Case Report

A 4 Years Old Boy with

Severe Diphtheria and Its Complications

By:
Khodimatur Rofiah , MD

Tutor :
Irene Ratridewi, MD, Paed (C)

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 ABBREVIATION
• ADS : Anti Diphtheria Serum
• C : Celcius
• C.diphtheria : Corynebacterium diphtheria
• G : gram
• mg : miligram
• IU : International Unit
• kg : kilogram
• P : Percentile
• PCR : Polymerase Chain Reaction
• WHO : World Health Organization

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 Introduction
• According to the WHO, 4,500-5,500 cases of diphtheria were
reported annually worldwide between 2011 and 2013, with the
majority occurring in India and Indonesia
World Health Organization , 2014

• Increased immunization rates, rare circulation of toxigenic strains,

and improved living conditions have controlled diphtheria in
developed countries
Pikering L et al, 2012

• The disease persists because of regional variations in compliance

with vaccination and inadequate booster regimens

Tiwari T, 2011

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 Introduction

The aim of this paper is to report a rare case of a 4-years-old boy with
complete imunization status may suffer from severe diphtheria with
its complications

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CASE REPORT

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 Identity
• Name : RZ
• Sex : Boy
• Age : 4 years old
• Body weight : 14.5 kgs
• Admitted : March 9th, 2018
• Address : Ds. Karang Megah, Wonorejo
Pasuruan

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 History of Present Illness

Main complain : Dysphagia , Fever,

Sore throat

March 6th, 2018 March 7th, 2018 March 8th, 2018 March 9th, 2018

Public Health Center

Midwife Public Health Center Pediatrician
(no doctor)
2 medication (no doctor) in Pasuruan
(pulv) with diagnosed Tonsilitis
Got Pulv Medika Pandaan
Mouth drops Pasuruan with diagnose
Severe Diphtheria

Neck looked swollen

Breath by mouth but no dispnea, snorring Saiful Anwar Hospital
 History Taking

History of immunization
• Hep Bo,1,2,3 (+)
• BCG (+)
• DPT 1,2,3,4, ORI (+) 1x
• Polio 1,2,3,4
• Campak (+)

Contact History of Diphtheria ?

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 History Taking

History of mother’s pregnancy

• Within normal limit

Nutrition History
• He get good nutrition from dishes, vegetables, and milk

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 Physical Examination
March 9th, 2018
General Appearance : spontaneous breathing, compos mentis
Vital Signs : GCS 456 HR 142 x/mnt, RR 32 x/mnt, Tax: 38,2 C, SaO2 96% BP 95/54
mmHg
Head and Neck : greyish-white discharge on the bilateral tonsil and larynx
nasal flare
Thorax : Symmetric , retraction (+) intertercostal, suprasternal, stidor
Pulmo : ronkhi – wheezing -/-
Cor : S1 S2 regular(+), murmur (-), gallop (-)
Abdomen : normal
Extremities : no cyanosis, warm acral
Status Neurological : normal

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 ANTROPOMETRIC MEASUREMENT

Body Weight : 14.5 kg (-

2SD to mean)

Body Height : 97 cm (-
2SD to mean)

Upper Arm Circumference:

14 cm (-2SD to -1SD)

Head Circumference: 52 cm
(mean to 2SD)

Body weight for height:

mean
The nutrition status is a good nutrition
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CLINICAL MANIFESTATION

March 10th, 2018

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 Consult to Otolaryngology Department
(March 10th, 2018)

Conclusion:
• Upper Respiratory Tract Obstruction Jackson II-III

Suggestion :
• Tracheostomy cito

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 Working Diagnosis

1. Laryngeal Diphtheria & Bullneck

2. Upper Airway Obstruction Type Jackson II-
III dt Larynx Diphtheria
3. Myocarditis

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 THERAPY

- Tracheostomy  mechanical ventilator

- IVFD C 1:2 500 ml/day
- IV. Paracetamol 10 mg/kg/times
- IV. Metylprednisolone 2 mg/kg/day
- IM. Penicillin Procain 100,000 IU/kgBW
- Anti Diphtheria Serum 80,000 IU (separated dose,
because of the ADS availability)
- Nebulization epinephrine per 1-2 hour

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 PROGRESSION OF THE DISEASE

March 19th, 2018

March 11st, 2018
(nine days of hospitalization)
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CHEST X-RAY (March 10th, 2018)

