Diphtheria Resurgence – A Prospective Study in a Tertiary Care Teaching Hospital

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Diphtheria Resurgence – A Prospective Study in a Tertiary Care
Teaching Hospital
Mohammad Ashraf1, Sadia Ashraf2, Ibrahim al Jabr3*
1Assistant Professor, Dept. of ENT, Hind Institute of Medical Sciences, Safedabad, Barabanki, Uttar Pradesh.
2Assistant Professor, Dept. of Obst. & Gynae, Career Institute of Medical Sciences, Lucknow, Uttar Pradesh.
3Assistant Professor, Dept. of Surgery, College of Medicine, King Faisal University, KSA.
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Original Article
www.iabcr.org International Archives of BioMedical and Clinical Research | Oct-Dec 2016 | Vol 2 | Issue 4
ABSTRACT
Background: Diphtheria was one of the six killer diseases of childhood and was presumed to have been
controlled if not eradicated through immunization programme. Emergence of diphtheria once again has
challenged our health policies, immunization and public awareness campaign. Stringent measures need to be
taken lest the disease is blown out of proportion and control measures fail. Hence, to highlight the resurgence of
diphtheria, its repercussion, mitigation activities under taken by the government we have undertaken to pen
down this paper. Methods: This prospective study was carried on n= 5 patients included in our study on the
basis of inclusion and exclusion criteria. Results: Our approach to the diphtheritic patient should be
multifaceted and thorough examination and investigation is required by team approach to counter the impact of
the toxins released as it starts with Otorhinolaryngological manifestations and terminates with the
cardiovascular and neurological complications. Conclusions: Three major measures are indicated to counter
the resurgence of diphtheria i.e. high immunization coverage of target groups, prompt diagnosis and
management of diphtheria cases, and rapid identification of close contacts with their effective management to
prevent secondary cases.
Key words: resurgence, diphtheria, antitoxin
INTRODUCTION
Diphtheria was a disease of childhood. Diphtheria occurs
worldwide. The incidence has decreased because of the
universal immunization and expanded immunization
programme of World Health Organization (WHO). The
adults have been increasing affected in the countries where
the childhood immunization has been interrupted as in
Russia or Eastern Europe. In India too, people not
immunized in childhood or lack of booster doses in
adulthood, poor surveillance has resulted in the resurgence
of this disease process[1]. Developing countries account for
80–90% of the global burden of diphtheria.[2]
Diphtheria is an acute, toxin-mediated contagious disease
caused by bacteria called Corynebacterium Diphtheria. It
lives in the mouth, throat and nose of an infected person
and can be spread to others by coughing or sneezing. A
child with diphtheria can infect others for two to four
weeks. The incubation period of diphtheria is 2–5 days
(range 1–10 days). Diphtheria is of following types –
a) Anterior nasal diphtheria,
b) Pharyngeal and tonsillar diphtheria,
c) Laryngeal diphtheria,
d) Cutaneous (skin) diphtheria.[3]
Diphtheria usually starts with a sore throat, fever and chills.
But if it is neglected, not properly diagnosed and treated, it
produces a toxin (poison) that causes serious complications
such as heart failure or paralysis. One out of every ten
patients who gets diphtheria dies from it.
Here we describe five full blown cases of diphtheria to
emphasize the resurgence of this disease in India as we
prevail with the wrong notion that communicable disease is
a history.
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DOI:
10.21276/iabcr.2016.2.4.12
Received:05.07.15| Revised:17.07.15| Accepted:18.07.15
Corresponding Author
Dr. Ibrahim al Jabr, Assistant Professor, Dept. of Surgery,
College of Medicine, King Faisal University, KSA
Copyright: © the author(s) and publisher. IABCR is an official publication of
Ibn Sina Academy of Medieval Medicine & Sciences, registered in 2001
under Indian Trusts Act, 1882. This is an open access article distributed under
the terms of the Creative Commons Attribution Non-commercial License,
which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work is properly cited.

Ashraf M et al.: Diphtheria-Resurgence
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www.iabcr.org International Archives of BioMedical and Clinical Research | Oct-Dec 2016 | Vol 2 | Issue 4
METHODS
This prospective study was carried on n= 5 patients
attending ENT department of Hind Institute of Medical
Sciences, Safedabad, Barabanki, Uttar Pradesh were
included on the basis of inclusion and exclusion criteria.
