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Epidemiologic Notes and Reports Fatal Diphtheria -- Wisconsin

A fatal case of diphtheria was recently reported to the Wisconsin State Department of Health and Social Services (1). A 9-year-old unimmunized female developed listlessness and a sore throat on June 30, 1982, 10 days after arriving at a camp in Colorado operated by a religious group that does not accept immunizations. On July 3, she returned to Wisconsin on a camp bus along with other unimmunized children and adults who had also attended the camp. On July 6, a physician evaluated the patient for her sore throat; a throat culture was taken and oral penicillin prescribed. The patient was hospitalized on July 8 for persistent sore throat, diminished fluid intake, and gingival bleeding. Laboratory tests revealed a white blood cell count of 26,500 /mm((3)) with 92% polymorphonuclear cells, a blood urea nitrogen of 214 mg/dl, a creatinine of 12.4 mg/dl, and a platelet count of 10,000/mm((3)). The throat culture obtained July 6 was reported to contain normal flora, group A beta hemolytic streptococci, and large numbers of diphtheroids. The patient was transferred on July 8 to a tertiary care children's hospital.

On admission, she was afebrile and had moderate upper airway obstruction, diffuse ecchymoses, bleeding from the nose and gums, prominent cervical adenopathy, and swelling of the jaw and throat. Initially, the pharynx was poorly visualized due to trismus. On later examination, it revealed severe hemorrhagic and necrotic tonsillitis; no membrane was observed. Treatment with penicillin G, gentamycin, moxalactam, peritoneal dialysis, and platelet transfusions was instituted. The hospital course was complicated by disseminated intravascular coagulation, cardiac conduction abnormalities, and mental confusion. The patient died on July l4. A Corynebacterium species isolated from a throat culture obtained July 10 was subsequently confirmed by the Milwaukee Bureau of Laboratories and State Laboratory of Hygiene to be a toxigenic strain of C. diphtheriae.

An investigation was undertaken to determine the source of exposure to C. diphtheriae and to identify and evaluate the patient's contacts. The camp session had been attended by 108 employees, campers, and counselors from Wisconsin and 12 other states; many were unimmunized. In addition, 119 immediate and extended family members and hospital employees in Wisconsin, who might have had close contact with the patient after onset of illness, were identified. With the aid of state and local health departments and private physicians, 224 of the 227 contacts were evaluated. None reported respiratory illness before or after exposure to the patient, and nasopharyngeal or throat cultures obtained from 218 contacts were negative for C. diphtheriae. Reported by SD Davis, MD, Milwaukee Children's Hospital, R Kellner, JP Davis, MD, State Epidemiologist, Wisconsin State Dept of Health and Social Svcs; RS Hopkins, MD, State Epidemiologist, Colorado State Dept of Health; PM Hotchkiss, DVM, State Epidemiologist, Arizona State Dept of Health Svcs; J Chin, MD, State Epidemiologist, California Dept of Health Svcs; ME Levy, MD, District of Columbia Dept of Human Svcs; JJ Sacks, MD, Acting State Epidemiologist, Florida State Dept of Health; BJ Francis, MD, State Epidemiologist, Illinois State Dept of Public Health; NS Hayner, MD, State Epidemiologist, Michigan State Dept of Public Health, JH Carr, MD, Acting State Epidemiologist, Nevada State Dept of Human Resources; K Mosser, State Epidemiologist, North Dakota State Dept of Health; TJ Halpin, MD, State Epidemiologist, Ohio State Dept of Health; EJ Witte, VMD, State Epidemiologist, Pennsylvania State Dept of Health; CR Webb, Jr, MD, State Epidemiologist, Texas State Dept of Health; Field Svcs Div, Epidemiology Program Office, Respiratory and Special Pathogens Br, Bacterial Diseases Div, Center for Infectious Diseases, Immunization Div, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The last reported case of diphtheria in Wisconsin occurred in 1979, and the last reported case in Colorado occurred in 1978. This is the first reported diphtheria-associated fatality in Wisconsin since 1968; none has been reported in Colorado since 1976. Nationally, the number of reported diphtheria cases declined steadily from 435 in 1970 to five in 1981(2). The average annual incidence rate of reported diphtheria in the United States has declined from 0.13 cases per 100,000 population for 1970-1975 to 0.03/100,000 for 1976-1981. The mortality rate from all types of diphtheria has declined from 0.015 deaths per 100,000 population in 1970 to 0.002/100,000 in 1978, the last year for which mortality information is available (3). From 1971 through 1981, 431 (52%) of the 829 reported noncutaneous diphtheria cases occurred among persons 15 years of age.

The clinical manifestations of diphtheria depend on the anatomic location of infection, the virulence and toxigenicity of the infecting strain, and the host's immunity to diphtheria toxin. In the usual pharyngeal form of diphtheria, an adherent grayish-white membrane covers, to some degree, the pharyngeal and/or tonsillar areas (4). Infrequently, as in this case, diphtheria may present as a necrotic tonsillitis. Common complications fall into two groups: 1) the membrane and associated tissue swelling, which may cause airway obstruction; and 2) the bacterial toxin, which may cause myocarditis or neuropathy. Mortality occurs predominantly among noncutaneous cases, which accounted for 59 (95%) of the 62 reported diphtheria deaths from 1971 through 1981. Twenty-seven (46%) of the deaths among persons with noncutaneous diphtheria occurred among persons 15 years of age.

Diphtheria is acquired primarily by contact with the infected respiratory droplets or nasopharyngeal secretions of another patient or a carrier. Infectious skin exudate is involved in spread from cutaneous diphtheria. Disease occurs most frequently and more severely among unimmunized or partially immunized persons. Carrier status may occur among both immunized and unimmunized persons. The absence of any isolates of C. diphtheriae among the numerous contacts cultured in this investigation may be, in part, a result of delay in diagnosing the case and, therefore, delay in obtaining cultures.

Persons with suspected or proven diphtheria should receive diphtheria antitoxin and parenteral penicillin as soon as possible. Since diphtheria infection may not confer immunity, active immunization should be initiated or completed during convalescence. All household and other close contacts of respiratory diphtheria patients should be cultured and should receive an injection of an appropriate diphtheria-toxoid preparation and should be placed under active surveillance for 7 days for evidence of disease. Unimmunized or inadequately immunized close contacts and other close contacts whose cultures are positive should receive either intramuscular benzathine penicillin or 7 days of oral erythromycin, as well as toxoid. Culture specimens should be obtained before the initiation of antibiotics and, in the instance of a toxigenic C. diphtheria-positive culture, following completion of the antibiotic course (5,6). All close contacts should complete immunization with diphtheria toxoid.

References

  1. A case of diphtheria in Wisconsin. Wisconsin Epidemiology Bulletin. September 1982;4.

  2. CDC. Annual Summary 1980. MMWR 1981;29:12-3.

  3. Vital Statistics of the United States. Washington, D.C.: U.S. National Center for Health Statistics (unpublished data).

  4. Dobie RA, Tobey DN. Clinical features of diphtheria in the respiratory tract. JAMA 1979;242:2197-201.

  5. American Academy of Pediatrics. Report of the Committee on Infectious Diseases. 19th Ed. Evanston, Illinois: American Academy of Pediatrics 1982:71-4.

  6. ACIP. Diphtheria, tetanus and pertussis: guidelines for vaccine prophylaxis and other preventive measures. MMWR 1981;30:392-6, 401-7.



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