Diphtheria

Diphtheria
Taxonomy

Genus:
Corynebacterium
Species:
C.diphtheriae

Diphtheria
Morphology

Gram positive rod

clubbing at both ends
metachromatic granules
(volutin).
nonsporing,
noncapsulated and
nonmotile
appear in pairs, palisades,
or small group (Chinese
letters).

Diphtheria
 Cultural characteristics
Facultative anaerobe;
Requires nutrional rich media, such as
Loeffler’s serum and tellurite blood agar;
Most strains grow well on lipid-free media;
Types of colonies: mitis, garvis and
intermedius;

Corynebacterium
diphtheriae colonies on
blood agar
Diphtheria
 Cultural characteristics

Corynebacterium diphtheriae Corynebacterium diphtheriae

hem+ hem-

Diphtheria
 Cultural characteristics

C.Diphtheriae gravis C.Diphtheriae mitis

Diphtheria
Morphological and cultural properties of
Corynebacterium diphtheriae

Gravis Intermedius Mitis

Long, curved,
Forms with clubbed
Short rods, few or no pleomorphic
Morphology ends, poor granulation,
valutine granules rods with
very pleomorphic
prominent

In 18 hours, colony is 1-2

Colony on
mm in size, with greyish 18 hour colony small,
tellurite blood Shiny black
black centre, paler, 1mm in size, misty
agar
semitranslucent periphery

Moves as a whole on the Intermediate Soft, buttery,

Consistency of
plate, not easily picked out easily
colonies
or emulsifiable Between gravis ant mitis emulsifiable

Usually
Hemolysis Variable Nonhemolytic
hemolytic

Diphtheria
Corynebacterium diphtheriae: tests to identify and distinguish
gravis, intermedius and mitis biotypes

Sucrose Mannitol Starch Glucogen Nitrate D Cp Both

Organism Urease produc
hydrolysis toxin toxins
tion
C.diphtheriae
+ + + + + +
var.gravis
C.diphtheriae
var. - + - - + +
intermedius
C.Diphtheriae
+ + - - + +
var.mitis

C.ulcerans - + + - + + +

Diphtheria
 Epidemiology

Worldwide distribution maintained in asymptomatic

carriers and unvaccinated hosts;
Humans are the only known reservoir. With carriage
in oropharynx or on skin surface;
Spread person to person by exposure to respiratory
droplets or skin contact;
Disease observed in unvaccinated people, children
or adults with waning immunity;

Diphtheria
Respiratory diphtheria

Diphtheria
Cutaneous diphtheria

Diphtheria
 Virulence factors

Adhesive factors- pili, microcapsule?

Invasive factors- hyaluronidase, neuraminidase;

A-B exotoxin that inhibits protein synthesis by

inactivating elongation factor (EF-2);

Diphtheria
The Beta phage that encodes the tox gene for the
diphtheria toxin

Strains of
Corynebacterium
diphtheria which
elaborate exotoxin
(tox+) are lysogenic
(infected with a
specific
bacteriophage-β).

Diphtheria
 Toxin

 Exotoxin is a heat-labile polypeptide;

 Consist of 2 fragments: A and B;
 When released by the bacterium the toxin is inactive
because the active site on fragment A is masked;
 Activation is probably is accomplished by proteases group in
culture medium and infected tissues;
 All the enzymatic activity of the toxin present in fragment A;
 Fragment B is responsible for binding the toxin to the cells.
The receptor for the toxin is the heparin-binding epidermal
growth factor (present on the surface of many eukaryotic
cells);

Diphtheria
 Toxin

 The diphthery toxin is a cytotoxin;

 It’s mechanism of action is inhibition of protein synthesis;
 Inhibition of protein synthesis is responsible for both the
necrotic and neurotoxic effect of the toxin;
 The antibody to fragment B is protective by preventing the
binding of the toxin to the cell;
 Prolonged storage, incubation at 37 C for 4 to 6 weeks ,
treatment with 0.2 to 0.4 % formalin or acid pH converts it to
toxoid;
 Toxoid is toxin that has lost its toxicity but not its antigenicity
which is capable of inducing antitoxin and reacting
specifically with it;

Diphtheria
Toxin

The Diphtheria Toxin (DTx)

Monomer.

A (red) is the catalytic domain;

B (yellow) is the binding domain
which displays the receptor for
cell attachment;
T (blue) is the hydrophobic
domain responsible for insertion
into the endosome membrane to
secure the release of A.
The protein is illustrated in its
"closed" configuration.

Diphtheria
The Mechanism of action of Diphtheria toxin DTxA

Diphtheria
 Mechanism

EF-2+ NAD+→ADP-RIBOSE-EF-2+
NICOTINAMIDE + H+

Diphtheria toxin catalyzes the

ADP-ribosylation, and
inactivates, the elongation factor
eEF-2. In this way, it acts to
inhibit translation during
eukaryotic protein synthesis

Diphtheria
Pathogenesis of Diphtheria

Diphtheria is an upper respiratory

tract illness characterized by
sore throat, low fever, and an
adherent membrane (called a
pseudomembrane) on the
tonsils, pharynx, and/or nasal
cavity.
Diphtheria toxin produced by C.
diphtheriae, can cause
myocarditis, polyneuritis, and
other systemic toxic effects. A
milder form of diphtheria can be
restricted to the skin.

