Diphtheria

Four year old boy bought with fever sore throat for the last four days.
He was on oral antibiotics. As local doctor noticed this patch in the throat he was referred here




Second child, older one is 7 years. Both of them un  immunized. No vaccine taken so far. Many kids in the neighborhood also
At the time of admission child was sick, Drooling of saliva and cervical lymph node enlarged odema neck plus
In view of unimmunised child developing this typical patch in the throat provisional diagnosis of diphtheria was made.
Took a throat swab for gram stain, and culture and patient was put on Crystalline penicillin 
Diphtheria antitoxin 80000 unit was planned.
While administration rashes and BP fall occurred.Under cover of Adrenalin and supportive measures could give 100000 units of antitoxin.

Differential diagnosis 

To rule out other possibilities like membranous tonsillitis and Infectious mononucleosis investigations were taken.
Peripheral smear taken showed normal distribution of WBC , no atypical lymphocytes.
 clinical examination heart was normal.
Baseline ECG taken normal.
We got gram stain of the throat swab today. Thanks to Department of Microbiology and Professor Dr.Preethi Nair.
They have sent the specimen for toxicological studies to Regional Public Health Lab Trivandrum

gram stain 

On the day of diagnosis itself the Health system was activated so that all contacts are given prophylactic drugs. Adults (parents and other close contacts) were put on Erythromycin and Td vaccine. 

After this there was a good response from the resisting group.Most of them were willing to take drugs and vaccine 

Today there was a phone call 

"Sir few members in the neighborhood had chickenpox and the rashes are just fading , What to do.Can we give vaccine?

These are situations in real life we encounter,Here we are faced with dilemma

1. If vaccine given immediately following viral infection immunoconversion may be a bit less. But no contraindication for vaccine here as it is toxoid combination. Even if you start vaccine , it wont protect for this contact . Antibodies will take time to develop at least two weeks. More than that they need to complete the course of two more doses. What work here is chemo prophylaxis with drug. Erythromycin , which we are giving anyway. So may be we can postpone the vaccine for a while 

2. But in a community resistant to vaccination is it wise to postpone a chance to vaccinate. May be the immunoconversion may be less than normal. Still it wont do harm.

Discussed the pros and cons of the above decisions. They have decided to give the prophylactic drugs for the time being and give the vaccine after two weeks. May be they are confident that they can get back to them and convince them about the need.

Follow up of the case on 6/1/2019

Not dyspnoeic, Pulse volume good ,regular.

Hemodynamically stable 

First heart sound muffled. No third heart sound 

ECG 

Normal rate and rhythm 

LBBB. 

Planning ECHO.