DIPHTHERIA

A Case Report
Presented to the College of Nursing

In Partial Fulfillment
of the Requirement in
NCM 98: INTENSIVE PRACTICUM

DOROTHY PEARL L. PALABRICA, SN IV

APRIL 2017
 I. INTRODUCTION
Diphtheria manifests as either an upper respiratory tract or cutaneous
infection and is caused by the aerobic gram-positive bacteria, Corynebacterium
diphtheria. The infection usually occurs in the spring or winter months. It is
communicable for 26 weeks without antibiotic treatment. People who are most
susceptible to infection are those who are not completely immunized or have low
antitoxin antibody levels and have been exposed to a carrier or diseased individual.
A carrier is someone whose cultures are positive for the diphtheria species but does
not exhibit signs and symptoms.
C diphtheria is a non-encapsulated, non-motile, gram-positive bacillus
Pathogenic strains can result in severe localized upper respiratory infection,
localized cutaneous infections, and rarely systemic infection.
According to the World Health Organization (WHO), diphtheria epidemics
remain a health threat in developing nations. Since the introduction and widespread
use of diphtheria toxoid in the 1920s, respiratory diphtheria has been well controlled,
with an incidence of approximately 1000 cases reported annually (CDC, 2003). In
the Philippines, according to the Department of Health, a total of 22 diphtheria cases
were reported nationwide from January 1 to April 9, 2016.
No racial predilection for diphtheria has been reported. No significant
differences exist between the incidence of diphtheria in males and females. In
certain regions of the world, however, women may have lower immunization rates
than males. Female infants and young children account for the majority of deaths in
endemic regions. Historically, diphtheria has been primarily a disease of childhood,
affecting populations younger than 12 years. Infants become susceptible to the
disease at age 6-12 months after their transplacentally derived immunity wanes
(Mandell et. al, 2015).
Diphtheria is an "air and surface" attacker. The cough or sneeze of a person
who has a throat full of diphtheria bacteria releases tiny droplets into the air. If
someone else breathes in that wetness, diphtheria rides in ready to start another
infection. Diphtheria also loves to lie in wait on some surfaceslike in the mucus on
a used tissue or on a toy thats been in an infected persons mouth.

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 II. ANATOMY AND PHYSIOLOGY

The respiratory system performs function by facilitating life-sustaining

processes such as oxygen transport, respiration and ventilation, and gas exchange.
The lungs are paired elastic structures enclosed in the thoracic cage, which is
an airtight chamber with distensible walls. Ventilation requires movement of the walls
of the thoracic cage and of its floor, the diaphragm. The effect of these movements is
alternately to increase and decrease the capacity of the chest. When the capacity of
the chest is increased, air enters through the trachea (inspiration) because of the
lowered pressure within and inflates the lungs. When the chest wall and diaphragm
return to their previous positions (expiration), the lungs recoil and force the air out
through the bronchi and trachea. The inspiratory phase of respiration normally
requires energy the expiratory phase is normally passive. Inspiration occurs during
the first third of the respiratory cycle, expiration during the latter two thirds.
The lungs and wall of the thorax are lined with a serous membrane called the
pleura. The visceral pleura cover the lungs the parietal pleura line the thorax. The
visceral and parietal pleura and the small amount of pleural fluid between these two
membranes serve to lubricate the thorax and lungs and permit smooth motion of the
lungs within the thoracic cavity with each breath.
The mediastinum is in the middle of the thorax, between th pleural sacs that
contain the two lungs. It extends from the sternum to the vertebral column and
contains all the thoracic tissue outside the lungs.

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 Each lung is divided into lobes. The left lung consists of an upper and lower
lobe, whereas the right lung has an upper, middle, and lower lobe. Each lobe is
further subdivided into two to five segments separated by fissures, which are
extensions of the pleura.
There are several divisions of the bronchi within each lobe of the lung. First
are the lobar bronchi (three in the right lung and two in the left lung). Lobar bronchi
divide into segmental bronchi (10 on the right and 8 on the left), which are the
structures identified when choosing the most effective postural drainage position for
a given patient. Segmental bronchi then divide into subsegmental bronchi. These
bronchi are surrounded by connective tissue that contains arteries, lymphatics, and
nerves.

