Difteri

Masa inkubasi: 2–5 hari

Difteri faring/tonsil (paling umum):

• Sakit tenggorokan yang memberat secara progresif

• Pseudomembran abu-abu keputihan di faring/tonsil — melekat erat, mudah berdarah jika dilepas paksa

• Demam ringan-sedang (37,5–38,5°C)

• "Bull neck" (leher banteng): Pembengkakan kelenjar getah bening dan edema jaringan lunak leher — tanda penyakit berat

• Suara serak, stridor (tanda obstruksi jalan napas)

• Disfagia (kesulitan menelan)

Difteri laring (croup difterik):

• Stridor, suara serak, batuk menggonggong

• Obstruksi jalan napas — dapat mengancam jiwa

Difteri kulit:

• Ulkus dengan dasar kotor dan pseudomembran — lebih umum di daerah tropis (termasuk Indonesia)

The risk of diphtheria is primarily determined by vaccination status and proximity to endemic or outbreak settings. The following factors increase the likelihood of infection and/or severe disease:

Risk factors for infection:

• Incomplete or absent vaccination: The dominant risk factor globally. In the 1990s outbreak in the former Soviet Union (>150,000 cases, >5,000 deaths), the majority of cases occurred in adults whose childhood vaccine-induced immunity had waned without booster doses.

• Living in or traveling to endemic areas: Regions with DTP3 coverage <80%, particularly sub-Saharan Africa, South Asia, and Southeast Asia

• Crowded living conditions: Military barracks, refugee camps, prisons, homeless shelters — outbreaks propagate rapidly in overcrowded settings with poor hygiene

• Close contact with a case or carrier: Household contacts of a diphtheria case have a secondary attack rate of 2–5% even in partially immunized populations

• Low socioeconomic status and poor hygiene: Both respiratory and cutaneous diphtheria are diseases of poverty

Risk factors for severe disease and death:

• Age: CFR is highest in children <5 years (up to 20%) and adults >40 years (up to 20–30%). The relatively lower CFR in older children and young adults (3–5%) reflects both immune maturity and lower membrane burden.

• Delayed antitoxin administration: Every day of delay after day 2 of illness increases mortality. Antitoxin given on day 1 is associated with ~1% CFR; by day 4+, CFR exceeds 15%.

• Extensive membrane: Membrane involving the larynx, trachea, or extending across the entire pharynx carries higher risk of airway obstruction and systemic toxicity.

• Bull-neck (severe cervical edema): Indicates massive toxin production and correlates with higher rates of myocarditis and neuropathy.

• Biotype: C. diphtheriae biotype gravis has historically been associated with more severe disease, though this correlation is not absolute.

Populations at increased risk in high-income countries:

• Adults aged >50 years (waning immunity, inadequate booster uptake — serological studies show 30–60% are below protective antibody levels)

• Immigrants and refugees from low-coverage countries

• Homeless populations (cutaneous diphtheria)

• Healthcare workers in contact with cases

Miokarditis toksik (10–25%): Penyebab kematian utama. Onset 1–2 minggu setelah infeksi. Manifestasi: aritmia (blok AV, blok cabang), gagal jantung akut. Mortalitas miokarditis difteri: 50–60%. Neuropati perifer: Paralisis palatum (suara sengau, regurgitasi nasal, minggu ke-3), paralisis otot ekstraokular, neuropati perifer ascending (mirip Guillain-Barré, minggu ke-5–7). Obstruksi jalan napas: Pseudomembran yang meluas ke laring/trakea. Gagal ginjal akut: Akibat nefrotoksisitas toksin.

Mortalitas: 5–10% secara keseluruhan. Tanpa antitoksin: hingga 50%. Indonesia (KLB 2017): CFR ~2–5%.