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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
A case of diphtheria in Wisconsin. Wisconsin Epidemiology
Bulletin. September 1982;4.
CDC. Annual Summary 1980. MMWR 1981;29:12-3.
Vital Statistics of the United States. Washington, D.C.: U.S.
National Center for Health Statistics (unpublished data).
Dobie RA, Tobey DN. Clinical features of diphtheria in the
respiratory tract. JAMA 1979;242:2197-201.
American Academy of Pediatrics. Report of the Committee on
Infectious Diseases. 19th Ed. Evanston, Illinois: American
Academy of Pediatrics 1982:71-4.
ACIP. Diphtheria, tetanus and pertussis: guidelines for
vaccine
prophylaxis and other preventive measures. MMWR 1981;30:392-6,
401-7.
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