Introduction Despite the rarity of respiratory diphtheria in Australia, with an incidence of 0.002 per 100000 population per year, it is imperative Otolaryngologists hold a high index of suspicion when reviewing cases of tonsillitis, especially in rural Queensland. The risk of case fatality ranges from 5-20% depending on vaccination status and treatment availability. This case describes a fully vaccinated 13-year-old who presented with respiratory diphtheria to Townsville University Hospital. Case Presentation 13-year-old indigenous female, previously well and fully immunised, presented to the Emergency Department with a 2-day history of fevers and odynophagia. She was initially referred to the ENT team for a peritonsillar abscess. She had been treated with 2 days of oral phenoxymethylpenicillin in the community and was commenced on intravenous dexamethasone, benzylpenicillin and metronidazole. On examination she had left cervical lymphadenopathy, and a grey-white membrane covering the left tonsil. She had an aspirate of her peritonsillar space under local anaesthetic where no pus was received but a swab was taken. 2 days later, the pharyngeal swab had cultured Corynebacterium diphtheriae. The Infectious Diseases and Public Health team were contacted, a normal ECG was obtained, and 40000 units of intravenous Diphtheria anti-toxin was administered. The confirmation of toxigenic Diphtheria was only received 5 days after her admission, due to weather delays between Townsville and Brisbane. She remained well throughout her 6-day admission, with no evidence of systemic toxicity. She was discharged on oral phenoxymethylpenicillin, and household contacts and close contact staff were commenced on clearance antibiotics. Conclusion Locally acquired respiratory diphtheria is exceptionally rare and requires a high index of suspicion in rural Australia. ENT surgeons must be aware of the pharyngeal signs as these patients may be referred to us with tonsillitis, or as above quinsy.