The lung is made up of about 300 million alveoli, which are arranged in
clusters of 15 to 20. These alveoli are so numerous that if their surfaces were united
to form one sheet, it would cover 70 square metersthe size of a tennis court. There
are three types of alveolar cells. Type I alveolar cells are epithelial cells that form the
alveolar walls. Type II alveolar cells are metabolically active. These cells secrete
surfactant, a phospholipid that lines the inner surface and prevents alveolar collapse.
Type III alveolar cell macrophages are large phagocytic cells that ingest foreign
matter (eg, mucus, bacteria) and act as an important defense mechanism.

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 III. PATHOPHYSIOLOGY

Predisposing Factors: Precipitating Factors:

Gender (Female) Exposure to epidemic and
Race (African, Indian and other endemic areas
developing countires) Immunocompromised
Age (12 years below) Low socioeconomic status
Overcrowding
Invasion of the bacteria
(Corynebacterium Diphtheriae)

Legend:
C diphtheria adheres to mucosal epithelial cells
Pathway

Signs/Symptoms Endosomes release exotoxins

Nursing Diagnosis

Treatment Localized inflammatory reaction Low grade fever

Diagnostics
B fragment binds to receptor on surface of susceptible host

Fragment A enters and inhibit amino acid transfer from RNA

translocase to the ribosomal amino acid chain

Inhibition of protein synthesis

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 Inactivation/modification of key cellular constituents

Tissue destruction

Necrosis

Cell death

"Bull's neck" Enables the toxin to be carried lymphatically and Malaise, weakness
hematologically to other parts of the body.

Bacteriologic testing (Gram staining) Respiratory involvement Inoculation using Loeffler media

Diphtheria antitoxin Elek test Sore throat Pharyngeal inflammation ErythromycinPenicillin

Development of a localized or coalescing pseudomembrane

Dyspnea Cough Nasal discharge

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Pathophysiology of Diphtheria: A narrative
Immunocompromised states facilitate susceptibility to diphtheria and are risk
factors associated with transmission of this disease. Human carriers are the main
reservoir of infection However, case reports have linked the disease to livestock.
Infected patients and asymptomatic carriers can transmit C diphtheria via respiratory
droplets, nasopharyngeal secretions, and rarely fomites. In the case of cutaneous
disease, contact with wound exudates may result in the transmission of the disease
to the skin as well the respiratory tract.
Immunity from exposure or vaccination wanes over time. Inadequate boosting
of previously vaccinated individuals may result in increased risk of acquiring the
disease from a carrier, even if adequately immunized previously. Additionally, since
the advent of widespread vaccination, cases of non-toxigenic strains causing
invasive disease have increased.
C diphtheria adheres to mucosal epithelial cells where the exotoxin, released by
endosomes, causes a localized inflammatory reaction followed by tissue destruction
and necrosis. The toxin is made of two joined proteins. The B fragment binds to a
receptor on the surface of the susceptible host cell, which proteolytically cleaves the
membrane lipid layer enabling segment A to enter. Molecularly, it is suggested that
the cellular susceptibility is also due to diphthamide modification, dependent on
human leukocyte antigen (HLA) types predisposing to more severe infection. The
diphthamide molecule is present in all eukaryotic organisms and is located on a
histidine residue of the translation elongation factor 2 (eEF2). eEF2 is responsible for
the modification of this histidine residue and is the target for the diphtheria toxin
(DT).
Fragment A inhibits an amino acid transfer from RNA translocase to the
ribosomal amino acid chain, thus inhibiting protein synthesis is required for normal
host cell functioning. DT causes a catalytic transfer of NAD to diphthamide, which
inactivates the elongation factor, resulting in the inactivation eEF2, which results in
protein synthesis blockage and subsequent cell death.
Local tissue destruction enables the toxin to be carried lymphatically and
hematologically to other parts of the body. Elaboration of the diphtheria toxin may
affect distant organs such as the myocardium, kidneys, and nervous system.
Nontoxigenic strains tend to produce less severe infections however, since
widespread vaccination, case reports of nontoxigenic strains of C diphtheria ausing
invasive disease have been documented.

