Diphtheria with polyneuropathy in a closed community despite receiving recent booster vaccination

Spectrum of Neurological Outcomes in Diphtheria: A Case Series

Diphtheria is an acute infectious disease caused by the exotoxin produced by Corynebacterium diphtheriae, a gram positive bacteria. It has propensity to affect mainly cardiac muscle and nervous system. To study the percentage, spectrum of patients with various neurological complications and the pattern of recovery in followed up confirmed cases of diphtheria. Single centre prospective analysis of neurological complications in diphtheria patients from June 2019 to September 2020 at SMS Medical College and hospital,Jaipur. In this study, 60 cases were included. Immunised cases were 60% (36 out of 60 cases) whereas unimmunised constituted the rest 40% (24 out of 60 cases). Neurological complications were observed in 15% of the cases (9 out of 60). Isolated palatal palsy was the most common complication (4 out of 9 cases, 44.44%), succeeded by lower limb LMN palsies (2 out of 9 cases, 22.22%) with unilateral facial nerve palsy, bilateral abductor palsy and paralytic ileus constituting the rest (1 out of 9 cases each, 11.11% each). Onset of complications ranged from 10 to 36 days whereas recovery was complete and without any residual sequelae between 60 to 240 days. Our study concluded that neurological complications form a sizeable portion of post diptheritic complications and carries good prognosis, hence timely diagnosis and differentiation from other neuropathies is a pre requisite for rational management and contact tracing.

Infections of the Peripheral Nervous System

PURPOSE OF REVIEW

This article describes infections that affect the peripheral nervous system, including their clinical features, differential diagnoses, and treatments.

RECENT FINDINGS

Rates of pyomyositis have increased recently in the United States, possibly because of an increase in risk factors such as IV drug use, obesity, and diabetes. Other peripheral nervous system infections, such as diphtheria, have become more common in older patients secondary to a lack of revaccination or waning immunity. Although recommended treatment regimens for most infections remain unchanged over recent years, debate over the ideal dosing and route of administration continues for some infections such as tetanus and leprosy (Hansen disease).

SUMMARY

Infections of the peripheral nervous system are varied in terms of the type of infection, localization, and potential treatment. Nerve conduction studies and EMG can help determine localization, which is key to determining an initial differential diagnosis. It is important to recognize infections quickly to minimize diagnostic delays that could lead to patient morbidity and mortality.

Diphtheria outbreak in Jakarta and Tangerang, Indonesia: Epidemiological and clinical predictor factors for death

Background

In 2017, a diphtheria outbreak occurred in several provinces in Indonesia. The aim of this study was to identify predictors of mortality outcome of pediatric patients with clinical diphtheria.

Methods

A retrospective cohort study was conducted using patient medical records at five referral hospitals in the Province of Jakarta and one in Tangerang District, Banten Province during January 2017 to 31 August 2018. All children in the age group of 1–18 years old discharged with diagnosis of clinical diphtheria formed the study group. All anonymized patient data were evaluated for demographic issues, clinical features, immunization status, complication, laboratory profiles and outcome.

Results

A total of 283 patients with clinical diphtheria were included in the study group with case fatality rate of 3.5%. All mortal patients had the complication of myocarditis. Regression analyses revealed factors for predicting mortality. Incomplete primary diphtheria toxoid immunization, stridor, bull neck, leukocytosis ≥15 x10⁹ cells/L and thrombocytopenia ≤150 x10⁹ cells/L in each combination for 2 predictors modeling were correlated with death.

Conclusions

We report key predictors of mortality in pediatric patients with clinical diphtheria. The presence of these features when admitted to the hospital must be taken into account, because they can lead to fatal outcome.

Prospective Study of Diphtheria for Neurological Complications

Aim

To study the spectrum of neurological complications of diphtheria, timing of onset with respect to respiratory disease, and pattern of recovery.

Settings and Design

Prospective, observational, hospital-based study conducted in tertiary care hospital.

Materials and Methods

Twenty-eight cases of diphtheria with neurological complications were admitted during the period of study. Demographic profile, age, gender, status of immunization, past history stressing on the severity of the respiratory disease, and complaints regarding diverse complications of diphtheria were recorded. Detailed clinical and central nervous system examinations along with relevant investigations were carried out.

Results

Children were in the age group of 3-18 years. All 28 children presented with bulbar symptoms. Isolated palatal palsy was present in 18 children (64%). Third cranial involvement was present in four children. Three children had unilateral lower motor neuron facial palsy and one child had sixth cranial nerve palsy. Nine children developed symmetric limb weakness. Diaphragmatic palsy was present in three children with the onset from 1-3 weeks after pharyngeal diphtheria. Loss of vasomotor tone was present in two children. Recovery was complete in all 28 children.

