Death from diphtheria
Authors: Nicholas J White
Journal: The Lancet (2024)

The cruelty of lethal diphtheria is difficult to exaggerate. A child who is slowly strangled by an unstable expanding coagulum of necrotic tissue in the upper airway, a toxic and untreatable rapidly progressive cardiomyopathy or, after surviving these, death from neuropathic acute respiratory failure.1Christie AB Diphtheria.in: Infectious diseases: epidemiology and clinical practice. Churchill Livingstone, London1987Google Scholar This terrible disease is completely preventable with the diphtheria toxoid vaccine. But for those unfortunate children with pharyngeal diphtheria who did not receive this vaccine, their chances of survival can be increased substantially by early protection of the airway with intubation or tracheostomy and prompt administration of antitoxin. In 1890, in the Charité Hospital in Berlin, Germany, Emil von Behring (1854–1917) and Kitasato Shibasaburō (1853–1931) showed that antibodies raised in animals could protect against the lethal effects of diphtheria and tetanus toxins. In the following years, as the equine antitoxin was deployed, the mortality of diphtheria in Europe and North America fell substantially(appendix).2Goodall EW On the value of the treatment of diphtheria by antitoxin.Br Med J. 1899; 1: 268-270Crossref Scopus (0) Google Scholar, 3Rendu MR Mortalité diphtérique à Paris avant et après la vaccination.Lyon Med. 1939; 30 (in French).: 91-99Google Scholar In 1901, von Behring received the first Nobel Prize in Medicine. The citation reads "for his work on serum therapy, especially its application against diphtheria, by which he has opened a new road in the domain of medical science and thereby placed in the hands of the physician a victorious weapon against illness and deaths".4Nobel PrizeThe Nobel Prize in Physiology or Medicine.https://www.nobelprize.org/prizes/medicine/1901/summary/Date: 1901Date accessed: November 30, 2023Google Scholar The discovery and subsequent deployment of antitoxin was decades before the discovery of antibiotics or the deployment of the toxoid vaccines. Yet today—some 130 years later—outbreaks of diphtheria continue to occur in low-resource or conflict-affected settings, and there is usually no available life-saving antitoxin.5WHODiphtheria—Nigeria.https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON485Date: Sept 13, 2023Date accessed: November 1, 2023Google Scholar Diphtheria mortality is often higher than it was 100 years ago.6Truelove SA Keegan LT Moss WJ et al.Clinical and epidemiological aspects of diphtheria: a systematic review and pooled analysis.Clin Infect Dis. 2020; 71: 89-97Crossref PubMed Scopus (68) Google Scholar However, because we have a good vaccine, because diphtheria does not affect wealthier countries, and, perhaps, because it is perceived as old medicine, diphtheria is a neglected problem. Indeed, diphtheria is almost an embarrassment. If the lysogenic diphtheria β-corynebacteriophage that encodes the lethal toxin were a newly emerging virus, it would garner more attention from international agencies, donors, and health ministries. Diphtheria is terrible, preventable, and treatable. The perennial global shortage of life-saving diphtheria antitoxin is indeed an embarrassment. I declare no competing interests. Download .pdf (.1 MB) Help with pdf files Supplementary appendix