Clinical spectrum and outcomes of pediatric diphtheria

Main Article Content

Herry D. Nawing
Ninny Meutia Pelupessy
Herniati Alimadong
Husein Albar


Background Although vaccination programs have succeeded in reducing the incidence of diphtheria, it remains a health problem in Asia, including Indonesia.

Objective To investigate the clinical spectrum and outcomes of pediatric diphtheria in Wahidin Sudirohusodo Hospital.

Methods This study was a retrospective review of childhood diphtheria medical records from January 2011 to December 2017 in Wahidin Sudirohusodo Hospital, Makassar, South Sulawesi. Recorded data consisted of age, gender, nutritional and immunization statuses, signs and symptoms, throat swab culture results, complications, and outcomes.   

Results Of 28 subjects aged 9 months to 17.10 years, the majority were >5 years (57.1%) and male (60.7%). Subjects’ mean age was 6.15 years and 82.1% of cases were well nourished. Overall, 85.7% had received complete immunizations, while 14.3% were not immunized, having received neither basic nor booster vaccines. The presenting manifestations were fever, pseudomembranes, and sore throat in all subjects, enlarged tonsils (78.57%), dysphagia (67.86%), cough (57.14%), headache (57.14%), hoarseness (67.86%), bull neck (25%), and myocarditis (14.3%). Most subjects had hospital stays of >10 days (67.9%). Mortality was 14.3%, usually in those admitted with a late, deteriorating condition and dying before getting optimal treatment. Poor outcome was significantly associated with the lack of basic or booster immunizations, poor nourishment, bull neck, myocarditis, and hospital stays < 5 days (P<0.05 for all). 

Conclusion The clinical spectrum and outcomes of pediatric diphtheria in this study are relatively similar to reports from other hospitals. Mortality was mostly in patients who lack basic or booster immunizations, are poorly nourished, or have bull neck, myocarditis, or hospital stays < 5 days.

Article Details

How to Cite
Nawing H, Pelupessy N, Alimadong H, Albar H. Clinical spectrum and outcomes of pediatric diphtheria. PI [Internet]. 18Feb.2019 [cited 6Dec.2021];59(1):38-3. Available from:
Infection & Tropical Pediatrics
Received 2018-11-26
Accepted 2019-02-18
Published 2019-02-18


