Girl with thick, grey coating of dead tissue building up in the throat

Diphtheria is an acute toxin-mediated disease caused by the bacteria Corynebacterium diphtheriae. Photo kwanchaichaiudom via Canva.com

 Dr. Mattias Larsson*

Linh, a usually active seven-year-old girl, is successful in her schoolwork and participates in sports. One morning she woke up and felt fatigue, had a sore throat and pain when eating. She felt warm and the mother measured her temperature that was 39 degrees Celsius. She was given paracetamol which decreased the pain to some extent. However, the pain got worse again so the next day they went to the local doctor who diagnosed a throat infection and prescribed antibiotics and steroids for one week. The symptoms improved during the treatment but after, it relapsed and got worse. Linh found it hard to breathe and swallow.

The mother had heard that Family Medical Practice (FMP) had good ability for diagnostics. At FMP Linh described her symptoms, the paediatrician could see that the tonsils were enlarged and that it was a white coating, the initial tests strep A was negative, also influenza and COVID, mononucleosis Epstein Barr virus test was also negative.  The paediatrician noticed swollen glands in the neck and that Linh had a hoarse voice and throwed the head back to relieve pressure on the throat. Re-checking the throat the doctor recognised the white coating as pseudomembrane‎, very rare and an indication of diphtheria. This is due to a toxin that kills healthy tissues in the respiratory system causing a thick, grey coating of dead tissue building up in the throat and nose.

The paediatrician asked about the vaccination status as diphtheria is part of the global and national vaccination program. The diphtheria, tetanus, pertussis (DTP) vaccine, part of the “5 and 6 in one” vaccine should be given at two, four and six months and one year as well as booster after four years and adolescence. The mother then replied that she was not sure as Linh was adopted after her mother, a distant relative in the countryside, was unable to take care of her due to a tragic accident. 

Diphtheria: From sore throat to potential suffocation and fatal complications. Photo courtesy of Dr Mattias Larsson

Some tests were performed, the blood samples for serum antibodies were positive. A pharyngeal swab from the membrane as well as from the nose and throat was obtained for culture and a toxigenicity testing using the Elek was also performed. Diphtheria antitoxin was obtained and administered with infusion. Antibiotic therapy for two weeks was prescribed. Also, the whole family and other close contacts were tested to exclude transmission or colonisation.

The paediatrician explained that Diphtheria is an acute toxin-mediated disease caused by the bacteria Corynebacterium diphtheriae. After an average incubation period of two to four days, local signs and symptoms of inflammation develop. In most patients the tonsils or pharynx are affected, sometimes also the nose and larynx. Fever is rarely higher than 39 degrees Celsius. Symptoms begin with a sore throat, membrane formation begins after the two to five days that can cause airway obstruction and eventual suffocation. If the toxin gets into the bloodstream, it can kill tissue and harm other organs.  Severe diphtheria may cause circulatory collapse, airway blockage, respiratory failure, kidney failure, myocarditis (damage to the heart muscle), polyneuropathy (nerve damage) coma and death.  Even with treatment, about 1 in 10 people with respiratory diphtheria dies. Without treatment, up to half of people die from the disease.

Linh recovered with the treatment and her mother was relieved that FMP managed to diagnose this rare disease before it became too severe. Family Medical Practice 

Dr Mattias Larsson. Photo courtesy of FMP

*Dr Mattias Larsson is a paediatric doctor at Family Medical Practice and associate professor at Karolinska Institutet and has a long experience in research on infectious diseases. He has worked with the Oxford University Clinical Research Unit and the Ministry of Health of Vietnam. He is fluent in English, Swedish, Vietnamese, German and some Spanish.

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