Case of sorethroat

6 year old boy.
1st child of non consanguineous marriage , developmentally normal unimmunised with no significant past history now presented with c/o low grade fever since 6 days associated with throat pain on day 1 of illness.
On day 2,was taken to hospital and was treated as Out patient  basis.
On day 3, developed 5-6 episodes of vomiting.
On day 4,mother noticed swelling side of neck , which was gradually increasing in size So he was hospitalised on same day and started with Iv Ceftriaxone.
On day 5, fever decreased but vomiting persisted.
Day 6, swelling increased over right side and minimal swelling over left side and was referred to here i/v/o suspecting diphtheria.

At admission,

child was conscious, sick looking,
Pulse rate 90/mt, good volume,occasional irregularity.
Respiratory rate 24/mt,
afebrile,
swelling side of neck below mandible and ears both sides.
tonsillitis with greyish white membrane in tonsil and posterior pharyngeal wall with bleeding spots and had inspiratory stridor.







No other lymph nodes enlarged, No rashes.

Blood investigation

showed neutrophilic leucocytosis with  thrombocytopenia (67000),
CRP positivity 2.4 mg.
Liver enzymes SGOT (1253),
SGPT(378)
Deranged RFT (urea 162, Creatinine 2.2).
Provisional diagnosis of Faucal diphtheria,with features of organ involvement in the form of myocarditis, renal involvement and thrombocytopenia.

ECGs

Absence of P wave, junctional rhythm. sixth and seventh beats in the rhytm strip shows normal sinus capture .There is ST T wave changes indicating myocarditis.

Managed with

diphtheria antitoxin(80,000 iu),
IV Crystalline Penicillin and supportive measures.
Child had facial puffiness after 10 hrs of admission (lasix given). Child went to cardiac arrest by 12 hrs of admission.
Throat swab sent to microbiology , no growth till today

SO

An unimmunised child with fever sore-throat with significant grayish patch on both sides and bull neck with features of myocarditis clinical possibility is ninety nine percent diphtheria 

Immediate closer diagnosis of membranous tonsillitis and infectious mononucleosis considered but peripheral blood picture rules out infectious mononucleosis.
Features of myocarditis and ECG showing no atrial impulse generation , junctional rhythm and features of myocarditis narrows down the possibility to diphtheria.
Prognosis explained to the parents as already there is evidence of toxin fixed to heart kidney and other tissues it is too advanced to get result with antiserum.
Still we gave 80000 units of Diptheria antitoxin , put on crystalline penicillin.
Patient expired of cardiac arrest ,
Throat swab negativity does nt rule out the diagnosis , which is clinically certain.
Parents were given one dose of erythromycin  after consultation with adult medicine people . Vaccines not initiated for parents
As the patient had all the features of toxin ,ie myocardial , renal and hematological the diphtheria organism is certainly one producing toxin.
In case the herd immunity status in his village is low   high chance of sub clinical cases and carrier states high chance that secondary cases or epidemic in the coming weeks.
This should be given high priority in the preventive measures , may be a wider range selected than usual for preventive measures
( This blog was made with help of my Post graduate students. Dr.Said Bakri, Basima,Keerthi Amal.They managed the case under my supervision)