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IV. DIAGNOSTIC TESTS

1. Bacteriologic testing (Gram staining)

- Gram staining is one of the oldest and most useful microbiologic staining
techniques. It involves smearing a small amount of sputum on a slide and
then exposing it to gentian or crystal violet, iodine, alcohol, and safranine,
a red dye. (Cavanaugh, 2003).
Preparation:
-Explain to the client:
That results are most reliable if the specimen is obtained in
the morning upon arising, after secretions have accumulated
overnight
That a sample of secretions from deep in the respiratory tract,
not saliva or postnasal drainage, is needed
That increasing fluid intake before retiring for the night aids in
liquefying secretions and may make them easier to
expectorate
That, if feasible, the client should brush the teeth or rinse the
mouth before obtaining the specimen to avoid excessive
contamination of the specimen with organisms normally found
in the mouth
Nursing considerations:
-Assist in providing extra fluids, unless contraindicated, and proper
humidification
-Assist with mouth care as needed.
-Provide sputum collection container/s
-Assist the client to sit upright and instruct to take two or three deep
breaths and cough deeply.
-Instruct not to touch the lip or the inside of the container with the
hands or mouth. A 10- to 15-mL specimen is adequate.

2. Inoculation using Loeffler media

- Hardy Diagnostics Loeffler Medium is
a modification of the original formula
developed by Loeffler in 1887. The
medium contains horse serum, beef
extract, dextrose and proteose
peptones which together supply the
complex nitrogenous substances and
nutrients necessary to support the
growth of Corynebacterium
diphtheriae. Sodium chloride is
added to supply essential ions
(Havaldar, et.al, 2000). Identification is accomplished by taking swab
samples from nose and any tonsillar crypts, any ulcerations, or
discolorations.
Preparation:

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 - A history should include information regarding the presenting signs
and symptoms, past immunizations, and antimicrobial therapy
administered before the test.
- The client is placed in a sitting position or, if a child, on the
caregivers lap with the head and body held to immobilize while the
procedure takes place.
- The tilt the head slightly backward, depress the tongue with a
tongue blade, and insert the swab through the mouth to the
pharyngeal and tonsillar area without touching any part of the oral
cavity.
- Rub the areas, including any lesions, inflammation, or exudate, with
the swab
- For children, a doll may be used as the patient for demonstration
purposes.
- For all clients, encourage questions and verbalization of concerns
about the procedure, and provide calm, reassuring environment and
manner.
Nursing considerations:
-Ensure patient safety while performing the test.
-Transport the specimen to the laboratory for immediate testing
-Provide comfort measures and treatment such as antiseptic gargles
warm, moist applications and inhalants.
-Practice standard precaution procedures in collection and
transportation of specimens and disposal of used articles.

3. Elek Test
- Elek test is an in vitro immunoprecipitation (immunodiffusion) test to
determine whether or not a strain of
Corynebacterium diphtheriae is
toxigenic. A test strip of filter paper
containing diphtheria antitoxin is
placed in the center of the agar
plate. Strains to be tested (patients
isolate), known positive and
negative toxigenic strains are also
streaked on the agars surface in a
line across the plate and at a right angle to the antitoxin paper strip.
Preparation:

