CORYNEBACTERIUM DIPHTHERIAE

Mary Ann A. Wagas, MD,DPPS

Corynebacterium diphtheriae

Acute infection : Diphtheria Primary lesion is in the throat or nasopharynx & characterized by the presence of a grayish pseudomembrane composed of fibrin, leukocytes, necrotic epithelial cells & C. diphtheriae cells Exotoxin is released into the blood that damages the heart & neural cells by interfering in protein synthesis

Corynebacterium diphtheriae

Loffler isolated the organism in pure culture Roux & Yersin provided complete understanding of the pathogenesis of infection after discovering the exotoxin Most members of the genus are normal flora of the skin, naso- & oropharynx, urogenital tract & gastrointestinal tract C. diphtheriae is the only pathogenic species

Corynebacterium diphtheriae: Morphology

Pleomorphic Gram positive rods often with clubbed ends, in pairs or trios Cells are 1.5- 5um length by 0.5- 1.0um width Metachromatic (Babes-Ernst) granules accumulations of polyphosphates Non-capsulated, non-motile

Corynebacterium diphtheriae: Physiology

Aerobic & facultatively anaerobic Culture media: Loefflers agar

used

for primary isolation Enhances the formation of metachromatic granules Minute, grayish white glistening colonies grow in 12-24HR incubation at 37C Tellurite salts reduces the number of contaminants

Corynebacterium diphtheriae: Physiology

Tinsdales agar
Selective

medium, inhibits growth of other

organism Allows differentiation from other Corynebacterium species by colony morphology

3 major colonial types:

Gravis Mitis Intermedius

Corynebacterium diphtheriae: Physiology

Gravis strains large, flat, gray to black with a dull surface Mitis strains medium-sized colonies, that are smaller, blacker, glossy & more convex Intermedius colonies very small & either smooth or rough C.diphtheriae are resistant to light, dessication & freezing; sensitive to a 1-minute exposure to 100C

Antigenic Structure

K antigen
Responsible

for the type specificity of C.

diphtheriae Heat labile proteins in superficial layers of the wall Role in antibacterial immunity & hypersensitivity Major determinants of invasiveness & virulence: K antigen & glycolipid cord factor

O antigen
Heat

stable Responsible for cross-reactivity with mycobacterium & nocardia

Determinants of Pathogenecity

Systemic disease is caused by strains producing exotoxin Toxin Synthesis

Only

strains that have been lysogenized with a bacteriophage carrying the tox gene produce diphtheria toxin Production is activated as organism enter death phase Low iron concentration in culture media promotes toxin synthesis

Determinants of Pathogenecity
Toxin Structure Fraction B (binding) moiety
Mediates

attachment of toxin to cells & transport of the toxin into cells for the biologic properties if the toxin

Fraction A (active) moiety

Responsible

Determinants of Pathogenecity
Mechanism of Action: Fraction A disrupts protein synthesis by catalyzing transfer of adenosinediphosphoribose (ADPR) moiety of Nicotinamide adenine dinucleotide (NAD) to the elongation factor-2 (EF-2) The ribosylation of EF-2 blocks polypeptide chain elongation

Clinical Disease: Epidemiology

Humans are the only natural hosts Very contagious & transmitted via aerosolized nasopharyngeal secretions In developing countries, where fewer infants are immunized, an estimated 1M deaths per year The marked decrease in incidence is due to successful active immunization programs Immunity declines with age

Clinical Disease: Pathogenesis

Incubation pd: 1-7 days Organisms usually localized to oropharynx

Organisms multiply on epithelial cells, producing EXOTOXIN

Formation of PSEUDOMEMBRANE over the tonsils, uvula, soft palate or pharyngeal wall

Exotoxin is absorbed into the systemic circulation where it causes myocarditis & peripheral neuropathy

Clinical Manifestations

Initial symptoms : Pharyngitis or Tonsillitis Clinical manifestation depends on the location & extent of infection A) Anterior nasal diphtheria not very severe B) Tonsillar diphtheria most common presentation, causes sore throat with low grade fever & malaise C) Pharyngeal diphtheria more extensive pseudomembrane, which can obstruct airway & cause suffocation

Clinical Manifestations

Extra-Respiratory disease Skin Skin diphtheria

appear

as chronic, spreading, non-healing ulcers covered with grayish membrane Streptococcus pyogenes or Staphylococcus aureus may be present Mitis strains present

Rarely conjunctiva, cornea, vagina & ear

Complications

Cardiac disease
after the 2nd week of disease in 20% of patients Fatty myocardial degeneration
Appear

Neurologic symptoms
in the 3rd 5th week of disease Cranial nerve involvement paralysis of soft palate, difficulty in swallowing & regurgitation Peripheral nerve involvement - polyneuritis
Appear

Laboratory Diagnosis

Initial diagnosis clinical presentation Differential diagnosis :

Infectious

mononucleosis Streptococcal pharyngitis Leukemia with agranulocytosis

Definitive diagnosis culture & isolation of organism

Treatment

Entails suppression of bacterial growth, neutralization of toxin & supportive measures Penicillin drug of choice Erythromycin in patients allergic to PCN Diphtheria antitoxin dose depend on severity
20,000U

mild case, 100,000U severe IM

Supportive measures
Tracheostomy

for airway obstruction Full cardiovascular support for myocarditis

Prevention

Active immunization : diphtheria toxoid Primary of immunization started at 6-8weeks of life 0.5ml dose of diphtheria toxoid combined with tetanus toxoid & pertussis vaccine (DPT) given IM on 4 occasions the first 3doses at 48weeks interval, the forth dose at 6 to 12 months after the 3rd dose For 7yo & older, booster dose of tetanus & diphtheria toxoid (Td) should be given every 10 years

Prophylaxis for Case Contacts

All household contacts closely monitored Contact immunized within the previous 5yrs should receive booster dose of toxoid Unimmunized or inadequately immunized contacts should complete the immunization sequence & receive PCN or Erythromycin Passive immunization : 5,000-10,000U of antitoxin

Establishment of Immune Status

SCHICK Test
Injection

of 0.1ml purified toxin Intradermal to

forearm Control injection to the other arm Positive test local inflammatory reaction 10mm diameter within 4-7 days, indicates absence of immunity to diphtheria Negative test antitoxin greater than 0.03U/ml, able to neutralize toxin & person is immune