Case No 1 A student of 20 years’ male presented in ENT
OPD with difficulty in swallowing for 4 - 6 days. He had
low grade fever and had a expressionless face. On
examination of the oral cavity he had B/L enlarged tonsils
almost kissing each other. Greyish white membrane was
seen over the surface of the tonsils. Posterior pharyngeal
wall was also covered by the slough. The neck was swollen
more on the right side. The throat swab was sent
immediately to microbiology lab for Alberts staining. This
confirmed our suspicion of diphtheria, Chinese letter
pattern and metachromatic granules were seen.
Subsequently culture was also done for the same.
Treatment was started without much delay. Diphtheria
antitoxin was given in a dose of 80,000 IU IV. after
sensitivity (5ml vial, 10,000 IU each, manufactured by
Berna, Swiss Serum and Vaccine Institute, Benra
Switzerland), Crystalline Penicillin10 lac, IVI four times a
day was given for 14 days after sensitivity. All the contacts
who turned out to be positive after Alberts staining for
throat swab were kept in isolation and were given
prophylaxis and diphtheria antitoxin (DAT).
Case no 2
A young boy of about five years presented in emergency
for difficulty in breathing and swallowing. On examination,
the boys general condition was poor and had pain in throat.
Oral cavity examination showed white slough covering
both the tonsils and extending into hypopharynx. Patient
was having very severe inspiratory stridor. He was
immediately moved to emergency operation theatre where
he was tracheostomised. The oxygen saturation went up to
hundred percent. We send the throat swab culture which
was positive for diphtheria on Alberts staining. The patient
was kept in isolation. We tried to procure the antidiphtheric
serum but was not available. We gave penicillin injections
after allergic testing and other supportive treatment was
rendered. After twelve days, the patient’s tracheostomy
tube was plugged and was kept for observation overnight.
Next day his stoma was closed. Luckily patient was saved
and was discharged without complications.
Case no 3 A young boy of seven years presented in OPD
and had difficulty in swallowing and breathing. The boy
was irritable and his general condition was also grim. His
orally cavity was having whitish material covering the
tonsils bilaterally. The patient was admitted in the isolation
ward and we send the throat swab culture. We got the result
as negative. We send all the relevant investigations
including the X-ray cervical spine lateral view. The x-ray
depicted ‘Thumb sign’ and we suspected epiglottitis. The
patient was fine, improving, breathlessness and dysphagia
had vanished but still he was sick, so we send the patient to
pediatric department for thorough evaluation. He was under
treatment when after five days he developed weakness of
lower limbs and was unable to stand without support. After
two days, he started having nasal regurgitation and next day
he had severe chest pain and collapsed. He was intubated
and put on ventilator but could not survive.
Case no 4 A young boy of ten years presented in the OPD
with the complains of the nasal regurgitation of the food
and water. On examination, the tonsils were swollen with
whitish slough on it. He gave history of upper respiratory
infection and difficulty in swallowing. He got treated by the
local doctor but could not get any benefit. He was later
referred to the medical college when he had developed
nasal regurgitation. His swab culture was positive for
diphtheria. He was admitted in isolation ward and referred
to the pediatric department for thorough neurologic
evaluation. There was no history of booster vaccination.
Case No 5 A young girl of ten years presented with
difficulty in swallowing and respiration. She was suffering
from last five days with fever, sore throat, chills etc. On
examination, she was looking quite sick, had congested oral
cavity with pseudomembrane formation on both the tonsils
which extended posteriorly. Throat swab and other
investigations were carried out and patient was positive for
Diphtheria patient
Diphtheria patient

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Diphtheria patient
diphtheria, culture was carried out. The patient was
admitted in the isolation ward with extensive monitoring
and DAT along with antibiotics were given. Patient
improved and contacts were given prophylaxis. Patient was
discharged after seven days but treatment was given for
fourteen days.
RESULTS & DISCUSSION
Diphtheria is caused by Corynebacterium diphtheria, a
gram-positive bacillus. Transmission is through droplet
infection & inoculation period is 2 - 7 days. Strains
carrying the tox gene are capable of toxin production.
