DIPHTHERIA CASES 2015

Dr. N. Naidoo Department of Medical Microbiology

UKZN/NHLS

CASE 1 SM CONFIRMED

Date of Presentation 15 March 2015

Age 8 yr old male Referred : ENT - IALCH

Hospital / Area Umlazi –PMMH

Presenting History 3 day hx of : fever, sore throat,dyspnoea, odynophagia Ceftriaxone + Cloxacillin

Examination On arrival: Resp distress, swollen anterior neck, marked drooling •ENT : Tonsillar hypertrophy, greyish membrane covering uvula ?Diphtheria Emergency tracheostomy-securing of airway-ventilated Intra-op specimens – Tonsillar swab

CASE 1 SM CONFIRMED

Antibiotics Started on Penicillin, Gentamycin, Metronidazole empirically

Laboratory Results Tonsil swab : cultured C.diphtheriae Toxin testing : Positive

Immunisation History Immunisation Hx : 6, 10, 14 weeks, 18 months were RECEIVED Booster at 6 years – NOT RECEIVED

Outcome •Initial improvement •Referred back to PMMH •Died on 22 March 2015 ? Myocarditis related •Post mortem : Inconclusive

Contact Tracing Nil positive

Case 2 NM CONFIRMED

Date of Presentation 15 days later

Age • 9 yr old female

Hospital / Area • Umlazi – PMMH

Presenting History • 5 day hx of sore throat, progressive swelling of neck, difficulty swallowing &drooling.

Examination • Clinical exam : not in resp distress, bullneck • ENT : -Greyish, white membrane posterior

pharynx and uvula

Case 2 NM CONFIRMED

Laboratory Results • Throat swab : cultured C. diphtheriae • Toxin testing : Positive

Immunisation History • Immunisation Hx: 6, 10, 14 weeks received

• Did not receive : 18 months and booster at 6yrs

Outcome • Stable, D/C, No complications

Contact Tracing • Nil positive

Case 3 AS CONFIRMED

Date of Presentation • 30 March 2015 • 4 days after onset of sx- presented to RKK • On exam : swollen neck, cervical LAD, no UAO

Age • 9 yr old male

Hospital / Area • Chatsworth

Presenting History • GP : 2 day hx of sore throat, fever & dysphagia

Examination • Deteriorated- next 2 days • ENT exam : Whitish membrane back of throat Specimens taken

Case 3 AS CONFIRMED

Antibiotics • Tx with Penicillin IM at GP

Laboratory Results • Throat swab : cultured C.diphtheriae • Toxin testing : Positive

Immunisation History • Immunisation Hx : 6, 10, 14 weeks and 18 months received

• Did not receive the booster at 6 years

Outcome • Started on Co-amoxiclav, metronidazole

• Remained stable in hospital

• Developed myocarditis 10 days later • Cardiac failure

• Improved in hospital, D/C, cardiac clinic ffg up

Contact Tracing • Nil positive

Case 4 ZM

Date of Presentation 09 March 2015

Age 31 year old female

Hospital / Area • Briardene --Addington Hospital •Presenting History • Presented in resp distress • CXR-infective changes • Clinically dx as disem TB/PCP • c/o painful ulcer left inguinal

Examination • On exam : • 2 punched out lesions on left inguinal area

Case 4 ZMAntibiotics • Started on TB tx, Bactrim, Co-amoxi-

clav • Px responded to Tx clinically

Laboratory Results • Wound swab- groin : cultured C.diphtheriae • Toxin testing : negative

Immunisation History • Immunisation Hx: 6,10 ,14 weeks, 18 months received

• Booster at 6 years - not received

Outcome • Co-amoxiclav stopped, azithromycin added

Contact Tracing • 2 positive : • Non-toxigenic C. diphtheriae

CASE 5 SS STRONG CLINICAL SUSPICIONDate of Presentation 20 April 2015

Age 11 year old male

Hospital / Area Inanda- Nu-Shifa Hospital

Presenting History • 2 day hx of sore throat & fever

Examination • Dx as tonsillitis • Swabs taken by nursing staff • Within 12 hours-deteriorated-swelling of anterior neck,

drooling but no UAO • Seen by ENT: Oedema of oropharynx with whitish

membrane – • Strong clinical suspicion of Diphtheria Swabs repeated by ENT

CASE 5 SS STRONG CLINICAL SUSPICION

Antibiotics • Ceftriaxone

Laboratory Results • Both sets of Swabs : Negative

Immunisation History • Immunisation Hx: 6, 10, 14 weeks, 18 months-received

• Booster at 6 years - not received

Outcome • Subsequently Developed Myocarditis

• Condition improved

• After 3 weeks in hospital- D/C • Re-admitted this week: progressive worsening of

dysphagia

• Clinical examination –Neurological deficits

• Currently admitted

Contact Tracing Nil positive

CASE 6 AN CONFIRMEDDate of Presentation 22 April 2015

Age 8 years old female

Hospital / Area Port Shepstone

Presenting History • 3 day hx : sore throat, fever, neck swelling • Seen by GP : Dx Tonsillitis • 2 days later- Progressive worsening of sx • Referred to IALCH from P/S hospital

Examination • On presentation: neck swelling, drooling • ENT: • Bilateral inflamed tonsils with whitish membrane -Peritonsillar abscess : Aspirated

CASE 6 AN CONFIRMEDAntibiotics • Intubated-ICU

• Penicilin and azithromycin started

Laboratory Results • Swabs taken in ward and intra op • Throat and Tonsil swab : cultured C.diphtheriae • Toxin testing : Positive

