2
49
progression. This early onset of cardiac manifestation is
associated with rapid disease progression and is a poor
prognostic feature as was the case of our patient. Drool-
ing of saliva and hoarse voice in this patient may be due
to sore throat and dysphagia or to paralysis of the soft
palate.
respond to it. This was probably because the disease has
reached an advanced stage before presentation and
elaborated toxins may have fixed to tissues which are
not affected by antibiotics. Management of complica-
tions was also challenging. Our case developed both
cardiac and neurologic complications both of which may
have contributed to the mortality. Although she was
diagnosed of having complete heart block, lack of funds
and unavailability of the pacemaker made this manage-
ment option not available
A
diagnosis of diphtheria may be described as
“probable” or “confirmed”. It is probable if the case
meets the clinical description or confirmed if a probable
case is laboratory confirmed or linked epidemiologically
to a laboratory confirmed case. A clinical description is
an illness characterized by laryngitis or pharyngitis or
tonsillitis, and an adherent membrane on the tonsils,
pharynx and/or nose. However, persons with positive C.
diphtheriae cultures and not meeting the clinical de-
scription (i.e. asymptomatic carriers) should not be re-
ported as probable or confirmed diphtheria cases. Our
patient met the criteria for probable diphtheria but could
not be confirmed. Our centre and many others in Nigeria
lack the appropriate capacity and skills for the isolation
of this organism and this does have several deleterious
effects on the management and surveillance of this
vaccine preventable disease.
Primary prevention in form of active immunization as
DPT vaccine at 6,10, 14 weeks of age and booster dose
at 15-18 months and again between 4-6 years of age is
recommended. The National Programme on Immuniza-
tion (NPI) presently does not provide booster doses but
a high coverage rate in infancy provides significant dis-
ease protection. Unfortunately, our case received neither
the primary vaccine nor booster dose. This buttresses the
need to reinforce and ensure full coverage of primary
immunization by checking immunization cards as a re-
quirement for school enrolment.
All household contacts and those who have had intimate
physical contact with a patient are closely monitored for
illness through the 7-day incubation period. Antibiotic
prophylaxis is given, regardless of immunization status
using erythromycin (40-50 mg/kg/day) for 7-14 days or
A lot of challenges were encountered in the management
of this patient. Once diphtheria is suspected, manage-
ment entails isolation of the patient, use of specific anti-
toxin and antibiotics, management of complications,
supportive care and chemoprophylaxis for close contacts
of patient. The first management challenge was lack of
specific diphtheria antitoxin. The use of specific anti-
toxin is vital in halting disease progression. Antitoxin
can neutralize circulating toxin or toxin that is absorbed
to cells but is ineffective once cell penetration has oc-
curred. Specific antitoxin is the main stay of therapy and
should be administered as early as possible by intrave-
nous route and in a dosage sufficient to neutralize the
free toxin. Unfortunately as important as this is in the
treatment of patient with diphtheria this anti toxin is
unavailable in the country. Only a probable diagnosis
could be made in this case as it could not be bacte-
riologically confirmed by the appropriate culture
1
a single injection of benzathine penicillin. This was
done for all close contacts of our patient including the
managing team. Unfortunately, it was not possible to
trace the asymptomatic carrier from whom our patient
contracted the disease, neither was it possible to trace
other adolescents that participated in the youth camp for
possible development of symptoms.
Conclusion
In conclusion, diphtheria, a vaccine preventable disease
(VPD) is a disease with rapid progression and requires a
high index of suspicion. Facilities necessary for the di-
agnosis and treatment of this disease especially diphthe-
ria specific antitoxin should be made readily available in
Nigeria. Parents and caregivers of children should utilize
the opportunity of free immunizations to vaccinate their
children, for indeed, prevention is better than cure.
medium. This challenge may not be limited to our cen-
tre as many other centres contacted to assist with the
culture also admitted not having the culture medium.
Antibiotics are indicated to clear the causative organism
and thereby halt toxin production, and prevent transmis-
sion of organisms to contacts. Our patient received intra
venous crystalline penicilline and metronidazole which
have very good coverage for diphtheria but did not
Conflict of interest: None
Funding: None
References
2
.
Seto Y, Komiya T, Iwaki M,
3. De Zoysa A, Hawkey PM, Engler
K, George R, Mann G, Reilly W.
Characterization of toxigenic
Corynebacterium ulcerans strains
isolated from humans and domes-
tic cats in the United Kingdom. J
Clin Microbiol. 2005;43:4377–81
1
.
Stephen B E. Diphtheria In: Behr-
man RE, Kliegman RM, Jenson
HB, Stanton BF. (editors) Nelson
Textbook of Pediatrics, 18th edi-
tion. Philadelphia: W.B. Saunders
Company, 2007. 1153-1157.
Kohda T, Mukamoto M, Takaha-
shi M. Properties of corynephage
attachment site and molecular
epidemiology of Corynebacterium
ulcerans isolated from humans and
animals in Japan. Jpn J Infect Dis.
2
008;61:116–22