Case Study: Faucial Diphtheria Complicated with Myocarditis and Cardiac Failure

By Dr. Swapan Samanta and Dr. Malay Acharyya

Summary

Due to universal immunization, cases of diphtheria are rare now-a-days. Recently a 12-year-old male with incomplete vaccination history presented with a fever, sore throat and “bull-neck.” Investigations confirmed the diagnosis of palatal diphtheria with features of heart failure. Intensive medical therapy saved his life after a one-month struggle!

Background

Now-a-days, cases of diphtheria are rare, thanks to immunization programs. Partially vaccinated or unvaccinated individuals may contract the disease, and in certain cases, the picture might be complicated, leading to a difficult clinical situation. Due to cardiac involvement, the patient might suffer from heart failure. Such a case of a 12-year-old male is discussed here.

Case Presentation

A 12-year-old Muslim male complained of low-grade fever and gradually progressive sore throat, along with dysphagia and gradually increasing swelling in the neck, leading to “bull-neck” formation for the last 10 days. [s2If !is_user_logged_in()]…

[/s2If][s2If is_user_logged_in()] He had an incomplete vaccination status, as he did not receive a DT booster at 5 years. On clinical examination, he had bilateral tonsillar enlargement with formation of a grayish-white membrane involving the tonsils, posterior pharyngeal wall and soft palate. His pulse rate was 110/min, and BP was 130/90 mmHg. He was unable to deglut . No skin lesions were found. No significant past medical or surgical history. No contact or family history could be traced.

Investigations

A routine hemogram revealed neutrophilic leukocytosis, high ESR, mild hypochromic microcytic anemia and mild thrombocytosis.

X-ray and CT-scan of neck revealed bilateral tonsillar enlargement, along with peritonsillar and peri-pharyngeal collection.

Sputum and pus for Z-N stain were negative for AFB. Monteux tuberculin test was negative. Throat swab for KLB was positive.

ECG showed sinus tachycardia along with ST/T wave changes in all precordial and chest leads.

Differential Diagnosis

• Faucial diphtheria
• Tonsillar abscess
• Tuberculosis
• Faucial neoplasm
• Diphtheria myocarditis
• Viral infection
• Infection(s) in a case of congenital heart disease

Treatment

We administered 100,000 units of ADS IM and started IV crystalline penicillin, but his condition remained the same for the next 2 days; not able to drink anything.
From day 3, his fever regressed, neck swelling started regressing, and in the morning, he coughed out the membrane. His throat now became much clearer, and he continued a povidone-iodine solution gargle as advised, but over-all signs of well-being were not there.

He received antibiotics for 10 days more, and then his condition started improving. But, in the meantime, he developed features of heart failure and abnormal ECG findings on day 13, which was managed with fluid restriction, ACE inhibitors, low-dose diuretics and Carvedilol.

Outcome and Follow Up

After 10 days, the patient was hemodynamically stable and was discharged. The patient is being followed up in the out-patient department and is doing well, 4 months after the attack.

Discussion

The endemicity of diphtheria in India, even in the era of the Universal Immunization Program, is probably due to inadequate vaccination coverage, overcrowding, decreased incidence of skin infection by C. diphtheriae and possibly ineffectiveness of the administered diphtheria vaccine.

Diphtheria in the 5- to 10-year age group is mostly due to the lack of booster doses (DT) and silent diphtheria carriers . Myocarditis is the most common complication observed in patients under 10 years of age, while neurological complications are mainly found in adults. The majority of patients with myocarditis are asymptomatic in some studies. They only had ECG changes, SGOT elevation and had a favorable course . (1) But in the present case, the child suffered a lot. Generally, almost all patients develop cardiac involvement within the first week of the onset of respiratory symptoms, but this child developed it after the second week. Patients who have bull-neck and extensive faucial patches typically suffer more from cardiac involvement. In some studies, patients improved with fewer complications if they had received adequate immunization and had received ADS earlier . (1) This happened to the present child, and additional antibiotics and measures to improve cardiac failure helped much in this case!

Learning Points/Take Home Messages

Diphtheria myocarditis, a very serious complication of respiratory diphtheria, may occur in unimmunized or partially immunized individuals and should be recognized and treated promptly. In addition to antibiotics and ADS, management of the cardiac failure is challenging!