Toxin has two submits A and B.
Diphtheria patient (paralytic)
Diphtheria anti-toxin
Treated diphtheria patient
Diphtheria anti-toxin
Diphtheria anti-toxin (Berna)
A is responsible for clinical toxicity and B serves as carrier
to specific receptors located on myocardium and peripheral
nervous system. Diphtheria can be either respiratory or
cutaneous. Regional lymphadenopathy gives rise to "bull
neck" appearance. Membrane presence is not essential for
diagnosis. Alberts staining if positive is sufficient to start
therapy.
Diphtheria in India accounted for 19-84% of the global
burden from 1998 to 2008.[4] A shift in age incidence has
been observed from preschool to school age (5-15 years)
with more and more cases now being reported in adults.[5]
The resurgence in India reminds us of the Soviet Union of

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nineties and in India the cause behind this was attributed to
decreased childhood immunization, increased susceptibility
among adults and high population movement.[4] Common
clinical features observed were throat pain in 74% cases
and fever in 56% cases. Complications observed were
myocarditis in 68% cases, neuropathy in 15% cases, and
respiratory compromise in 7% cases. Death occurred in
2.5% patients.[6]
The disease is subdivided into three stages – early, late and
severe. In the early stages, manifestations are localized to
either the skin or the upper respiratory tract which can lead
on to the severe stage associated with toxic circulatory
collapse, edema of the neck, skin petechiae and acute renal
failure. The late stages can involve cardiac and nervous
system such as myocarditis, respiratory paralysis and limb
paralysis. All stages are associated with a pseudomembrane
formation which bleeds on removal. Cardiac involvement
with arrhythmias occurs in one-quarter of patients who
have late and severe disease, increasing the mortality to
three to four times.[7]
Complications in form of acute circulatory failure due to
myocarditis or neurological manifestation like CN palsies,
paresthesia or polyneuropathy or encephahtis can be
manifested. Cutaneous diphtheria can present a punched-
out ulcer with undermined edges and covered with greyish
white adherent membrane.
Diphtheria although is a vaccine preventable disease and is
a part of universal immunization programme but it still
occurs in various countries especially developing. In India,
the disease does occur but in areas of lower socioeconomic
groups, overcrowding, lower awareness level and recently
the trend of involving higher age group is alarming.
In 2014 India’s National Health Profile released by the
health ministry witnessed 4,071 cases of diphtheria and 104
deaths, while among the states, Delhi had the highest
number of cases at 1,418 and also the highest number of
deaths with 60 mortalities. Haryana recorded the second
highest diphtheria cases at 663. However, it was West
Bengal that saw the second highest number of deaths with
10. Assam recorded the third highest figure of cases at 506,
followed by Maharashtra at 444. Our study highlights the
persistence of diphtheria in Delhi and NCR from 2012 to
2014. Various States of India have reported the persistence
and resurgence of diphtheria.[5]
The alarming trend detected was increasing involvement of
the older age group,[5] under coverage of the UIP, lack of
boosters, altered clinical picture because of rural quackery,
reluctance of the people to get immunized because of
certain myths, different branches of medicine which
discourage vaccination, improper cold chain maintenance
and lastly lack of availability of anti-diphtheric serum
(ADS) and medications.
Our approach to the diphtheritic patient should be
multifaceted and thorough examination and investigation is
required by team approach to counter the impact of the
toxins released as it starts with Otorhinolaryngological
manifestations and terminates with the cardiovascular and
neurological complications. Otolaryngologically,
diphtheritic emergency is to ensure airway and counter
dysphagia. Neurological complications are serious
complication and patient need to be followed.[8] Any child
diagnosed with diphtheria should be followed for 3-6
months in anticipation of neurological complications.
Diphtheritic polyneuropathy carries good prognosis hence
timely diagnosis and differentiation from other
neuropathies is a prerequisite for rational management.[9]
Diphtheritic polyneuropathy had 53% fatality.[10]
Tracheostomy is required in few cases with respiratory
distress. Primary identification of Corynebacterium
diphtheria was done by standard culture, staining and
biochemical tests followed by toxigenicity testing by Elek's
test on samples positive for C. diphtheria.
