Adult diphtheria in Malaysia: A case report

In November 2016, a 28-year-old Malay man presented to the emergency department in respiratory distress, with a history of fever and sore throat. A clinical diagnosis of acute diphtheria was made and the patient was isolated and ventilated in the intensive care unit, and received diphtheria antitoxin and intravenous antibiotics. Initial laboratory findings failed to confirm diphtheria, leading to discontinuation of antibiotics and quarantine. Public health measures were reinstated after a reference laboratory cultured Corynebacterium diphtheriae. Although there was no contact with ill persons, investigation revealed incomplete immunisation history, and injection of high dose steroids prior to onset of symptoms.

Diphtheria, pertussis, and tetanus: evidence-based management of pediatric patients in the emergency department

Diphtheria, pertussis, and tetanus are potentially deadly bacterial infections that are largely preventable through vaccination, though they remain in the population. This issue reviews the epidemiology, pathophysiology, diagnosis, and current recommended emergency management of these conditions. Disease-specific medications, as well as treatment of the secondary complications, are examined in light of the best current evidence. Resources include obtaining diphtheria antitoxin from the United States Centers for Disease Control and Prevention and best-practice recommendations with regard to testing, involvement of government health agencies, isolation of the patient, and identification and treatment of close contacts. Most importantly, issues regarding vaccination and prevention are highlighted.

Notes from the field: respiratory diphtheria-like illness caused by toxigenic Corynebacterium ulcerans --- Idaho, 2010

On September 12, 2010, the Idaho Department of Health and Welfare was notified of a case of respiratory diphtheria-like illness in an Idaho man aged 80 years whose pharyngeal specimens yielded Corynebacterium ulcerans. Although C. ulcerans is zoonotic, the patient reported no animal contact or consumption of an unpasteurized dairy product. His vaccination history was unknown. Respiratory diphtheria-like illness from C. ulcerans is uncommon but has been reported in industrialized countries where respiratory diphtheria is rare. The last case of diphtheria-like illness caused by C. ulcerans in the United States was reported in 2005.

A diphtheria outbreak in Buri Ram, Thailand

In May 1996 there was an outbreak of diphtheria in Buri Ram, Thailand which infected 31 patients, 8 males and 23 females. The mean age of the patients was 8 +/- 5 years. Seventy-four percent had a history of childhood vaccinations. Common signs and symptoms included fever (100%) which was low grade in 61%, sore throat (90%), upper airway obstruction (3%), and hoarseness (10%). Pseudomembranes (seen in 100%) were located on the tonsils (71%), pharynx (22%), larynx (9.6%), and uvula (6%). The mean duration of symptoms prior to admission was 2 days with a range of 1 to 5 days. Complications included upper airway obstruction (10%) and cardiac complications (10%). There were no neurological complication or deaths. There were negative associations between cardiac complications, severity of disease and previous diphtheria vaccination. The ages varied from children to adults. Early recognition and prompt treatment decreased complications and mortality in this group of patients when compared with Chiang Mai and Queen Sirikit National Institute of Child Health (QSNICH) studies.

Locating therapeutic vaccines in nineteenth-century history

This essay places some therapeutic vaccines, including particularly the diphtheria antitoxin, into their larger historical context of the late nineteenth century. As industrially produced drugs, these vaccines ought to be seen in connection with the structural changes in medicine and pharmacology at the time. Given the spread of industrial culture and technology into the field of medicine and pharmacology, therapeutic vaccines can be understood as boundary objects that required and facilitated communication between industrialists, medical researchers, public health officials, and clinicians. It was in particular in relation to evaluation and testing for efficacy in animal models that these medicines became a model for twentieth-century medicine. In addition, these medicines came into being as a parallel invention in two very distinct local cultures of research: the Institut Pasteur in Paris and the Institut für Infektionskrankheiten in Berlin. While their local cultural origins were plainly visible, the medicines played an important role in the alignment of the methods and objects that took place in bacteriology research in France and Germany in the 1890s. This article assesses the two locally specific regimes for control in France and in Imperial Germany. In France the Institut Pasteur, building on earlier successful vaccines, enjoyed freedom from scrutinizing control. The tight and elaborate system of control that evolved in Imperial Germany is portrayed as being reliant on experiences that were drawn from the dramatic events that surrounded the launching of a first example of so-called "bacteriological medicine," tuberculin, in 1890.

