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S116

The Pathology of Diphtheria


Ted L. Hadfield,1 Peter McEvoy,1 Yury Polotsky,2 1
Armed Forces Institute of Pathology, 2Walter Reed Army Institute
Vsevolod A. Tzinserling,3 and Alexey A. Yakovlev3 of Research, Washington, DC; 3St. Petersburg Pediatric Medical
Institute, St. Petersburg, Russia

Diphtheria is an acute, communicable disease caused by Corynebacterium diphtheriae.


The disease is generally characterized by local growth of the bacterium in the pharynx with
pseudomembrane formation or, less commonly, in the stomach or lungs; systemic dissemi-
nation of toxin then invokes lesions in distant organs. Acute disease of the upper respiratory
tract usually involves one or more of the following: tonsillar zones, larynx, soft palate, uvula,
and nasal cavities. A recent epidemic in Russia emphasized the role of vaccination in reducing
disease in children and adults.

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Clinical descriptions of diphtheria appeared in Hippocratic Respiratory Tract Diphtheria
writings, but the illness was not clearly differentiated from other
upper respiratory disease until clinician-pathologist Pierre Bre- The upper respiratory tract mucosa is the most common site
tonneau first described its unique clinical characteristics [1, 2]. of infection in children but was a rare site for localization of
Diphtheria is an acute, communicable disease caused by exo- diphtheria in adult patients in a recently described epidemic
toxin-producing Corynebacterium diphtheriae. Review of pa- occurring in the former USSR. In adult patients with oral mu-
thology in archived cases and the literature shows that C. cosal lesions, unusual sites of infection included buccal mucosa,
diphtheriae usually localizes in the upper respiratory tract, ul- upper and lower lips, hard and soft palate, and tongue [6].
cerates the mucosa, and induces the formation of an inflam- Anterior nasal infection presents with serosanguinous or se-
matory pseudomembrane. The exceedingly potent toxin is ab- ropurulent nasal discharge, which is often associated with subtle
sorbed into the circulation and damages remote organs, whitish patches on the mucosal membrane of the septum. The
discharge can incite an erosion of the external nares and upper
potentially resulting in death. Although primary infection can
lip, but symptoms are usually mild. Faucial diphtheria involves
occur at sites other than the pharyngeal mucosa, lesions usually
the posterior structures of the mouth and proximal pharynx.
occur as local pseudomembranous inflammation on mucosal
This is the area of infection most characteristic for clinical diph-
surfaces of the upper respiratory tract and systemic lesions of
theria. A membrane typically develops on one or both tonsils,
the heart and (to a lesser extent) nerves.
with extension to the tonsillar pillars, uvula, soft palate, oro-
C. diphtheriae is usually transmitted by direct contact or by
pharynx, and nasopharynx. C. diphtheriae multiplies on the
sneezing or coughing. No age group is completely immune, but surface of the mucous membrane, resulting in the formation
nonimmune children are commonly affected before age 5 [3]. of the “pseudomembrane” [7]. Initially, the pseudomembrane
In populations with a high rate of immunization, improved is white, becoming a dirty gray color over time. Late in the
coverage in children has shifted the age distribution of those course of infection, the membrane may have patches of green
afflicted to unimmunized or poorly immunized adults [4]. Fur- or black necrosis.
thermore, relatively increased isolation of nontoxigenic strains Our review of diphtheria shows that laryngeal and trach-
of C. diphtheriae versus toxigenic strains is noted when im- eobronchial diphtheria are uncommon. Both can be primary
munization rates are improved [5]. infection sites or extensions of a pharyngeal infection. Edema
A widespread epidemic of diphtheria began in 1990 in the and pseudomembrane coating of the trachea and bronchi can
former Union of Soviet Socialist Republics (USSR). This ep- reduce and eventually block air flow through the respiratory
idemic was notable for the high incidence of infection in adults tree, resulting in cyanosis or suffocation of the infected person.
and the extent of disease. The organism establishes itself on the surface of mucous
membranes, and primary foci of infection coalesce during the
course of the disease. Satellite infections may occur in the
esophagus, stomach, or lower airways. The growth of organ-
Reprints or correspondence: Dr. Ted L. Hadfield, Lt. Col, USAF, BSC, isms remains localized, but exotoxin is absorbed into the blood
Armed Forces Institute of Pathology, Bldg. 54, CPS-M, Washington, DC
20306 (hadfield@afip.osd.mil).
and evokes severe systemic pathology. The exotoxin inhibits
cellular protein synthesis by stimulating adenosine diphosphate
The Journal of Infectious Diseases 2000; 181(Suppl 1):S116–20
q 2000 by the Infectious Diseases Society of America. All rights reserved.
ribosylation, thus inactivating protein synthesis elongation fac-
0022-1899/2000/18102S-0020$02.00 tor 2. In addition, Lessnick et al. [8] and Chang et al. [9] re-
JID 2000;181 (Suppl 1) Pathology of Diphtheria S117