Diphtheria
The clinical appearance of Diphtheria

Diphtheria: the off white, smooth pseudomembrane affects

the tonsils and pharynx.

Diphtheria
Diphtheria: bull-neck appearance and tracheostomy

Diphtheria
 Treatment

 Obstruction of throat with pseudomembranes may require

intubation or tracheotomy.
 Early use of diphtheria antitoxin is necessary for
neutralization of exotoxin.
 Antitoxin is derived from horses, so test for
hypersensitivity is needed.
 Use of penicillin or erythromycin to eliminate C.diphtheriae
and terminate toxin production.

Diphtheria
 Prevention and Control

 Administration of diphtheria vaccine (toxoid) during

childhood and booster doses every 10 years through life.

 Toxoid is given together with tetanus toxoid and

pertussis vaccine (DTP).

 Toxoid is prepared by formalin treatment of the

diphtheria toxin.

Diphtheria
 Laboratory diagnosis

Microscopy is nonspecific. Special stains Neisser’s or

Loeffler’s have been devised for demonstrating the volutin
granules.

 Culture is perfomed on selective media (Tinsdale’s agar,

which contain potassium tellurite).

 Toxigenicity testing. Demonstration of exotoxin is

performed by molecular or immunologic methods
(immunodiffusion assay).

Diphtheria
 Corynebacterium Species Associated with human
Disease
Organism Disease
Diphtheria (Respiratory, cutaneous); Pharyngitis and
C.diphtheriae
endocarditis (nontoxigenic strains)

Septicemia, endocarditis, wound infections, foreign body

C.jeikeium (group JK)
(catheter, shunt, prosthesis) infections
Urinary tract infections including pyelonephritis and
C.urealyticum (group
alkaline-encrusted cystitis, septicemia, endocarditis,
D2)
wound infections.

Wound infections, foreign body infections, septicemia,

C.amycolatum
urinary tract infections, respiratory tract infections

C.macginleyi Eye infections

Lymphadenitis, ulcerative lymphangitis, abscess
C.pseudotuberculosis
formation
C.ulcerans Respiratory diphtheria
Diphtheria
Summary of Other Corynebacterium species

Physiology and structure

 Gram-positive bacilli with an irregular shape;

 Some species reguire lipids for good growth

(e.g.,C.jeikeium, C.urealyticum, C.macginleyi);
 Most strains are facultative anaerobes;

Diphtheria
 Virulence

 A-B exotoxin may be carried by C.ulcerans and

C.pseudotuberculosis;
 Urinary tract pathogens produce urease
(e.g.,C.amycolatum, C.glucuronolyticum, C.riegelli,
C.urealyticum);
 Many species able to adhere to foreign bodies
(e.g.,catheters, shunts, prosthetic devices);
 Some species resistant to most antibiotics (e.g.,
C.amycolatum, C.jeikeium, C.urealyticum);

Diphtheria
 Epidemiology

Most infections are endogenous (produced by

species that are part of the host’s normal
bacterial population on the skin surface and
mucosal membranes).

Diphtheria
 Epidemiology of Corynebacterium

Organism Habitat (reservoir) Mode of Transmission

Inhabits human
Person to person by exposure to
nasopharynx but only in
contaminated respiratory droplets
carrier state, not
Corynebacterium or direct contact with infected
considered part of
diphtheriae cutaneous lesions, may also be
normal flora isolation
transferred by exposure to
from healthy humans is
contaminated objects.
not common

Uncertain, may be person to person

Skin flora of hospitalized or selection of endogenous
Corynebacterium patients, most commonly resistant strains during
jeikeium in the inguinal, axillary, antimicrobial therapy, introduced
and rectal sites during placement or improper care
of intravenous catheters

Diphtheria
 Epidemiology of Corynebacterium

Organism Habitat (reservoir) Mode of Transmission

Uncertain, asotiated with close

Corynebacterium Normal flora of humans
ulcerans
animal contact, especially during
and cattle.
summer
Assotiated with
Uncertain, assotiated with close
Corynebacterium infections in animals
pseudotuberculosis such as sheep, goats,
animal contact, but infections in
humans are rare
and horses

Uncertain, probably by access of

Corynebacterium Normal human skin
urealyticum
patient’s endogenous strain to
flora
normally sterile site

Normal flora of human Uncertain, probably by access of

Corynebacterium
xerosis
conjunctiva, skin, and patient’s endogenous strain to
nasopharynx normally sterile site

Diphtheria
iseases

epticemia, endocarditis, foreign body infections, wound

infections, urinary tract infections, respiratory infections
including diphtheria.

iagnosis

ulture on selective and nonselective media. Growth

may be slow and media may require supplementation
with lipids.

reatment, Prevention, and Control

Diphtheria
Thank you for your attention!
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