Niger J Paed 2014; 41 (3): 247 –250  
Paul NI  
Ugwu RO  
Diphtheria in a 13 year old  
adolescent girl: Management  
Accepted: 10th April 2013  
Abstract: Background: Diphthe-  
ria is an acute toxic infection which  
is associated with a high morbidity  
and mortality and can pose man-  
agement challenges especially in  
the absence of proper diagnostic  
and therapeutic facilities.  
Case report: A.S. was a 13 year  
old girl who presented with fever  
of five days duration, dysphagia  
and neck swelling of 4 days dura-  
tion and sore throat and hoarse  
voice of 3days duration. Her ill-  
ness started a day after returning  
from a 4-day holiday youth camp.  
She received only oral polio vac-  
cine immunization in childhood.  
Significant physical examination  
findings included a swollen neck, a  
greyish membrane covering the  
soft palate and uvula with haemor-  
rhagic spots. The pharynx, anterior  
nares and the nasal turbinates were  
inflamed and erythematous.  
A working diagnosis of respiratory  
diphtheria was made. Throat swab  
microscopy showed club shaped  
Gram positive baccilli. Appropri-  
ate culture medium for C. diphthe-  
ria was not available.  
She received intravenous crystal-  
line penicillin and metronidazole  
and lateroral erythromyctihn in an  
isolated ward. On the 6 day of  
admission she developed cardiac  
and neurologic complications–  
bradycardia (PR=40bpm),  
hypotension (BP=70/40mmHg),  
drooling of saliva and paraparesis.  
Electrocardiography confirmed a  
completthe heart block. She died on  
the 11 day of admission while  
efforts were being made to raise  
funds for a cardiac pace maker.  
Conclusion: Management of this  
vaccine preventable disease re-  
quires a high index of suspicion  
and diphtheria antitoxin should be  
made readily available.  
Paul NI (  
Ugwu RO  
Department of Paediatrics & Child  
Faculty of Clinical Sciences  
University of Port Harcourt,  
Port Harcourt Nigeria.  
>95% across the region in the past 10 years . In Nigeria  
also, reported cases of diphtheria has been declining  
Diphtheria is an acute toxic infection caused by Coryne-  
bacterium species, typically Corynebacterium diphthe-  
riae and ,2r,3arely toxigenic strains of Corynebacterium  
even with just low to moderate coverage with DPT3.  
Accordingly, there has been no reported case from  
Our centre in the past 10 years.  
ulcerans . The classic disease affects the upper respi-  
ratory tract with the formation of an adherent gray-white  
pseudomembrane in the infected place followed by sys-  
temic symptoms caused by elaboration of an exotoxin  
However, recently there are pockets of sporadic cases  
being reported in Nigeria. Sadoh et al reported nine  
cases of diphtheria in children who were aged between  
11months and 10years in the University of Benin Teach-  
ing Hospital (UBTH) between 2008 and 2010, while  
produced by the bacillus . The disease progresses rap-  
idly with a case fatality rate as high as >20% in acute  
disease states if there is no sufficient diagnostic proce-  
Oyeyemi et al reported ten cases of diphtheria in chil-  
dure and therapy option . Therefore it requires a high  
dren aged 3-13years in the Federal Medical Centre  
Katsina on two clusters of diphtheria outbreak between  
2009 and 2010 involving three contiguous local govern-  
ment area in Katsina State. In this case we report a 13  
year old girl who died from probable diphtheria myocar-  
ditis and the diagnostic and management challenges  
index of suspicion. The most dominant factor causing  
death is myocarditis and diphtheria myocarditis inci-  
dences related to nasopharyngeal d5iphtheria is 10-20%  
with a death rate as high as 50-60% .  
The emergence of immunization program changed the  
epidemiology of the disease and reduced its prevalence  
worldwide. In the Western world, diphtheria is near  
Case Report  
eradication level in most countries . Also, in many Afri-  
can countries with a high diphtheria immunization cov-  
erage rate, the incidence of diphtheria has decreased by  
AS was a 13 year old girl who presented at the Children  
Out Patient Clinic of the University of Port Harcourt  
Teaching Hospital with complaints of fever of five  
days duration, dysphagia and neck swelling of four days  
duration, sore throat and hoarse voice of three days  
duration. Her illness started a day after returning from a  
four-day holiday youth camp. She received amoxicillin  
capsules before presentation. She had never been immu-  
nized except for Oral Polio Vaccines which she received  
on National Immunization Days (NIDs).  