ported an alternative cytotoxic pathway consisting of a nuclease erosion with slight hemorrhage and an attached thick fibri-
activity stimulated by Ca11 and Mg11, which comigrates with nopurulent exudate. These pseudomembranes are indistin-
the A subunit of the toxin. They propose that the toxin directly guishable from lesions in the respiratory tract [10].
attacks the chromosomal DNA to initiate cell lysis.
In fatal diphtheria, gross findings often include disseminated
Lymph Nodes
ulcers of the mucosa covered by a “dirty” coating. Pharynx,
larynx, trachea, and the main bronchi may be covered by pseu- Lymph nodes in advanced cases are enlarged and may appear
domembranes that may or may not be firmly attached to the blackish-red and be hemorrhagic. Regional nodes respond, re-
tissues. Smaller bronchi are often reddened and coated with a sulting in a nonspecific acute lymphadenitis, particularly in the
similar thin membrane. Chest films reveal a bronchopneumonia cervical area. Respiratory embarrassment, severe adenitis, and
[10]. The lungs are hemorrhagic with a moderately solid con- soft tissue edema result in a “bull neck” appearance in ad-
sistency [11]. Edema and hyperemia of the affected epithelial vancing cases.
surface appear first. This is followed by necrosis of the epithe-
lium, accompanied by outpouring of a fibrinosuppurative ex-

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udate. The coagulation of this exudate on the ulcerated necrotic Pathology Associated with Toxigenicity
surface creates the characteristic tough, dirty gray to gray-white Diphtheriae toxin, which is secreted by toxigenic strains of
superficial pseudomembrane (figure 1). The pseudomembrane C. diphtheriae, is a single polypeptide of Mr 58,342. Toxigenic
also contains necrotic sloughed epithelial cells and numerous strains of C. diphtheriae carry the tox structural gene found in
colonies or organisms of C. diphtheriae (figure 2). lysogenic corynebacteriophages b tox1, g tox1, and q tox1.
Caution should be exercised in the histologic diagnosis of Highly toxic strains have two or three tox1 genes inserted into
diphtheria because nonvirulent diphtheroids are normal inhab- the genome. Expression of the gene is regulated by the bacterial
itants of the oral cavity and may also be enmeshed within the host and is iron dependent. In the presence of low concentra-
pseudomembrane. However, in diphtheria, the membrane has tions of iron, the gene regulator is inhibited, resulting in in-
patches of intense collections of C. diphtheriae as opposed to creased toxin production. Toxin is excreted from the bacterial
the small collections of nontoxigenic diphtheroids seen in fig- cell and undergoes cleavage to form two chains, A and B, which
ures 3 and 4. Mild neutrophilic infiltration of the underlying are held together by an interchain disulfide bond between cys-
tissues becomes progressively more severe with the continuance teine residues at positions 186 and 201. As toxin concentrations
of the bacterial invasion. Severe lesions have marked vascular increase, the toxic effects extend beyond the local area due to
congestion, interstitial edema, fibrin exudation, and intense distribution of the toxin by the circulation. Diphtheriae toxin
neutrophil infiltration. When the pseudomembrane is torn off does not have a specific target organ, but myocardium and
this highly vascularized bed, bleeding occurs. By centrifugal peripheral nerves are most affected [12].
spread, the pseudomembrane reaches the larynx, trachea, and
even the lower respiratory tract. Likewise, it may rise to cause
nasal obstruction. Occasionally, intense suppurative inflam- Myocardium
mation and necrosis of the subjacent tissues permit spontaneous Human diphtheria infection may terminate with acute car-
dislodgment and aspiration of the membrane. diac failure or may prove fatal weeks later during convales-
Pseudomembranes may show an inner band of fibrin and a cence. Examination of heart tissues after death demonstrates
lumenal zone of polymorphonuclear leukocytes, but this zoning cardiac damage in many cases, although the pathologic lesions
may be reversed or absent. Over the vocal cords, the membrane are varied and inconsistent, perhaps representing a spectrum
is almost entirely fibrin, and in the main bronchus, it is usually of changes related to cumulative exposure to toxin. When toxin
a uniform mixture of fibrin and neutrophils. In laryngeal le- concentrations are low, the heart chambers may be dilated with
sions, there is a deep layer of lymphocytes. The acute inflam- no effusion or malformation. The valves, coronary vessels, ep-
matory reaction often extends into the mucous glands of the icardium, and endocardium are normal. The myocardium ap-
respiratory tract. Tonsil and laryngeal diphtheria lesions pene- pears pale brown and soft. The myocardium appears distorted
trate adjacent skeletal muscle. There may be marked hemor- by widely distributed areas of granular degeneration and loss
rhage in and around the parabronchial and mediastinal lymph of cross striations. Neutral fat droplets occur in ∼50% of fatal
nodes, with numerous polymorphonuclear neutrophils in the cases of diphtheria. The fat droplets appear as beaded config-
peripheral sinuses. Pulmonary pathology includes extension of urations in the sarcoplasm of muscle cells with oil Red O stains.
the fibrinopurulent exudate to line and partly fill small bronchi, Nuclei may form caterpillar chromatin configurations. Some
bronchioles, and alveoli, leading to early bronchopneumonia nuclei are pyknotic. “Caterpillar” cells are histiocytes [13]. Neu-
[10]. trophils in the sarcoplasm of degenerating myocardial cells are
Diphtheria lesions in the stomach have superficial mucosal rare except in areas of maximal degeneration, where they are
Figure 1. Pharyngeal pseudomembrane. Epithelium is absent; at one side, inflammatory exudate extends to underlying muscle. Hematoxylin-