The result was within normal limit

After ventilator 17
 CHEST X-RAY (March 10th, 2018)

Airway stricture of the cervical vertrebae as high as 2,3,4 18

 Parameter March 9th March 10th March 12nd
INITIAL LABORATORY FINDINGS
Hemoglobin 12,1 11,3 9,1
Leucocyte 11.540 10.540 10.350
Hematocrits 36,4 33,1 27,3
Trombocyte 253000 233.000 282.000
Eosinfil 0 0 0
Basofil 0,7 0,1 0
Neutrofil 33,2 41 44,89
Lymphocyte 53,2 45,3 42,2
Monocyte 12,9 13,6 12,9
CRP 3,02
PPT/APTT 11,2 / 26,3
AST/ALT/Alb 32/15/3,09
Ur/Cr 23,7/0,26 15,3/0,25
Electrolyte serum 134/4,12/105/8,4 136/4,13/106/8,0
BGA 7,39/26/208,4/16,2/-9/99,7 7,43/27/136/18,3/-6,2/99

Troponin I 0,1 (negatif) 19

 Parameter March 10th March 13rd March 15th March 17th
INITIAL LABORATORY FINDINGS
A troath swab Diphtheria : Diphtheria : Diphtheria : negative
culture: negative negative

ECG Strain : - Strain : -

Normo axis Normo axis
Rhytm : Sinus Tachycardia Rhytm : Sinus Tachycardia
(no prolong P-R interval,
(no prolong P-R interval, no T-wave change)
no T-wave change)

Echo- Chamber dilatation LA,LV.

cardiografi Systolic function : EF 30-46% , FS 16-23%
Dyastolic function: E/A 1,82
Mild Aorta Regurgitation, mild pulmonal regurgitation

Conclution : Dilated cardiomyopati due to myocarditis

Advice: IV. Metylprednisolon 2 mg/kg/day
Dobutamin 5 mcg/kg/m
iv. Furosemid 2x10 mg
Target deficit balances 10cc/kg

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 Electrocardiography (March 10th, 2018)

Electrocardiograhy indicated sinus tachycardia 150 times/minute,

normal axis, and no heart chamber enlargement

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 CHIEF COMPLAINT

4-years-old boy
Dysphagia

Diphtheria Infectious Streptococcal Vincent’s

Mononucleosis Tonsilitis Angina

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 Differensial Diagnosis
Infectious Streptococcus throat Vincent’s Angina Diphtheria
mononucleus
- Fever - Sore throat - Swelling and - Dysphagia
- Sore throat - Fever of greater sloughing off of - Sore throat
- Enlarge tonsil with than 38 °C dead tissue from - fever less than
pus - Tonsillar exudates the mouth and 38.2 °C
- Lymphadenopathy (pus on the throat , - greyish-white
(posterior), tonsils) - interdental discharge on the
mobile, no pain, - Large cervical papillae are bilateral tonsil and
nonerytaemotous lymph nodes ulceratif larynx which
- Cervical lymph bleeds on removal
node enlargement
are rare

could be excluded
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Based on history taking,
physical findings,
laboratory findings

Laryngeal Diphtheria
(pseudomembrane,
snorring) with upper
respiratory tract blockage
(dyspneu, stridor)
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 The result swab culture throat in this case showed
negative for C. Diphtheriae.

• Specimen handling (swab cannot be taken to the deep surface

of the membrane)
• Swab was taken after antibiotic therapy
• Clinical appearance  strongly indicated as diphtheria (low
grade fever, pain while swallowing, pseudomembrane +)
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 Diphtheria

An infection disease, manifests as either

upper respiratory tract or cutaneus
infection and is caused by the aerobic
gram-positive bacteria, Corynebacterium
diphtheria
Soedarmo S, 2012
Long S, Pickering LK, Prober C. 2012

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 Pathogenesis of Diphtheria
Penetration of bacillus
(no bacteremia)