Fig 2: ECG tracing of  
AS showing complete  
dissociation of the p  
wave and QRS com-  
plex which are wid-  
ened (172ms), idio-  
ventricular rhythm  
with rate of 25/mm  
and a giant T wave  
Physical examination revealed a lethargic child in pain-  
ful distress with a bull neck, hoarse voice, and drooling  
saliva. Throat inspection showed a thick greyish mem-  
brane covering most part of the soft palate and hanging  
down over the uvula with areas of haemorrhagic spots.  
The pharynx was erythematous, the anterior nares and  
the nasal turbinates were inflamed and plugged with  
blood crusts. (Fig 1) She had a good volume and regular  
pulse with a rate of 82 beats per minute, a blood  
Diphtheria is an acute toxic infection caused by Coryne-  
bacterium diphtheriae, an aerobic, non-encapsulated,  
Gram positive bacillus. C. diphtheriae is an exclusive  
pressure of 100/70mmhg and normal heart sounds. She  
had no neurological deficits.  
inhabitant of human mucous membranes and skin. It  
spreads primarily by airborne respiratory droplets, direct  
contact with respiratory secretions or exudates from  
infected skin lesion. Incidence peaks during the dry sea-  
son with majority of the cases occurring in unimmu-  
nized children below 15 years of age. Diphtheria occurs  
by entry of C. diphtheriae into the nose or mouth. After  
a 2-4 day incubation period, toxins are secreted which  
leads to toxin-mediated tissue necrosis. This coupled  
with local inflammatory response produces patchy exu-  
dates which later forms fibrinous exudates and a tough  
Fig 1: Greyish  
adherent membrane  
in the soft palate and  
uvula, and the haem-  
orrhagic exudates in  
the nostrils  
adherent membrane. Respiratory embarrassment may  
follow extension of disease into larynx or tracheobron-  
chial tree.  
A diagnosis of probable respiratory diphtheria was  
made. Microscopy of the throat swab and swab of the  
anterior nares showed club shaped Gram positive rods.  
Culture using Tellurite salt agar could not be done as  
this was not available. She was reviewed by the Otorhi-  
nolaryngologist while the State Disease Surveillance and  
Notification (DSN) unit was notified.  
Our patient never had DPT vaccine and hadjust returned  
from a crowded youth camp. These are strong risk fac-  
tors for respiratory diphtheria. She also presented with  
features typical of probable respiratory diphtheria like  
sore throat and dysphagia, progressive neck swelling,  
haemorrhagic and inflamed nasal turbinates and an ad-  
herent greyish white membrane hanging down the phar-  
ynx. The early presentation and short duration of these  
symptoms confirms the short incubation period and  
rapid progression of the disease as this child at presenta-  
tion within five days of disease onset was already very  
ill and lethargic.  
She was nursed in an isolation room, received intrave-  
nous crystalline penicillin at 0.4MU/kg/day in 4 divided  
doses, intravenous Metronidazole at 8mg/kg/dose every  
hours, intra venous fluid, oral toileting with saline wa-  
ter and bed rest. All close contacts were counseled espe-  
cially on the need to immunize all under-5 children  
whose last DPT dose was more than 12 months ago and  
were placed on Tablets Erythromycin – 500mg qds for  
two weeks.  
Complications remain the greatest cause of morbidity  
and mortality following infection with diphtheria. Com-  
plications secondary to the elaborated diphtheria toxin  
are the most common. Toxic cardiomyopathy most com-  
monly occur in the second week of the disease but can  
appear ,a10s early as the first or as late as the sixth week of  
By the 6 day of admission, she developed cardiovascu-  
lar complications – bradycardia (PR=40bpm) and  
hypotension (BP=70/40Hg). She received 20mls/kg of  
normal saline over 30minutes, intravenous hydrocorti-  
sone and Atropine with no apparent clinical ithmprove-  
ment. Her condition deteriorated and by the 7 day of  
admission her pulse rate dropped further down to 24bpm  
and the power in the lower limbs was reduced to grade  
two. A diagnosis of Diphtheria Toxic cardiomyopathy  
illness . Toxic cardiomyopathy occurs in 10–25% of  
patients with respiratory diphtheria and is responsible  
for 50–60% of deaths . Neurologic complications appear  
after a variable latent period, are predominantly bilateral  
and are motor rather than sensory and usually resolve  
completely. Paralysis of the soft palate is common and  
generally appears in the third week. Our patient devel-  
oped features of myocarditis by the second week of dis-  
ease onset and bilateral motor weakness of the lower  
limbs by the third week which is in line with disease  
Heart Block) and neuropathy (Para paresis) was made.  
An electrocardiogram confirmed a Complete Heart  
Block. (Fig 2) Parents were counselled on the need for  
an urgent pacemaker. Efforts were ongoing to raise fund  
for a pacemaker before she died on the 11 day of  
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  
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  
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  
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.  
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  
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