9
 - A history should include information regarding the presenting signs
and symptoms, past immunizations, and antimicrobial therapy
administered before the test.
- The client is placed in a sitting position or, if a child, on the
caregivers lap with the head and body held to immobilize while the
procedure takes place.
- The tilt the head slightly backward, depress the tongue with a
tongue blade, and insert the swab through the mouth to the
pharyngeal and tonsillar area without touching any part of the oral
cavity.
- Rub the areas, including any lesions, inflammation, or exudate, with
the swab
- For children, a doll may be used as the patient for demonstration
purposes.
- For all clients, encourage questions and verbalization of concerns
about the procedure, and provide calm, reassuring environment and
manner.
Nursing considerations:
-Ensure patient safety while performing the test.
-Transport the specimen to the laboratory for immediate testing
-Provide comfort measures and treatment such as antiseptic gargles
warm, moist applications and inhalants.
-Practice standard precaution procedures in collection and
transportation of specimens and disposal of used articles.

V. INTERVENTIONS
A. General Nursing Interventions

Explanation of the disorder and treatment plan to the patient and family.
Provide reassurance that early and prompt treatment commonly results in
complete cure of the disease.
Assess for hoarseness, stridor, shortness of breath, and cyanosis
Keep patient on strict bed rest, strict isolation.
Room should be bright, sunny and with adequate means of ventilation
Provide cleansing throat gargle as ordered.
Give liquid or soft diet, gavage or parenteral fluid.
Provide Health teaching on proper hygiene and universal precaution
Monitor Vital signs
Provide oral care as the mouth, teeth and lips demand careful attention
Emphasize the need to adhere to regimen such as the taking of antibiotics to
prevent multi drug resistance.
B. Medical Interventions
1. Pharmacological Interventions
Patients with active disease as well as all close contacts should be treated
with antibiotics. Treatment is most effective in the early stages of disease and
decreases the transmissibility and improves the course of diphtheria.

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 Diphtheria antitoxin
Erythromycin
Penicillin
**DRUG STUDY FOR EACH MEDICATION IS PRESENTED BELOW
Generic Name:
Classification: Contraindication: Side/Adverse
Erythromycin

Brand Name: Hypersensitivity to CNS: Fatig

E-mycin Erythromycin, malaise, w
macrolide antibiotics EENT: Hea
Antibiotic
Pharmacologic class: or their components oral candid
Macrolide Patients currently on GI: Abdom
Astemizole, cisapride, cramps an
Dosage, timing & route Mechanism of Action pimozide, or diarrhea,
250 to 500 mg (base) terfenadine therapy GU: Vagin
q.i.d. or 20 to 50 mg Binds with the 50S candidiasis
(base)/kg daily in ribosomal subunit of SKIN: Eryt
divided doses for 10 the 70S ribosome in jaundice, p
days. many types of aerobic, rash
anaerobic, gram-positive,
and gram-negative
bacteria. This action
inhibits RNA dependent
protein synthesis in
bacterial cells, causing
them to die.

Generic Name:
Classification: Contraindication: Side/Adverse
Peniciliin G

Brand Name: Antibiotic Hypersensitivity to CNS: Confu

Bicillin penicillin or its dizziness,
components dysphasia,
Pharmacologic class: headache,
Penicillin irritation

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Dosage, timing & route Mechanism of Action

125 to 500 mg every 6 Inhibits final stage of

to 8 hr. bacterial cell wall
synthesis by
competitively binding to
penicillin-binding proteins
inside the cell wall.
Penicillin-binding
proteins are responsible
lfor various steps in
bacterial cell wall
synthesis. By binding to CV: Labile b
these proteins, penicillin pressure,
leads to cell wall lysis. palpitations
EENT: Blac
tongue, ora
candidiasis
stomatitis, t
perversion
GI: Abdomi
diarrhea, na
MS: Muscle
twitching

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 VI. NURSING CARE PLANS
Ineffective airway clearance related to pharyngeal inflammation and development of pseudomembrane as evidenced by dyspnea,
cough, restlessness and changes in respiratory rate and rhythm secondary to Diphtheria

