce •
Grey/Black
colonies.

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 Classification of McLeod
Classified in to 3 Types
1 Gravis
2 Intermedius
3.Mitis
Hemorrhagic Gravis produce Most serious
Paralytic complications - Epidemic
HemorrhagicIntermedius
- obstructive complications, Endemic Mitis
Geographic locations differ
Testing for toxigenicity is more important,

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 Toxin
Pathogenicity associated with Toxin •
95-99% are Gravis/Intermedius •
toxigenic
80 – 85%Mitis •
Some abundant others poorly •
Toxin production park William 8 •
Toxin •
M W 62,000
0.0001 can kill guinea pig
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 Toxin ( Contd )
Toxin contain two components •
24,000A
38,000B
A produce toxigenicity by proteolytic effect
B Produce binding
ToxoidToxin + Formalin =
not toxigenic Toxoid – Antigenic,What is
Toxin productionTox + Corynephage
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 Toxin ( contd )
• Need iron 0.1 mg/liter.
• Toxin inhibits protein synthesis
• Fragment A catalyzes the transfer of ADP ribose from
the Nicotinamide adenine dinucleotide ( NAD ) to the
eukaryotic elongation factor 2 /(Fragment A inhibits
polypeptide chain elongation in the presence of
Nicotinamide adenine dinucleotide by inactivating
elongation factor
Causes involvement with affinity. •
Myocarditis,
Adrenals
Nerve endings,
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 Resistance
Can be killed at •
in 10 mt 580 c
1 mt1000 c in
Survive in Blankets,
Floor dust, toys
inanimate objects

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 Pathogenicity
Bacteria Invade, Colonise,Proliferate •
Bacteria are lysogenized by Beta •
phage
Produce toxin, •
Kills epithelial and Neutrophils, •
Produce Pharyngitis and cutaneous •
lesions.
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 Pathogenicity
Incubation 3 – 4 days / one day •
Faucal / Nasal /Laryngeal / Otic / •
Conjunctiva,/Genital / Vulvae
Coetaneous
Diphtheria is a toxemic condition.
Sever toxemia ,Adenitis Bull Malignant
neck Circulatory failure
Septic Gangrene , pseudo membrane.
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 Pathogenicity
Hemorrhagic •
Epistaxis ,
Purpura
General Bleeding tendency
Asphyxia , Acute circulatory failure,
Paralysis Pneumonia, Septic shock, Otitis
media. Toxemia, Necrotic changes
Death in Guinea pigs
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 Diphtheria
Nasopharyngeal •
diphtheria
Pharyngeal –
Laryngeal –
Cutaneous •
diphtheria
Systemic •
complications
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 Clinical features
Malaise, Sore throat, Fever •
Adherent grey pseudo membrane •
Nasal ulcers, •
Obstruction of larynx and lower airways, •
Difficulty in swallowing •
Lead to Myocarditis, Peripheral neuritis, •
Paralysis of limbs, •

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Diphtheria Clinical Features
Incubation period 2-5 days
(range, 1-10 days)
May involve any mucous membrane
Classified based on site of infection
anterior nasal
pharyngeal and tonsillar
laryngeal
cutaneous
ocular
genital
Dr.T.V.Rao MD 33
Diphtheria Clinical Features
Incubation period 2-5 days
(range, 1-10 days)
May involve any mucous membrane
Classified based on site of infection
anterior nasal
pharyngeal and tonsillar
laryngeal
cutaneous
ocular
genital
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Thick Membrane

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Dr.T.V.Rao MD 36
Pseudo membrane

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Skin Lesions

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 Pathogenicity
Faucial Diphtheria very common,1
Malignant or Hyper toxic toxemia •
Marked adenitis, circulatory failure,
Paralytic sequale •
2 Septic ulceration cellulitis, gangrene
Epistaxis Bleeding tendency,