Local fibrous inflamation Pseudomembrane

Toxinemia & penetration of the toxin into the tissue Bullneck

Blocking of ribosomes & cell necrosis

Cardiomyocites & Myelin layer Tubular ephitelium

conducting sytem of the heart of peripheral nerves of the Kidney

MYOCARDITIS NEURITIS NEPHRITIS

Ford, 2010 27
 Complication

PARALICYS PARALICYS
PARALICYS
LOCAL LOCAL
MYOCARDITIS LOCAL NERVE
NERVE NERVE

Week 1 2 3 4 5 6 7 8 9 10

PARALICYS
BLOCK
NERVE
ACUTE CRANIALIS
KIDNEY
INJURY
• Complication of diphtheria in this case  myocarditis
• Clinical symptoms of myocarditis  persistent
tachycardia with cardiomyopathy in echocardiography
• Treatment  steroid  showed improvement
• Considered as mild myocarditis because we gave full
dose ADS immediately (80.000), but the myocarditis
still occur because the duration of illness and the
complete ADS was postponed for 24 hrs

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• It is interesting that severe dipththeria stil occurs
in this case  patient received 5 times of DTP
vaccines
• The efficacy of the vaccination should be
considered NOT EFFECTIVE
• Efficacy of vaccine depends on the cold chain and
host’s immune response

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• In this case, there is not evidence of lack of
immunity (no opportunistic infection revealed to
immunodeficiency)
• The proper cold chain of vaccine may need further
discussion and handle with the regional authority
of ministry of health department
• After hospitalization: DT immunization at least 3
times (considered as patient with none
immunization)

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 CONCLUSION
• In this case :
- upper respiratory tract blockage
- myocarditis based on : persisten tachycardia &
echocardiography shown dilated myocard
• Therapy :
- Penicillin Procain for eradicate the bacteria
- ADS for neutralized the toxin
• Possibilities of severe clinical:
1) Had complete immunization  quality of vaccine
 cold chain
2) ADS delayed (stock unavailable)

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 CONCLUSION

• Survive  - complete dose of ADS

- good response to Penicillin Procain
- early hypoxia handling by doing
tracheostomy and mechanical
ventilator

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THANK YOU

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 CONCLUSION
In this case: - upper respiratory tract blockage
- myocarditis

Myocarditis based on : persistent tachycardia & echocardiography shown dilated myocard

Therapy : - Penicillin Procain for eradicate the bacteria

- ADS for eadicate the toxin

Possibilities of severe clinical:

1) Had complete immunization  quality of vaccine
 cold chain
2) ADS delayed (stock unavailable)
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 History Taking
History of social & economy
• He was the first child
• Father/ 32 years old/ senior high scool/ entrepreneur
• Mother/ 24 years old/ senior high scool/ entrepreneur

Family History
• No family had history had of the disease

History of Disease
• Diarrhea at 1 y.o, Typhoid fever at 2 y.o, Hemorroid at 3 y.o

Social and Growth History

• He could roll over and lifted his head up at 4 month, sat with
assistance at 7 months, stand at 1 year, walked at 15 months, and
spoke at 18 months
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 History Taking

History of mother’s pregnancy

• States that during the period of pregnancy there were no bleeding,

vaginal discharge, diabetes mellitus, drinking herbs/ medicine nor
hypertension. he was delivered spontaneously at home and assisted
by midwife. He cried soon after birth and had a bodyweight of 3100
grams and no complication of birth

Nutrition History
• Breast milk since he was born to 15 months
• Formula milk at 2 months until 2 years
• Familily menu since 1 years, half plate of rice with meat, fish, tofu,
eggs & vegetables 3 times/day
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The result swab culture throat in this case showed
negative for C. Diphtheriae.

Host
(immune
status
Agent
Environment (virulence &
(cold chain) strain
mutation)
Possibilities of
inadequate
immune
respsons the
immunization

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 CONCLUSION

A 4-years-old boy was admitted to Saiful Anwar Hospital that suffered from
severe diphtheria, upper respiratory tract obstruction type Jackson II-III,
myocarditis

The diagnosis Diphtheria from history taking, physical examination, and

laboratories culture of throat for C. Diphtheria

The patient had complete immunization

One of the risk factor for this patient is may from vaccine administration

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 CONCLUSION
The treatment for severe diphtheria were anti diphtheria serum, antibiotic
penicillin procain, and corticosteroid

Second day of hospitalization, patient had dyspnea, stridor and fever, intercostal
and suprasternal retraction, assessment Upper Respiratory Tract Obstruction
Jackson class II-III

For Upper Respiratory Tract Obstruction Jackson class II-III, patient got
tracheostomy procedure

In this patient no sign and symptom suggest myocarditis from echocardiography

on third day of hospitalization

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