Immunisation History • Immunisation Hx: • All vaccinations not received

Outcome Stable but has developed a new murmur Worked up for ?Myocarditis

Contact Tracing 3 siblings- Prophylaxis given to all contacts

• All positive for C.diphtheriae- Toxin pending

CASE 7 EN (Sibling 2) CONFIRMED

Date of Presentation 04 May 2015

Age 10 year old female (sibling)

Hospital / Area • contact sibling- seen at Port Shepstone –referred to IALCH

Presenting History • Presented : sore throat, mild submandibular swelling and drooling. No UAO

Examination • ENT : hyperemic, whitish membrane over soft palate and tonsils

Clinically stable

CASE 7 EN (Sibling 2) CONFIRMED

Antibiotics • Penicillin

Laboratory Results • Throat and Tonsil swab : cultured C.diphtheriae • Toxin testing : Pending • Px received anti –toxin on 7/05/2015 • Stable - improving • D/C from ICU- to ward

Immunisation History • Immunisation Hx: • All vaccinations not received

Outcome Stable transferred to High care

Contact Tracing 3 siblings- Prophylaxis given to all contacts

• All positive for C.diphtheriae- Toxin pending

CASE 8 AN (Sibling 3) PROBABLE

Date of Presentation 10 May 2015

Age 6 years old female

Hospital / Area • Admitted Port Shepstone Hospital • HD penicillin

SIBLING 4 –REMAINS WELL

Presenting History • Contact sibling – fell sick at home

Examination • Clinically well • ENT exam –Normal

CASE 8 AN (Sibling 3) PROBABLE

Antibiotics Penicillin

Laboratory Results • Swabs : Cultured C. diphtheriae • Toxin Testing : pending

Immunisation History • Immunisation Hx: • All vaccinations not received

Outcome Stable in hospital

Contact Tracing Sibling 4 remains stable

CASE 9 MK PROBABLE

Date of Presentation 03 May 2015

Age 41 year old female

Hospital / Area Yellow-wood park Entabeni

Presenting History • Resp distress • ?UAO • 5 day Hx –illness

Examination • severely ill, renal fx • Not seen by ENT

CASE 9 MK PROBABLEAntibiotics • Started on Imipenem and clarithromycin

• Decompensated rapidly- intubated • Died within 2days

Laboratory Results • Swabs from ETA : Cultured C. diphtheriae • Toxin testing: Pending

Immunisation History No history

Outcome Died

Contact Tracing • Pending • Husband admitted in St Augustines- ? Anxiety

CASE 10 MN PROBABLE

Date of Presentation 07 May 2015

Age 14 year old ? 9 year old male

Hospital / Area Kwadebeka- RKK

Presenting History • T/F IALCH- ICU Adult • Presented : Severe sepsis with shock, Respiratory

distress UAO ? Clinical Diphtheria Renal failure • Difficulty : Taking swabs

Examination • ENT : difficult examination, whitish membrane laryngeal oedema

• Renal physician • HD catheter for placement under platelet cover • Died 4hours after arrival ( 3 am -7 am)

CASE 10 MN PROBABLE

Antibiotics • Ceftriaxone but changed to Meropenem

Laboratory Results • Post mortem • Tonsil swab-Cultured C.diphtheriae • Toxin Testing : Pending

Immunisation History Not Available

Outcome Died

Contact Tracing Nil positive

Case 11 WM CONFIRMED

Date of Presentation 10 May 2015

Age 17 years old male

Hospital / Area Chatsworth- RKK

Presenting History • Seen at emergency • Resp distress, trismus of jaw unable to examine-

referred to IALCH

Examination • Seen by ENT • “Slash” Tracheostomy • ENT : Difficult to examine Swabs taken

Case 11 WM CONFIRMED

Antibiotics • Started on Penicillin and Clindamycin • Received antitoxin

Laboratory Results • Swabs : Cultured C diphtheriae Toxin Testing : pending

Immunisation History • Immunisation Hx: 6, 10 , 14 weeks , 18 months-received

• Booster at 6 years - not received

Outcome • Clinically stable • Weaning off ventilator • For transfer back to base hospital •

Contact Tracing Nil positive

IMMUNISATION

PX 6 W 10 W 14 W 18 M 6 YRS 12 YRS

SM YES YES YES YES NO NO

NM YES YES YES NO NO NO

AS YES YES YES YES NO NO

ZM YES YES YES YES NO NO

AN NO NO NO NO NO NO

MK YES YES YES YES NO NO

MN YES YES YES YES NO NO

WM YES YES YES YES NO NO

C.DIPHTHERIAE CULTURE + TOXIN +

C.DIPHTHERIAE CULTURE + TOXIN PENDING

C.DIPHTHERIAE CULTURE + TOXIN NEGATIVE

STRONG CLINICAL SUSPICION

SM AS- CONTACT 1 ZM SS

NM AS- CONTACT 2 ZM- CONTACT 1

AS AS- CONTACT 3 ZM- CONTACT 2

AN MK

WM

4 CONFIRMED 5 TOXIN PENDING 3 NON TOXIGENIC 1 CLINICAL

Acknowledgements• ID STAFF –Dr Archary • ENT DEPT-IALCH • MICRO DEPT - IALCH • ICU 4 STAFF • PMMH – STAFF • RKK- STAFF • ADDINGTON -STAFF • PRIVATE HOSPITAL- STAFF + LABORATORY • KZN-DOH • NICD TEAM • GREEN POINT