1. Center for Disease Control and Prevention. Corynebacterium diphtheriae. In: Hamborsky J, Kroger A, Wolfe S, eds. Epidemiology & prevention of vaccine- preventable diseases. 13th ed. Washington D.C; Public Health Foundation, 2015. p. 107–17.
2. Galazka AM, Robertson SE. Diphtheria: changing patterns in the developing world and the industrialized world. Eur J Epidemiol. 1995;11:107-17.
3. WHO. Vaccine preventable disease: monitoring system 2016 global summary. Updated March 3, 2017; [cited 2017 March 27]. Available from:
4. WHO. Reported cases of selected vaccine preventable diseases. Diptheria year 2013. Last updated September 20, 2018. [cited 2017 March 27]. Available from:
5. Pusat Datan dan Informasi Kemenkes RI. Situasi imunisasi di Indonesia 2016. Jakarta: Kemenkes RI; 2016. p.5-6.
6. Murhekar MV, Bitragunta S. Persistence of diphtheria in India. Indian J Community Med. 2011;36:164–5. PMid:21976807 PMCid:PMC3180947
7. Bisgard KM, Rhodes P, Hardy IR, Litkina IL, Filatov NN, Monisov AA, et al. Diphtheria toxoid vaccine effectiveness: a case-control study in Russia. J Infect Dis. 2000;181 Suppl 1:S184–7. PMid:10657211
8. Nanthavong N, Black AP, Nouanthong P, Souvannaso C, Vilivong K, Muller CP, et al. Diphtheria in Lao PDR: insufficient coverage or ineffective vaccine? PLoS One. 2015;10:e0121749. PMid:25909365 PMCid:PMC4409043
9. Murakami H, Phuong NM, Thang HV, Chau NV, Giao PN, Tho ND. Endemic diphtheria in Ho Chi Minh City; Viet Nam: a matched case-control study to identify risk factors of incidence. Vaccine. 2010;28:8141–6. PMid:20937324
10. Maheriya KM, Pathak GH, Chauhan AV, Mehariya MK, Agrawal PC. Clinical and epidemiological profile of diphtheria in tertiary care hospital. Gujarat Med J. 2014;89:105-8.
11. Sardar JC, Saren AB, Haldar D, Chatterjee K, Biswas S, Chatterjee T, et al. Obstinate diphtheria needs innovation in immunization. Int J Contemp Pediatr. 2016;3:902-9.
12. Parande MV, Parande AM, Lakkannavar SL, Kholkute SD, Roy S. Diphtheria outbreak in rural North Karnataka, India. JMM Case Rep. 2014. DOI: 10.1099/jmmcr.0.003558.
13. Meera M, Rajarao M. Diphtheria in Andhra Pradesh- a clinical–epidemiological study. Int J Infect Dis. 2014;19:74-8. PMid:24295558
14. Singh SN, Singh A, Chandra S. Clinical profile and prediction of poor outcome of hospitalized diphtheria cases in children from Lucknow region of North India. Clinic Epidemiol Glob Health. 2014;2:75-9.
15. Kementrian Kesehatan RI. Imunisasi efektif cegah difteri. [cited 2017 March 27]. Available from:
16. Begg N & WHO. Manual for the management and control of diphtheria in the European region. Copenhagen: WHO, 1994. [cited 2017 March 27]. Available from:
17. Ikatan Dokter Anak Indonesia. Rekomendasi IDAI: Diagnosis dan tata laksana difteri. (Cited 2018 November 13). Available from:
18. WHO. Operational protocol for clinical management of diphtheria. [cited 2017 March 27]. Available from:
19. Diphtheria. NHS England; Department of Health and Social Care (DHSC). [cited 2015 June 28]. Available from:
20. Boyer NH, Weinstein L. Diphtheritic myocarditis. N Engl J Med. 1948;239:913-9. PMid:18103551
21. Ledbetter MK, Cannon AB, Costa AF. The electrocardiogram in diphtheritic myocarditis. Am Heart J. 1964;68:599-611.
22. Merritt RJ, Suskind RM. Nutritional survey of hospitalized pediatric patients. Am J Clin Nutr. 1979;32:1320-5. PMid:108993
23. WHO. The WHO child growth standards 2006. [cited 2017 March 27]. Available from:
24. Meshram RM, Patil A. Clinical profile and outcome of diphtheria in central India: a retrospective observational study. Int J Contemp Pediatr. 2018;5:1600-5.
25. Kole AK, Roy R, Kar SS. Cardiac involvement in diphtheria: study from a tertiary referral infectious disease hospital. Ann Trop Med Pub Health. 2012;5:302-6.
26. Basavaraja GV, Chebbi PG, Joshi S. Resurgence of diphtheria: clinical profile and outcome- a retrospective observational study. Int J Contemp Pediatr. 2016;3:60-3.
27. Bandichhode ST, Jatti GM, Anita MS, Nandimath VA. A clinical study of diphtheria cases in a pediatric population in tertiary care hospital in western Maharashtra. Indian J Child Health. 2016;3:251-3.
28. Khan MH, Aurakzai AI, Irshad M, Ullah I. Complications and outcome of diphtheria in admitted pediatric patients at a tertiary care setting in Peshawar. JPMI. 2018;32:242-5.
29. Morgan BC. Cardiac complications of diphtheria. Pediatrics. 1963;32:549-57 PMid:14069096
30. Ratageri VH, Bhanu PJ, Shivanand I, and Wari P. Diphtheria: time to introspect our immunization practices. Immunol Res Ther J. 2017;1:112.
31. Patel UV, Patel BH, Bhavsar BS, Dabhi HM, Doshi SK. A retrospective study of diphtheria cases, Rajkot, Gujarat. Indian J Com Med. 2004; 29:161.
32. Prasad PL, Rai PL. Prospective study of diphtheria for neurological complications. J Pediatr Neurosci. 2018;13:313-6. PMid:30271463 PMCid:PMC6144595
33. Havaldar PV, Sankpal MN, Doddannavar RP. Diphtheric myocarditis: clinical and laboratory parameters of prognosis and fatal outcome. Ann Trop Paediatr. 2000;20:209-15. PMid:11064774
34. Rapolu K, Parvathareddy KMR, Karumuri S, Polasa S, Thakkar A. Prognostic significance of electrocardiographic changes in diphtheria myocarditis: a cross-sectional study. Int J Clinic Med. 2014;5:910- 5.
35. Gundam BR, Sudarsi RK, Gundam A. Study of cardiac involvement in diphtheria. J Evid Based Med Health. 2016;3:3309-19.
36. Malley R, Lutsar I. Diptheria. In: Sharland M, Butler K, Cant A, Dagan R, Davies G, de Groot R, et al. Manual of childhood infection: the blue book. 4th edition. Oxford: Oxford University Press; 2016. p.520-3.
37. Center for Disease Control and Prevention. Corynebacterium diphtheriae. In: Hamborsky J, Kroger A, Wolfe S, eds. Epidemiology & prevention of vaccine- preventable diseases. 13th ed. Washington D.C; Public Health Foundation, 2015. p. 75–85.
38. Lalor MK, Floyd S, Gorak-Stolinska P, Weir RE, Blitz R, Branson K, et al. BCG vaccination: a role for vitamin D? PLoS One. 2011;6:e16709. PMid:21304967 PMCid:PMC3031626
39. Kaufman DR, De Calisto J, Simmons NL, Cruz AN, Villablanca EJ, Mora JR, et al. Vitamin A deficiency impairs vaccine-elicited gastrointestinal immunity. J Immunol. 2011;187:1877–83. PMid:21765014 PMCid:PMC3150351