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Anurag Sachan1, Sanjay Jain2

Author Affiliations: 

1Junior Resident, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India; 2Professor, Department of Internal Medicine, PGIMER, Chandigarh, India

Correspondence to: 

Dr Anurag Sachan, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India


Journal Issue: 
Volume 50: Issue 4: 2020
Cite paper as: 
J R Coll Physicians Edinb 2020; 50: 408–10



Diphtheria is a vaccination preventable infectious disease with local and systemic complications predominantly affecting upper respiratory tract in younger (<5-year age) children. Its virulence is due to its ability to produce toxin which can cause fatal complications such as myocarditis and permanent damage in form of peripheral neuropathy. Diagnosis of diphtheria is primarily clinical supported by demonstration of toxin producing bacteria by culture. Early diagnosis and management with diphtheria anti-toxin can prevent mortality and morbidity. Here we present a case of 16-year-old boy managed with azithromycin, amoxycillin-clavulanic acid and diphtheria anti-toxin with complete recovery.

This case brings out the importance of recognising the re-emergence of diphtheria in older age groups. Lacunae in the universal immunisation process, rumours on vaccination effects and poor living conditions for refugee population are likely reasons in Asia and Europe. Universal immunisation, early diagnosis, prophylaxis and adequate supportive care are measures to prevent it.

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Case presentation

A 16-year-old male resident of a remote village in Haryana was referred to our medical emergency for progressive dyspnoea of one day. He presented with complaints of fever with chills, progressive neck swelling and drooling of saliva for three days duration. The parents could not recall vaccination history, BCG scar was also absent suggesting unvaccinated status. Examination of the oral cavity revealed an off whitish raised membrane, adherent to the posterior pharyngeal wall with surrounding redness and edema [Figure-1A]. On general physical examination he had; tachycardia, tachypnoea and neck swelling [Figure-1B]. He was suspected of having diphtheria and a throat swab was sent immediately for albert/gram staining in the emergency laboratory. Investigations showed Hb -11.8gm/dl (12-18gm/dl), TLC-13300/µL (4000-11000/ µL), neutrophils-76% (40-75%), lymphocytes-12% (20-45%), monocytes-10% (2-10%) and eosinophils-2% (1-6%) with borderline (27 U/L) raised Creatine kinase-MB enzyme (CK-MB) (5-25 U/L). Throat swab gram stain [Figure 2A] and albert stain [Figure 2B] were positive for diphtheriae like bacteria; confirming the diagnosis of diphtheria.

Figure 1A Pseudo-membrane visualized at the posterior pharyngeal wall

Figure 1B Bull neck like swelling with cervical lymphadenopathy