[Paul Ehrlich and commercial serum production: on the control of diphtheria antitoxin in the laboratory and in industry]

The state control of the anti-diphtheria serum is a prime example for the efficient cooperation between state authorities, industrials and scientists. The article describes firstly the dynamics of this development and places it in the context of already existing approaches to drugs control. Of special interest are the motives which led the different actors to support the state control of sera. Secondly the reciprocal influences between Ehrlich and the serum producers are analyzed. It is shown that practical problems inspired Ehrlich's theoretical work, which in return led to an improvement of measurement techniques.

[Donor human antidiphtheritic immunoglobulin is an alternative to xenogeneic antidiphtheritic serum]

A new donor antidiphtheritic immunoglobulin produced in the Hematology and Transfusiology Institute of AMS of Ukraine and Donetsk transfusiology station is discussed in the article. The medication, antidiphtheritic horse serum had been used during the diphtheria epidemic, as a medication in Donetsk clinics. The medication meets requirements of State and International Standards and is registered in Ukraine.

Diphtheria: the patch remains

This study analysed the number of patients admitted with diphtheria to a teaching hospital in the state of Assam in India over a period of five years and compared the disease characteristics and management with outcomes and incidences of diphtheria reported in the literature. It was a retrospective analysis of data elicited from clinical records of patients admitted to hospital. A total of 101 admissions were recorded during a five-year period between March 1997 to March 2002, mostly with pharyngeal diphtheria (90 per cent). The majority of patients had no history of immunization (70 per cent). Significant presenting features were a tonsillar patch, sore throat, respiratory distress and fever. All patients were treated with anti-diphtheritic serum and intravenous antibiotics. Steroids were given to 81 per cent of patients and tracheostomy was carried out in 10 per cent of cases. The mortality was 16 per cent. Diphtheria of the respiratory tract remains a potentially fatal disease commonly presenting with membranous pharyngitis. Early diagnosis and treatment with anti-diphtheritic serum and antibiotics remain the cornerstone of treatment. Inadequate immunization cover is deemed responsible for the continued menace of diphtheria.

Cardiac diphtheria in a previously immunized individual

A previously healthy 19-year-old Asian female without significant past medical history presented to the emergency room complaining of a sore throat, difficulty in swallowing, fever, swollen neck, malaise, and myalgia for three to four days. The patient was initially seen at an outside hospital, evaluated by an ear, nose, and throat physician (ENT), and was found to have desquamative pharyngitis. The patient was transferred to our hospital after she continued to experience progressively worsening shortness of breath and went into acute respiratory distress. The patient was found to have laryngeal edema on exam with greenish-black, necrotic-looking tissue extending to the hypopharynx, nasopharynx, and oropharynx. A culture was taken. ENT was consulted for tracheostomy placement. The patient refused to have tracheostomy placed. She went into severe respiratory distress and required urgent tracheostomy. A cardiac consult was obtained. A 2D echocardiogram performed one day after admission revealed an ejection fraction (EF) of 10-20%, normal left ventricular cavity size, normal wall thickness, and severe global systolic dysfunction. There was mild to moderate mitral regurgitation and trace tricuspid regurgitation. The inferior vena cava was dilated and a 1 cm x 1.5 cm questionable mass or thrombus was seen. The patient's throat culture was positive for diphtheria. The CDC was contacted, and the patient was treated with antitoxin with prompt resolution of cardiac symptoms. A repeat echo done five days post-treatment showed improved EF of 65%, normal left ventricular thickness and function, with no clot visualized. She was treated with ceftriaxone and flagyl for ocular motor neuritis, otitis media, and strep. pneumonia with gradual improvement. These were all secondary to the diphtheria toxins, however, the patient continues to be followed as an outpatient by ENT for ongoing problems with swallowing, speech, and trach management.

[Treatment of acute experimental diphtheria toxemia by immunohemosorption]

The antitoxic antidiphtheric immunosorbent DATs was tested in experiments on mice and guinea-pigs using the model of acute diphtheric toxemia. In extracorporeal connecting with the circulation system of the animals the sorbent effectively bound and eliminated from the circulation molecules of diphtheric toxin and antitoxin, reduced significantly their levels in the blood after hemoperfusion. The effectiveness of the immunosorbent DATs was confirmed when it saved the ginea-pigs after injection of lethal toxin doses.

