Diphtheria in Children: Clinical Case and Viva QnA

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Clinical Case of Diphtheria in Children

Patient Presentation

A 4-year-old girl, Mia, is brought to the emergency department by her parents with a 5-day history of worsening symptoms. The family recently returned from a 3-month stay in Southeast Asia, where their vaccination status was unclear.

Chief Complaints:

  • Progressive sore throat
  • Difficulty swallowing
  • Low-grade fever
  • Fatigue and loss of appetite

History of Present Illness:

Mia's symptoms began with mild rhinorrhea and sore throat 5 days ago. Over the past 48 hours, she developed difficulty swallowing, refused to eat, and became increasingly lethargic. Her parents report a low-grade fever and noticed swelling in her neck.

Past Medical History:

  • Generally healthy
  • Incomplete vaccination records due to frequent travel

Physical Examination

Vital Signs:

  • Temperature: 38.7°C (101.7°F)
  • Heart rate: 118 bpm
  • Respiratory rate: 28 breaths/min
  • Blood pressure: 92/58 mmHg
  • Oxygen saturation: 97% on room air

General Appearance:

Mia appears ill, lethargic, and has difficulty swallowing her own saliva.

HEENT:

  • Bilateral tonsillar enlargement with a thick, grayish-white pseudomembrane extending to the uvula and soft palate
  • Attempted removal of the membrane results in bleeding
  • Bilateral cervical lymphadenopathy with marked neck swelling ("bull neck" appearance)
  • Nose: Serosanguineous discharge noted

Cardiovascular:

  • Tachycardia with regular rhythm
  • No murmurs or gallops

Respiratory:

  • Mild inspiratory stridor
  • Clear lung fields bilaterally

Laboratory and Diagnostic Studies

  • Complete Blood Count:
    • WBC: 18,500/μL with 75% neutrophils
    • Hemoglobin: 11.8 g/dL
    • Platelets: 195,000/μL
  • C-reactive protein: 95 mg/L
  • Electrolytes: Within normal limits
  • Renal function: Normal
  • Liver function tests: Mild elevation of transaminases
  • Throat swab: Gram stain shows gram-positive bacilli; culture pending
  • ECG: Sinus tachycardia, no ST-T wave changes
  • Chest X-ray: No significant findings

Clinical Course

Based on the clinical presentation and characteristic pseudomembrane, a presumptive diagnosis of respiratory diphtheria is made. The following actions are taken:

  1. Mia is immediately placed in respiratory isolation.
  2. Blood cultures are obtained before initiating antibiotics.
  3. Diphtheria antitoxin (DAT) is urgently requested from the national stockpile.
  4. Intravenous Penicillin G is started at 100,000 units/kg/day in four divided doses.
  5. The local health department is notified for contact tracing and prophylaxis.
  6. Mia is admitted to the pediatric intensive care unit for close monitoring.

Over the next 48 hours, Mia's condition stabilizes. The throat culture confirms toxigenic Corynebacterium diphtheriae. She completes a 14-day course of antibiotics and receives cardiac monitoring for potential myocarditis. After two weeks, she is discharged with follow-up appointments for cardiac and neurological evaluations to monitor for late complications.



Clinical Presentations of Diphtheria in Children

  1. Classic Respiratory (Tonsillar-Pharyngeal) Diphtheria

    • Incubation period: 2-5 days (range: 1-10 days)
    • Initial symptoms: Low-grade fever, malaise, sore throat
    • Progression:
      • Development of thick, grayish-white pseudomembrane on tonsils, pharynx, or larynx
      • Membrane strongly adherent; bleeds when removal is attempted
      • Progressive difficulty swallowing and breathing
    • Cervical lymphadenopathy leading to "bull neck" appearance
    • Potential for airway obstruction in severe cases
    • Systemic toxicity: Pallor, tachycardia, prostration

  2. Nasal Diphtheria

    • Often milder than pharyngeal form
    • Initial presentation: Serosanguineous or mucopurulent nasal discharge
    • Pseudomembrane formation in nasal passages
    • Excoriation of nares and upper lip due to discharge
    • May progress to pharyngeal involvement
    • Potential for chronic carriage state

  3. Laryngeal Diphtheria

    • Can occur primarily or as an extension of pharyngeal disease
    • Symptoms:
      • Hoarseness progressing to aphonia
      • Barking cough (croup-like)
      • Inspiratory stridor
      • Respiratory distress and cyanosis in severe cases
    • High risk of airway obstruction requiring intubation or tracheostomy
    • Potential for sudden complete airway obstruction due to sloughing of membrane

  4. Cutaneous Diphtheria

    • More common in tropical regions and areas with poor hygiene
    • Initial presentation: Non-healing ulcer or eczematous lesion
    • Characteristics:
      • Painless, often chronic ulcers
      • Gray membrane over the wound
      • Surrounding erythema and edema
    • Can serve as a reservoir for respiratory infection
    • Generally less toxic than respiratory forms but more contagious
    • May coexist with other skin pathogens (e.g., Staphylococcus aureus, Streptococcus pyogenes)

  5. Malignant (Severe) Diphtheria

    • Rapid onset and progression of symptoms
    • Extensive pseudomembrane formation extending beyond tonsils
    • Marked neck edema and lymphadenopathy
    • Severe toxemia with high fever (>40°C or 104°F)
    • Complications:
      • Myocarditis with circulatory collapse
      • Acute renal failure
      • Pneumonia or respiratory failure
      • Disseminated intravascular coagulation (DIC)
    • High mortality rate even with appropriate treatment

  6. Asymptomatic Carrier State

    • No clinical symptoms of disease
    • Positive throat or nasal culture for toxigenic C. diphtheriae
    • Can transmit the disease to susceptible individuals
    • More common in areas with inadequate immunization coverage
    • May persist for weeks to months without treatment

  7. Diphtheria with Systemic Complications

    • Myocarditis:
      • Occurs in up to 20-30% of cases
      • Typically presents in the second week of illness
      • Manifestations: Tachycardia, arrhythmias, heart failure
      • ECG changes: ST-T wave abnormalities, heart block
    • Neuritis:
      • Usually occurs 1-3 months after onset of infection
      • Manifestations:
        • Bulbar palsy (difficulty swallowing, nasal regurgitation)
        • Ocular palsies (blurred vision, accommodation difficulties)
        • Limb weakness (usually symmetrical and ascending)
      • Generally reversible but may take weeks to months for complete recovery
    • Renal Complications:
      • Proteinuria and oliguria in severe cases
      • Acute tubular necrosis may occur

  8. Neonatal Diphtheria

    • Rare in countries with good maternal immunization coverage
    • Presents within the first week of life
    • Manifestations:
      • Difficulty feeding
      • Feeble cry
      • Pseudomembrane formation (may be subtle)
    • Rapid progression to systemic disease
    • High mortality rate without prompt treatment


Knowledge Check: Question and Answers for Medical Students & Professionals

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The notes provided on Pediatime are generated from online resources and AI sources and have been carefully checked for accuracy. However, these notes are not intended to replace standard textbooks. They are designed to serve as a quick review and revision tool for medical students and professionals, and to aid in theory exam preparation. For comprehensive learning, please refer to recommended textbooks and guidelines.



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