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE

Short term: INDEPENDENT
May exhibit: At the end of 1 hour-8 hours,
the client will be able to:
State understanding of
Dyspnea
the oxygen demands and
Increased RR and
changes secondary to
irregular rhythm
disease
Cough 2. Mobilize patient to full
Maintain patent airway
Restlessness
Maintain vital signs within
normal range
Have an oxygen level in
normal range.
Long term:
At the end of 1 week, the client
will be able to:
Maintain an oxygen level
in normal range
Breathe deeply and 6. Suction, as ordered.
cough to remove
secretions.
Demonstrate controlled
coughing techniques.
Demonstrate skill in
conserving energy while
attempting to clear
1. Turn patient every 2 hr
place the patient in lateral,
sitting, prone, and upright
positions as much as
possible.
capabilities.
3. Teach patient an easily
performed cough technique
4. Avoid placing patient in a
supine position for
extended periods.
5. Encourage adequate water
intake (34 qt [34 L/day])
COLLABORATIVE:
7. Provide adequate
humidification and oxygen
as administered
8. Administer antibiotics as
prescribed
INDEPENDENT
1. For maximal aeration of lung
fields and mobilization of
secretions.
2. To facilitate chest expansion
and ventilation.
3. To clear airway without
fatigue.
4. To prevent atelectasis
5. To ensure optimal hydration
and loosening of secretions
COLLABORATIVE:
6. Stimulate cough and clear
airways
7. To loosen secretions and
promote oxygenation of cells
throughout the body.s
8. Aid in fighting bacteria that
produces toxins and prevent
further spread of systemic
infection

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 ASSESSMENT OBJECTIVES
airway.
Ineffective thermoregulation related to release of exotoxins causing local inflammation as evidenced by low grade fever, increased
respiratory and heart rate, moderate pallor, temperature of 37.5-39 degree Celsius secondary to C. Diphtheria infection
ASSESSMENT OBJECTIVES
Possibly evidenced by: Short term:
low grade fever At the end of 30 minutes to 1
increased respiratory hour, the client will be able to:
and heart rate Verbalize understanding of
moderate pallor health problem
Express understanding of
the teachings rendered.
Maintain body temperature
at normothermic levels.
Express feelings of comfort.
Long term:
At the end of 12 hours to 1
week, the client will be able to:
Maintain stable vital signs
and show no signs of
compromised health status
INTERVENTION
INTERVENTION
INDEPENDENT
1. Monitor patient's body
temperature every 4 hr or
more often as indicated.
2. Use non-pharmacologic
measures such as
removing sheets, blankets,
and most clothing placing
ice bags on axillae and
groin and sponging with
tepid water. Explain these
measures to patient.
3. Increased fluid intake to 2-
3 L a day
COLLABORATIVE:
4. Administer antipyretics as
prescribed and record
effectiveness
RATIONALE
RATIONALE
1. To determine effectiveness
of therapy or if intervention
is needed.
2. Nonpharmacologic
measures lower body
temperature and promote
comfort. Sponging reduces
body temperature by
increasing evaporation
from skin. Tepid water is
used because cold water
increases shivering,
thereby increasing
metabolic rate and causing
temperature to rise.
3. Because insensible fluid
loss increases by 10% for
every 1.8 degree F
(1degree C) increase in
temperature, patient must
increase fluid intake to
prevent dehydration.
4. Antipyretics act on
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 ASSESSMENT OBJECTIVES INTERVENTION RATIONALE
hypothalamus to regulate
temperature.