[Mathematical model of the infection process in diphtheria for determining the therapeutic dose of antitoxic anti-diphtheria serum]

It is known that administration of horse serum against diphtheria toxin can cause autoimmune and allergic complications. Therefore it is important for improvement of serotherapy to develop methods of prediction of disease course and quantity of diphtheria toxin and antitoxic antibodies in a serum. We have developed the mathematical model of diphtheria infection, which consists of six differential equations describing dynamics of diphtheria toxin and antitoxic antibodies in a serum, quantity of infection agent and macrophages in a site of inflammation. This mathematical model allows to predict the course of infectious process, the level of diphtheria toxin and antitoxic antibodies in the sera of people with diphtheria and to calculate the individual therapeutic dose of antitoxic serum for each patient.

Control of diphtheria: guidance for consultants in communicable disease control. World Health Organization

These guidelines for the control and management of diphtheria are intended for consultants in communicable disease control and regional epidemiologists in England and Wales. They are intended to complement existing guidance from the World Health Organization. The guidelines cover the immediate steps to be taken following identification of a case, what is required to confirm the diagnosis, steps to be taken to minimise the likelihood of further linked cases, and what should be done to disseminate information after a case.

[Fulminant diphtheria myocarditis in an unvaccinated preschool child]

We describe a case of a three year old unvaccinated child who developed a fulminant diphtheric myocarditis and nephritis four days after the onset of a tonsillar diphtheria. Despite of the administration of antitoxin on day three and four the child died within 48 hours from the beginning of rhythm disturbances. The cardiac involvement rapidly progressed from bradyarrhythmias with the necessity of a temporary pacemaker to ventricular rhythm disturbances with cardiac failure and final ventricular fibrillation.

Cutaneous and pharyngeal diphtheria imported from the Indian subcontinent

We report the case of a 32-year-old woman who presented upon returning from India with cutaneous ulcers on the feet and pharyngitis. Microbiological testing showed the causative organism to be a toxigenic strain of Corynebacterium diphtheriae. She was treated successfully with penicillin and diphtheria antitoxin. This case emphasises the importance of maintaining a high index of suspicion for such rare but significant infectious diseases.

[Toxic diphtheria caused by Corynebacterium ulcerans]

A 42-year-old woman with bronchial asthma since childhood was admitted to hospital because of severe dyspnoea. Emergency bronchoscopic intubation had to be performed for life-threatening inspiratory and expiratory stridor. This demonstrated that the larynx was covered by a dirty-grey membrane and the vocal-cord gap was narrowed to a mere slit. As laryngeal diphtheria was suspected 2000 IU/kg diphtheria antitoxin was administered together with 1 mega U penicillin G four times daily intravenously. On the same day, Corynebacterium ulcerans, a very rare cause of diphtheria, was isolated from a coughed-up piece of the membrane. Toxic, massive swelling of the lymph nodes and soft tissues of the neck necessitated maintenance of an open upper airway by intubation and (later) tracheostomy for 41 days. A week later the patient was discharged without any permanent defect.

Diphtheria in the eighties: experience in a south Indian district hospital

Epidemiological and clinical analysis of 228 cases of diphtheria treated during a 10-year period from 1980-1989 is presented. No statistically significant change in the incidence over a decade was noticed. A high percentage of cases (44.74%) were noted in the age group of 5 years and above. Bilateral tonsillar and pharyngeal membranes together were seen in 60% cases. All patients were treated with diphtheria antitoxin and benzyl penicillin. Severe myocarditis (9 cases), fulminant haemorrhagic complications (2 cases), palatal palsies (11 cases) and polyneuritis and cranial nerve paralysis (2 cases) were the significant complications. Case fatality rate was 13.21%. Statistically significant increase in the mortality (p less than 0.05) was noticed in the year 1987 and onwards. In this period, myocarditis (8 out of 16 deaths) is gradually replacing laryngeal obstruction, the major cause of death in early eighties or post-tracheostomy complications (6 out of 16 deaths). Only 2 patients died of haemorrhagic diphtheria in this period.