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eosin staining. Original magnification 32.5.

Figure 2. Higher magnification (original 325) of pseudomembrane Figure 3. Irregularly staining rods of C. diphtheriae comprising
comprising fibrin, neutrophilic inflammation, and gram-positive col- small colony. Brown-Hopps tissue gram stain. Original magnification
onies of C. diphtheriae. Brown-Hopps tissue gram stain. 3330.

Figure 4. Colony of C. diphtheriae with admixed gram-positive Figure 5. Cardiac muscle. Note loss of myofibrils, with extensive
cocci. Note relatively small size of rods. Brown-Hopps tissue gram fatty change. Few mononuclear cells (macrophages and lymphocytes)
stain. Original magnification 3330. are present. Hematoxylin-eosin staining. Original magnification 325.
JID 2000;181 (Suppl 1) Pathology of Diphtheria S119

associated with slight hemorrhage. No other inflammatory cells in configuration. At this stage, segmental demyelination is rare;
are observed. Conduction tissue lesions are not extensive. Ab- later (45–62 days in an animal model), segmental demyelination
normalities of coronary vessels, endocardium, or epicardium is the characteristic lesion [18]. Axonal degeneration is observed
are not seen [14]. in the most severe cases and appears secondary to the axon
In a study of 102 patients who died of diphtheria intoxica- being squeezed by the folded myelin and voluminous Schwann
tion, dystrophic-necrotic processes in cardiac conduction and cell cytoplasm invaginating into the axon [19].
intramural nervous systems in contractile myocardium were Muscle biopsies removed during acute stages of diphtheria
observed between days 1 and 8 [15]. (Myocarditis progression polyneuropathy reveal scattered small, angulated muscle fibers
undergoes two stages: early exudative [about day 3 of disease] adjacent to more generalized slight atrophy, predominately of
and late productive [beginning ∼9 days into disease]). The end type 2B fibers and target-like phenomena or cores of type 1
result for patients in the study was myocardiosclerosis [15]. fibers. Intramuscular vessels may exhibit a vasculitis comprising
Grossly, hearts are dilated, pale, and flabby, with a charac- lymphoid cells [20].
teristic “streaky” appearance in the myocardium. Sections of
myocardium show extensive areas of hyaline degeneration and