Treatment is instituted with diphtherial antitoxin (DAT).
Mild cases Antitoxins of 20,000 -30, 000 IV are given.
Moderate to serve cases are given 40,000 - 1 lakh QTD for
14 days is given and stopped after two culture / throat swab
are negative after 14 days therapy.
Prophylaxis is given to close contact or people positive for
throat swab by giving erythromycin (500mg) twice daily or
Penicillin along with antitoxin.
CONCLUSION
Three major measures are indicated to counter the
resurgence of diphtheria i.e. high immunization coverage of
target groups, prompt diagnosis and management of
diphtheria cases, and rapid identification of close contacts
with their effective management to prevent secondary
cases.[11] Apart from treatment and vaccination proper
education and awareness programs can help the country
and community to evade this public problem.[12]
REFERENCES
1. Phalkey RK, Bhosale RV, Joshi AP, Wakchoure SS, Tambe MP,
Awate P, Marx M. Preventing the preventable through effective
surveillance: the case of diphtheria in a rural district of
Maharashtra, India.BMC Public Health. 2013 Apr 8;13:317.
2. Manjunath Dandinarasaiah, Bhat Kemmannu Vikram, Naveen
Krishnamurthy, A. C. Chetan, Abhineet Jain. Diphtheria Re-
emergence: Problems Faced by Developing Countries. Indian
Journal of Otolaryngology and Head & Neck Surgery. December
2013, Volume 65, Issue 4, pp 314-318.
3. Narendra Patil, Nilesh Gawade, Abhay Gaidhane, Zahiruddin
Quazi Syed. Investigating diphtheria outbreak: A qualitative study
in rural area. Int J Med Sci Public Health. 2014; 3(4): 513-516.
4. Manoj V Murhekar, Sailaja Bitragunta.Persistence of diphtheria in
India, Indian Journal of Community Medicine, Vol. 36, No. 2,
April-June, 2011, pp. 164-165.
5. Bhagat S, Grover S S, Gupta N, Roy R D, Khare S. Persistence of
Corynebacterium diphtheriae in Delhi & National Capital Region
(NCR). Indian J Med Res 2015;142:459-61.
6. Kole A K, Roy R, Kar S S, Chanda D. Outcomes of respiratory
diphtheria in a tertiary referral infectious disease hospital. Indian J
Med Sci 2010;64:373-7.
7. Reddy BK, Basavaraja GV, Govindaraju M. (2013) Diphtheric
Myocarditis: Resurgence in Urban Bangalore, India. J Gen Pract
1:104.
8. Manikyamba D, Satyavani A, Deepa P. Diphtheritic
polyneuropathy in the wake of resurgence of diphtheria. J Pediatr
Neurosci. 2015 Oct-Dec;10(4):331-4.
9. Manikyamba D, Satyavani A, Deepa P. Diphtheritic
polyneuropathy in the wake of resurgence of diphtheria.
Pediatr Neurosci. 2015 Oct-Dec;10(4):331-4.

Ashraf M et al.: Diphtheria-Resurgence
56 | Page
www.iabcr.org International Archives of BioMedical and Clinical Research | Oct-Dec 2016 | Vol 2 | Issue 4
10. Mateen FJ, Bahl S, Khera A, Sutter RW. Detection of diphtheritic
polyneuropathy by acute flaccid paralysis surveillance, India.
Emerg Infect Dis. 2013;19(9):1368-73.
11. Galazka AM, Robertson SE, Oblapenko GP. Resurgence of
diphtheria. Eur J Epidemiol. 1995 Feb;11(1):95-105.
12. Allam RR, Uthappa CK, Duerst R, Sorley E, Udaragudi PR,
Kampa S, et al. A Case-control Study of Diphtheria in the High
Incidence City of Hyderabad, India. Pediatr Infect Dis J. 2016
Mar;35(3):253-6.
How to cite this article: Ashraf M, Ashraf S, Jabr I. Diphtheria
Resurgence – A Prospective Study in a Tertiary Care Teaching
Hospital. Int Arch BioMed Clin Res. 2016;2(4):52-56.DOI:
10.21276/iabcr.2016.2.4.12
Source of Support: Nil, Conflict of Interest: None