Impaired swallowing related to presence of respiratory tract pseudomembrane formation secondary to C. Diphtheria infection

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE

Possibly evidenced by: Short term:
Pharyngeal irritation At the end of 30 minutes to 3
Delayed swallowing hours, the client will be able to:
Express concerns and
Food refusal
anxieties regarding
Verbalization of pain
difficulties in swallowing
when swallowing
Understand the health
teachings and importance
of regimen
Maintain oral hygiene
Long term:
At the end of 8 hours to 1 week,
the client will be able to:
Achieve adequate
nutritional intake.
Maintain weight.
Demonstrate correct
feeding techniques to
INDEPENDENT
1. Elevate head of the bed 90 1. These measures
degrees during meal times decrease the risk of
and for 30 min after the aspiration.
completion of a meal. 2. Symptoms indicate the
Position patient on his or presence of material in
her side when recumbent. the lungs.
3. These measures
2. Keep suction apparatus at
the bedside to be prepared promote comfort and
for episodes of aspiration enhance appetite.
that require immediate 4. To allow patient to take
suctioning. Observe and an active role in
report instances of maintaining health.
5. A pleasant atmosphere
cyanosis, dyspnea, or
stimulates appetite.
choking.
3. Provide mouth care three Food aroma stimulates
times daily. Keep oral salivation.
mucous membrane moist by
frequent rinses use a bulb
syringe or suction if

15
 ASSESSMENT OBJECTIVES INTERVENTION RATIONALE
maximize swallowing.
necessary.
4. Teach patient and family
about positioning, dietary
requirements, and specific
feeding techniques
5. Serve food in attractive
surroundings. Encourage
patient to smell and look at
food.

Impaired physical mobility related to decreased muscle endurance and weakness as evidenced by limited ROM, body malaise,
postural instability and headache

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE

Possibly evidenced by: Short term:
Muscle weakness At the end of 30 minutes to 4
Narrowed focus hours, the client will be able to::
Limited ROM, Maintain position of function.
Body malaise, Increase strength/function of
Postural instability affected and compensatory
Headache body parts
Maintain maximum joint
range of motion (ROM).
Long term:
At the end of 12 hours, the client
will be able to:
1. Identify level of functioning
using a functional mobility
scale. Communicate
patients skill level to all
staff members
2. Monitor and record daily
any evidence of immobility
complications
3. Perform ROM exercises to
joints, unless
contraindicated, at least
once every shift
4. Turn and reposition patient
every 2 hr. Establish a
1. To provide continuity and
preserve identified level of
independence.
2. They may be more prone
to develop complications
3. To prevent joint
contractures and muscular
atrophy.
4. To prevent skin breakdown
by relieving pressure.
Place joints in functional
position.
5. To maintain joints in a
functional position and

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 ASSESSMENT OBJECTIVES
Demonstrate a decrease in
physiological signs of
intolerance
Demonstrate improvement
in activity intolerance
Participate willingly in
necessary
INTERVENTION RATIONALE
turning schedule and post prevent musculoskeletal
at bedside. Monitor deformities.
frequency of turning 6. To maintain muscle tone
5. Use trochanter roll along and prevent complications
the thigh, abduct thighs, of immobility.
use high-top sneakers, and
pull a small pillow under
patients head
6. Provide progressive
mobilization to the limits of
patients condition (bed
mobility to chair mobility to
ambulation)

Risk for suffocation related to possibility of pseudomembrane aspiration

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE

Possibly evidenced by: Short term: 1. To prevent relaxed neck

At the end of 5 minutes to 30 1. Position patient on side or muscles from obstructing
Choking minutes, the client will be able position head and neck. airway to allow maximal
to: 2. Obtain suction equipment,
Diminished breath chest expansion and
Demonstrate patent assemble, and keep at prevent aspiration and
sounds bedside
Dyspnea airway at all times airway obstruction.
3. Educate patients family
Maintain vital signs within 2. To ensure equipment
Increased RR, HR about safety measures in
normal parameters. readiness in case it is
Cyanosis the home, for example, needed.
proper positioning, suction 3. To enable them to take

17
ASSESSMENT OBJECTIVES INTERVENTION
procedure, fall prevention
4. Be attentive to the fears of
both patient and family.
Listen with sensitivity and
reinforce safety measures to
prevent injury.
RATIONALE
an active role in the
patients care and ensure
performance of safety
measures
4. To achieve a level of
comfort, the family may
need to ask the same
questions multiple times
and have the information
repeated frequently.
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