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 Complications
- causing Asphyxia •
mechanical obstruction.
May need tracheotomy •
Circulatory failure. •
Post Diphtheria paralysis •
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Non toxigenic
clinical
manifestations
can produceBacteria •
Endocarditis, .1
2.Meingitis,
Cerebral abscess. 3
Osteoarthritis. 4
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 Laboratory Diagnosis
Specific treatment •
is more important
than Laboratory
Diagnosis.
1 Isolation of
Diphtheria bacilli.
2.Testing for
toxigenicity,
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 Collection of Specimens
Throat swabs •
Smear examinations •
Gram s staining,
Albert's, Ponders
Immunoflorescent methods
Cultures on Loeffers serum slope
Tellurite Blood agar,
Blood agar.
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 Isolation of C.diptheria
Serum slope – Growth in 6 – 8 hours, •
Stain with Neissers stain Albert's •
stain
Bacilli have metachromatic granules, •
Tellurite Blood agar takes two days •
for manifestation of colonies,

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 Virulence tests,
In Vivo and In Vitro •
In Vivo in Animals •
Subcutaneous tests •
Inject broth from culture into two Guinea pigs,
0.8 ml
One animal given 500 units of antitoxin
Other no Vaccine.
Animal not given antitoxin will die
Loss of Animals. Restricts its testing.

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 Intracutaneous Method
500 units One animal given •
before toxin
ToxinOther 50 units after •
So the Animals can be saved •

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 In Vitro Testing
Elek s Gel precipitation testing •
Filter paper impregnated with Diphtheria •
antitoxin 1000 Units / ml
the horse serum agarTested on •
Positive / Negative /Test strains tested for •
Immunodiffusion
Line of precipitation – test positive •
Other methods testing in Tissue cultures. •
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 Toxigenicity Tests
In Vitro Elek test
In Vivo Animal
inoculation
rabbit skin test-
necrosis
guinea pig
challenge test-
lethal
low [Fe 2+] induces toxin
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 Epidemiology
Eradicated in developed nations, •
Children between 2 – 5 years. •
A symptomatic carriers •
Person to person contact. •
Carriers spread. •
Prolonged contact. •

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 Prophylaxis
Immunization •
PassiveActive – •
Active.passive andBoth •
Immunity.Herd •
Schick test •
AntitoxinwithImmunization •
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 Active Immunization.
Toxoid – Toxin treated with Formaldehyde •
Absorbed Toxoid •
Given by Intramuscular route •
Given in DTP –Triple Vaccine •
Primary Immunization •
Three Doses of DPT at least 4 weeks apart. •
Non vaccinated •
four weeks apartThree doses of Toxoid •
One dose after One Year. •
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 Prevention
Vaccination: Immunisation with diphtheria toxoid,
combined with tetanus and pertussis toxoid (DTP
vaccine), should be given to all children at two,
three and four months of age. Booster doses are
given between the ages of 3 and 5 .

The child is given a further booster vaccine

and is then considered to before leaving school
be protected for a further 10 years (16 – 18
years).

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 Passive Immunization
Given in Acute infections •
Give Subcutaneously •
500 – 1000 Units of Antitoxin •
Given as Horse Serum •
Combined in Acute Infections ( Both •
Active Immunization with Toxoid and
Antitoxin.
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 Treatment
Antibiotic not useful in Acute infections, •
Antitoxin a must. •
Anti toxin obtained from horse serum •
20,000 to 40,000Mild •
Moderate 40,000 to 60,000 •
80,000 to 1,00,000Severe •
Commonly used antibiotics, •
Penicillin parentally, •
Oral Erythromycin •
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 Diphtheria Epidemiology
Reservoir Human carriers
Usually asymptomatic

Transmission Respiratory
Skin and fomites rarely

Temporal pattern Winter and spring

Communicability Up to several weeks

without antibiotics

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 Treating Contacts
All contacts •
are advised to
receive
500 mg
Erythromycin
4 times a day.
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 Diptheroids
Resembles C.diptheria •
throat, skin,Commensals in •
C.hofmani •
C.xerosi •
Propioniebacterium •
P.acnes P.granulosum •
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