Conclusion

Pediatricians/neurophysicians should have a high index of suspicion to recognize diphtheritic polyneuropathy. It carries good prognosis, hence timely diagnosis and differentiation from other neuropathies is a prerequisite for rational management and contact tracing.

Diphtheritic polyneuropathy in the wake of resurgence of diphtheria

OBJECTIVE

To study the clinical profile and outcome in children with diphtheritic polyneuropathy (DP).

METHODOLOGY

13 children with polyneuropathy were included in this study. Their demographic profile, age, sex and immunization status were recorded. Detailed clinical and neurological examination was done. Investigations like CSF analysis, NCV studies, MRI brain were done. The results were tabulated and analyzed.

RESULTS

All the children presented with bulbar palsy and had h/o membranous tonsillitis. Isolated palatal palsy was seen in 7 children (53%). 6 (46.1%) children developed quadriparesis. 1 child expired and recovery is complete in rest of the 12 children. Children with isolated bulbar palsy recovered within 2 to 4 weeks while children with quadriparesis recovered within 5-6 wks.

CONCLUSIONS

Any child diagnosed with diphtheria should be followed for 3-6 months in anticipation of neurological complications. DP carries good prognosis hence timely diagnosis and differentiation from other neuropathies is a prerequisite for rational management.

Neurologic manifestations of diphtheria and pertussis

Historically, diphtheria was a major cause of morbidity and mortality in the prevaccine era. However, in recent times there has been a resurgence of diphtheria, especially in the newly independent states of the former USSR. Diphtheritic polyneuropathy can be a serious complication in patients who have a severe infection. In patients with pertussis, seizures and encephalopathy can occur as a complication of asphyxia. Vaccination against diphtheria and pertussis in children and booster vaccination in adults is recommended. DTP (diphtheria, tetanus, pertussis) vaccination has been shown to increase the risk of febrile seizures in children. Currently, it appears that the risk of vaccine-induced encephalopathy and/or epilepsy following DTP vaccination, if any, is extremely low.

Diphtheria in a 7-year-old child in north-eastern Nigeria - management in a resource-poor setting

We report a case of a 7-year-old unimmunized child who presented with a 2 week history of nasal quality speech, hoarseness of the voice, regurgitation of feeds, and unstable gait. He had a previous history of fever, severe sore throat and bloody nasal discharge. A throat swab was negative for Corynebacterium diphtheria; however, he had received antibiotics at a primary care clinic prior to presentation. A clinical diagnosis of diphtheria with neurologic complication was made and the child was started on oral erythromycin, nasogastric tube feeding and daily physiotherapy, following which he improved. We did not prescribe diphtheria anti-toxin because of its unavailability.

Post-diphtheritic neuropathy: a clinical study in paediatric intensive care unit of a developing country

Summary

A retrospective study was done on 48 consecutive patients with clinical diagnosis of postdiphtheritic neuropathy admitted to the paediatric intensive care unit of tertiary care hospital in North India between January 2008 and December 2010 to study the clinical profile of post-diphtheritic neuropathy in children. The case records were reviewed and information regarding personal details, clinical features, recovery parameters and outcome was recorded using a predesigned proforma. Median age was 4.25 years. All cases were unimmunized. Median latency period was 15 days. Of the children, 52% had palatal palsy whereas 48% had limb weakness initially. Median duration of progression of weakness was five days. Limb muscle weakness was present in 94%. Respiratory muscles were involved in 85.4% cases and 60.4% required mechanical ventilation, while 14.6% had fatal outcome and 10.4% had hypoxic neurological injury. Boys were affected more. Median duration of latency was shorter; muscle weakness, progression and recovery were faster as compared with observational studies in adults.

Evaluation of human antibody responses to diphtheria toxin subunits A and B in various age groups

This study aimed to evaluate human antibody responses to diphtheria toxin subunits in various age groups. Antibodies against the intact diphtheria toxin and the diphtheria toxin subunits A and B were evaluated in 1319 individuals using a double-antigen ELISA. Although high levels of protection (83.6%, 95% CI 79.2-87.4) were found in children and adolescents, the middle-aged adult population was less protected (28.8%, 95% CI 24.3-33.6). An increase in age was associated with a decrease in the frequency of protected individuals in the 0-39-year age group (p <0.001). Anti-subunit B levels correlated well (p <0.01) with levels of antibodies against the intact toxin. In children aged < or =16 years, the intervals at which the peaks in geometric mean titres of anti-subunit B antibodies were observed were found to correlate with the ages at which booster doses are administered. Overall, males appeared to be more protected than females (OR 1.67, 95% CI 1.34-2.08, p <0.001). A small group of individuals had antibody levels of > or =0.1 IU/mL against the intact toxin, but did not have protective antibody against subunit B. Determination of anti-subunit B antibody levels should help in evaluating the effectiveness of diphtheria boosters and other aspects of diphtheria immunity.