Diphtheria : Is it really OUT?
Objective: To study the clinical spectrum of presentation in children admitted with suspected diphtheria.
Material and Methods: Case records of 115 cases with suspected diphtheria admitted from April 2009 to October 2011 in the Department of Paediatrics S N Medical College, Agra were analysed. A working Performa was designed to include the clinical presentation, investigation findings, immunization status and outcome of the treatment.
Results: Majority of cases 99/115 (86.09%) had acute presentation with characteristic gray-white membrane, rest 16/115 (13.9%) had late presentation. The acute presentation was on an average after 48-96 hours of onset of illness. Sites of membrane were – pharyngotonsillar in 71(71.71%), pharyngolaryngeal in 20(20.20%) and nasal in 8(8.08%). Sore throat, dysphagia, bull neck, cervical lymphadenopathy, respiratory distress and hoarsness of voice was present in 91(91.92%), 64(64.64%), 54(54.54%), 50(50.5%), 34 (34.34%) and 28 (28.28%) cases respectively. Only 6% cases received DPT doses appropriate for age, 2% were partially immunised and 92% cases were unimmunised. Confirmation of diphtheria microbiologically (KLB on peripheral smear) was observed in 11/99 (11.11%) of those having acute presentation. The clinical presentation and outcome of both KLB positive and KLB negative patients was almost similar. Sixteen cases who presented late, presented with neurological and/ or cardiac complications. All of them had history of fever, sore throat, dysphagia 2 to 4 weeks prior to onset of these complications. Their presentation was palatal palsy, palpitation and polyneuropathy in 16(100%), 7(43.75%) and 1(6.25%) cases respectively. None of these cases were fully immunised with DPT, 25% cases were partially immunised and 75% cases were unimmunized.
Conclusion: Diphtheria is the first differential diagnosis in patients presenting with membranous tonsillopharyngitis. The present study clearly depicts that diphtheria is still not a lost entity. There is a need to have high index of suspicion for diphtheria in cases presenting with membranous tonsillopharyngitis. Poor routine immunization is probably the reason and need to be strengthened.
Centers for disease control and prevention. Diphtheria Available at http://www. cdc.gov /diphtheria/surveillance.html. Accessed on 20/06/ 20 Vitek CR, Wharton M.Diphtheria in the former Soviet Union: Reemergence of a pandemic disease.Emerg Infect Dis 1998;4:539-550. Galazka AM, Robertson SE. Diphtheria: Changing patterns in the developing world and the industrialized world. Eur J Epidemiol 1995; 11: 107-117.
Patel UV, Patel BH, Bhavsar BS, Dabhi HM, Doshi SK. A retrospective study of diphtheria cases, Rajkot, Gujarat. Indian J Community Med 2004;24:161-3.
WHO .Diphtheria reported cases. Last update: 4Jun - 2013 (data as of 27 May 2013). http://apps. who.int/immunization_monitoring/globalsummar y/timeseries/tsincidencediphtheria.html. Accessed on 26/06/2013.
Singhal T, Lodha R, Kapil A, Jain Y , Kabra SK. Diphtheria –Down but not out. Indian Pediatrics 2000, 37:728-738.
Nandi R, De M ,Purkayastha P., Bhattacharjee AK. Diphtheria –the patch still remains. International congress series 1254. 2003 :3913 Nasal voice 11 75
Nasal regurgitation 13 25 Coughing/choking associated with swallowing 16 100 Irregular PR/HR rhythm 8 50 Bradycardia 2 5 Tachycardia 6 5 Irregular respiratory rhythm 1 25 Hypotension 2 5 Weakness in limbs(all) 1 25 Signs and symptoms of CNS &other diseases 0.0