Diphtheria among alcoholic urban adults. A decade of experience in Seattle

Three outbreaks of Corynebacterium diphtheriae infection occurred in Seattle's Skid Road from 1972 through 1982. The first involved a single toxigenic, intermedius biotype clone, whereas the second and third outbreaks involved nontoxigenic mitis and gravis strains. Of 1100 total infections, 947 (86%) were cutaneous. The incidence was highest in winter and spring. In Skid Road, the estimated attack rate during 17 months in 1974 to 1975 was 5% for whites and 27% for native Americans. Streptococcus pyogenes was isolated from 73% of diphtheritic and 41% of nondiphtheritic skin lesions (P less than 0.001). Skin infection and environmental contamination by C. diphtheriae were correlated. Complications occurred in 21% of symptomatic nasopharyngeal and 3% of cutaneous toxigenic intermedius infections (P less than 0.001), and were significantly correlated with ages 60 years or more. Preferential use of erythromycin for diphtheria and pyodermas preceded plasmid-mediated resistance to erythromycin in C. diphtheriae. Diphtheria outbreaks in urban alcoholic persons are associated with poor hygiene, crowding, season, contaminated fomites, underlying skin disease, hyperendemic streptococcal pyoderma, and introduction of new strains from exogenous reservoirs.

[Pharyngeal diphtheria diagnosed too late, fatal course of the disease]

In the course of an endemic lasting 13 months we saw three cases of toxic pharyngeal diphtheria. In spite of immediate treatment with serum and penicillin two patients died, including a 14 year-old girl who had been treated inadequately for two weeks. Serum along with antibiotics must be given as soon as diphtheria is suspected. Without the immediate administration of serum the mortality of diphtheria remains very high.

The changing epidemiology of diphtheria in Jordan

Outbreaks of diphtheria used to occur regularly in Jordan, the last such outbreak being in 1977-78. Since that time, a massive immunization programme targeted at pre-school-age children has been markedly successful. Hence, when an outbreak of diphtheria occurred in 1982-83, it was unexpected. Of the 35 patients who were treated at the Jordan University Hospital, two died and the remaining 33 recovered uneventfully. Contrary to our findings in previous diphtheria epidemics in Jordan, this outbreak largely involved adolescents and young adults.

Hemorrhagic diphtheria

Two cases of hemorrhagic diphtheria, a rare entity and severest form are reported. Both of them have been mildly ill for more than 3 days and did not seek medical attention, suddenly developed bleeding episodes with clinical evidence of diphtheria in association with severe thrombocytopenia. Inspite of antitoxin, antibiotics therapy and supportive care one died on the third day. The second case was given additional steroid therapy to the regimen and survived with diphtheria myocarditis.

[A case of diphtheria resulting in death]

A 10 years old girl admitted to the hospital on 7.5.1983. She was sent from Etimesgut Hospital with the preliminary diagnosis of diphtheria bronchopneumonia, and glomerulonephritis. Cultures taken from the throat and nose of the patient yielded toxigenic diphtheria bacilli. Inspite of antitoxin and antibiotic treatment and a tracheostomy the patient died two days later. Diphtheritic membranes occluding larynx and trachea were found at the autopsy. In six out of the nine of the family members the throat cultures were found to be positive for toxigenic C. diphtheriae. The family was visited by a woman who had a bloody nasal discharge and ulcers around her nostrils. Close contacts, including the neighbours and the classmates of the children were checked for diphtheria bacilli and all were found to be negative.

Diphtheria carriers in Manchester: simultaneous infection with toxigenic and non-toxigenic mitis strains

A toxigenic strain of Corynebacterium diphtheriae mitis was isolated from a 10-week-old baby with membranous tonsillitis, and over the next 6 months thirty-nine symptom-free carriers of nitrate-positive mitis strains were found. All carriers were cleared by 14 days' treatment with erythromycin, though several relapsed after a 5-day course. Four contacts carried both toxigenic and non-toxigenic mitis strains; epidemiological evidence and phage studies suggest that these had a common origin. These findings have implications for the epidemiology of diphtheria and for the routine testing of isolates for toxigenicity.

[Severe diphtheria with acute myocardial infarction (author's transl)]

Report on a female patient with severe diphtheria and electrocardiographic changes of acute myocardial infarction. Cases of such a kind seem to be seldom, as a review of international literature shows.