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necrosis associated with active inflammation in the interstitial Other Pathologic Effects
spaces. Infiltrates of mononuclear cells with eosinophilic cy- The exotoxin also causes myocardial-like changes in inflam-
toplasm are present within these areas (figure 5). Fluorescent matory polyneuritis. Lesions show degeneration of myelin
antibody staining of tissue sections demonstrate toxin in a sheaths and, less commonly, fatty degenerative changes or focal
patchy distribution within myocardial fibers. Toxin is not ob- necroses of parenchymal cells in the liver, kidneys, and adrenals.
served in areas of advanced necrosis. Electron micrographs Occasionally, Zenker’s hyaline degeneration, or necrosis, occurs
show striking ultrastructural changes within involved myofi- in the striated voluntary and cardiac muscle fibers in the more
bers. Mitochondria are swollen and show loss of matrix and severe cases.
disorganization of the cristae. Dense osmophilic material is of- In addition to the toxigenic manifestations of C. diphtheriae,
ten seen within the mitochondria. Damaged myofibrils are dis- disease associated with nontoxigenic strains occurs. Guran et
rupted at scattered foci, leaving empty, structureless, pale al. [21] described a septic arthritis of the hip, which was caused
spaces. Numerous lipid droplets are seen within myofibers. Sar- by nontoxigenic C. diphtheriae in a child. Dissemination pre-
coplasmic reticulum tubules show no significant changes. Chro- sumably occurred from skin lesions on the toes. Nontoxigenic
matin granules are clumped and are located near the nuclear C. diphtheriae was isolated from excoriated skin lesions on the
membrane [16]. toes and from articular fluid of the hip.
Nontoxigenic C. diphtheriae was recently described as a cause
of sepsis and has been associated with splenic and hepatic ab-
Neurologic Toxicity scesses [22]. Well-differentiated, diffuse lymphocytic infiltrates
About three-fourths of patients with severe disease develop effaced the architecture of lymph nodes, spleen, and bone mar-
neuropathy. The incidence of neurologic complications is re- row. Similar interstitial infiltrates were present throughout the
lated directly to the severity of respiratory symptoms. About lungs, cortex, and medulla of kidney and hepatic portal triads.
20% of all symptomatic respiratory infections are followed by The liver showed multifocal panlobular areas of necrosis with
polyneuritis, but 75% of patients with severe disease develop a thin rim of scattered degenerating neutrophils and rare lym-
some form of neuropathy. The first indication of neuropathy phocytes. A few gram-positive, rod-shaped bacteria were ob-
is paralysis of the soft palate and posterior pharyngeal wall. served in the lesions. Similar lesions were seen in the spleen.
This often results in regurgitation of swallowed fluids through Small foci of interstitial hemorrhage were present in the skin,
the nose. Thereafter, cranial neuropathies causing oculomotor renal cortex, lung, and liver. C. diphtheriae sepsis can lead to
and ciliary paralysis are common; dysfunction of facial, pha- endocarditis [23].
ryngeal, or laryngeal nerves contributes to the risk of aspiration.
Peripheral neuritis develops later, from 10 days to 3 months
Cutaneous Diphtheria
after the onset of oropharyngeal disease [17].
Occasionally, motor nerves of the trunk, neck, and upper Today, we often think of diphtheria of the skin in the context
extremities are involved, as are sensory nerves, resulting in a of wound diphtheria, umbilical diphtheria, or impetiginous
glove-and-stocking neuropathy. Examination of affected nerves diphtheria. Skin lesions can be extremely variable owing to the
by microscopy shows degeneration of myelin sheaths and axon ability of C. diphtheriae to colonize any skin lesion of other
cylinders. The basis of diphtheritic polyneuropathy is toxic origin (e.g., surgical wounds, pyoderma, eczema, impetigo, der-
myelopathy with paranodal demyelination, especially in large matitis, or insect bites). Often, an ulcerative lesion (ecthyma
myelinated neural fibers. Early changes affect the paranodal diphtheriticum) is the presenting lesion. It begins as a vesicle
myelin so that the nodes of Ranvier appear widened and altered or pustule filled with straw-colored fluid, which breaks down
S120 Hadfield et al. JID 2000;181 (Suppl 1)

quickly. The lesion progresses to form a punched-out ulcer, ology and clinical manifestations. Report of the third international meet-
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