This document summarizes 11 cases of diphtheria that occurred in KwaZulu-Natal, South Africa in 2015. It describes the presenting symptoms, examination findings, laboratory results, treatment, outcomes, and immunization history of each case. 4 cases were confirmed diphtheria with a positive culture and toxin test. 5 other cases were pending toxin test results. There were also 3 probable non-toxigenic cases and 1 case considered clinically suspicious for diphtheria. Most cases were in children who had not received the full recommended immunization schedule. The outbreak highlighted gaps in childhood immunization leading to increased diphtheria risk.

1. DIPHTHERIA CASES
2015
Dr. N. Naidoo
Department of Medical Microbiology
UKZN/NHLS

2. CASE 1 SM CONFIRMED
Date of Presentation 15 March 2015
Age 8 yr old male
Referred : ENT - IALCH
Hospital / Area Umlazi –PMMH
Presenting History 3 day hx of : fever, sore throat,dyspnoea, odynophagia
Ceftriaxone + Cloxacillin
Examination On arrival:
Resp distress, swollen anterior neck, marked drooling
•
ENT :
Tonsillar hypertrophy, greyish membrane covering uvula
?Diphtheria
Emergency tracheostomy-securing of airway-ventilated
Intra-op specimens – Tonsillar swab

3. CASE 1 SM CONFIRMED
Antibiotics Started on Penicillin, Gentamycin, Metronidazole empirically
Laboratory Results Tonsil swab : cultured C.diphtheriae
Toxin testing : Positive
Immunisation History Immunisation Hx : 6, 10, 14 weeks, 18 months were RECEIVED
Booster at 6 years – NOT RECEIVED
Outcome •Initial improvement
•Referred back to PMMH
•Died on 22 March 2015 ? Myocarditis related
•Post mortem : Inconclusive
Contact Tracing Nil positive

4. Case 2 NM CONFIRMED
Date of Presentation 15 days later
Age • 9 yr old female
Hospital / Area • Umlazi – PMMH
Presenting History • 5 day hx of sore throat, progressive swelling of
neck, difficulty swallowing &drooling.
Examination • Clinical exam : not in resp distress, bullneck
• ENT : -Greyish, white membrane posterior
pharynx and uvula

5. Case 2 NM CONFIRMED
Laboratory Results • Throat swab : cultured C. diphtheriae
• Toxin testing : Positive
Immunisation History • Immunisation Hx:
6, 10, 14 weeks received
• Did not receive :
18 months and booster at 6yrs
Outcome • Stable, D/C, No complications
Contact Tracing • Nil positive

6. Case 3 AS CONFIRMED
Date of Presentation • 30 March 2015
• 4 days after onset of sx- presented to RKK
• On exam : swollen neck, cervical LAD, no UAO
Age • 9 yr old male
Hospital / Area • Chatsworth
Presenting History • GP : 2 day hx of sore throat, fever & dysphagia
Examination • Deteriorated- next 2 days
• ENT exam : Whitish membrane back of throat
Specimens taken

7. Case 3 AS CONFIRMED
Antibiotics • Tx with Penicillin IM at GP
Laboratory Results • Throat swab : cultured C.diphtheriae
• Toxin testing : Positive
Immunisation History • Immunisation Hx :
6, 10, 14 weeks and 18 months received
• Did not receive the booster at 6 years
Outcome • Started on Co-amoxiclav, metronidazole
• Remained stable in hospital
• Developed myocarditis 10 days later
• Cardiac failure
• Improved in hospital, D/C, cardiac clinic ffg up
Contact Tracing • Nil positive

8. Case 4 ZM
Date of Presentation 09 March 2015
Age 31 year old female
Hospital / Area • Briardene --Addington Hospital
•Presenting History • Presented in resp distress
• CXR-infective changes
• Clinically dx as disem TB/PCP
• c/o painful ulcer left inguinal
Examination • On exam :
• 2 punched out lesions on left inguinal area

9. Case 4 ZM
Antibiotics • Started on TB tx, Bactrim, Co-amoxi-
clav
• Px responded to Tx clinically
Laboratory Results • Wound swab- groin : cultured C.diphtheriae
• Toxin testing : negative
Immunisation History • Immunisation Hx:
6,10 ,14 weeks, 18 months received
• Booster at 6 years - not received
Outcome • Co-amoxiclav stopped, azithromycin added
Contact Tracing • 2 positive :
• Non-toxigenic C. diphtheriae

10. CASE 5 SS STRONG CLINICAL SUSPICION
Date of Presentation 20 April 2015
Age 11 year old male
Hospital / Area Inanda- Nu-Shifa Hospital
Presenting History • 2 day hx of sore throat & fever
Examination • Dx as tonsillitis
• Swabs taken by nursing staff
• Within 12 hours-deteriorated-swelling of anterior neck,
drooling but no UAO
• Seen by ENT: Oedema of oropharynx with whitish
membrane –
• Strong clinical suspicion of Diphtheria
Swabs repeated by ENT

11. CASE 5 SS STRONG CLINICAL SUSPICION
Antibiotics • Ceftriaxone
Laboratory Results • Both sets of Swabs : Negative
Immunisation History • Immunisation Hx:
6, 10, 14 weeks, 18 months-received
• Booster at 6 years - not received
Outcome • Subsequently Developed Myocarditis
• Condition improved
• After 3 weeks in hospital- D/C
• Re-admitted this week: progressive worsening of
dysphagia
• Clinical examination –Neurological deficits
• Currently admitted
Contact Tracing Nil positive

12. CASE 6 AN CONFIRMED
Date of Presentation 22 April 2015
Age 8 years old female
Hospital / Area Port Shepstone
Presenting History • 3 day hx : sore throat, fever, neck swelling
• Seen by GP : Dx Tonsillitis
• 2 days later- Progressive worsening of sx
• Referred to IALCH from P/S hospital
Examination • On presentation: neck swelling, drooling
• ENT:
• Bilateral inflamed tonsils with whitish membrane
-Peritonsillar abscess : Aspirated

13. CASE 6 AN CONFIRMED
Antibiotics • Intubated-ICU
• Penicilin and azithromycin started
Laboratory Results • Swabs taken in ward and intra op
• Throat and Tonsil swab : cultured C.diphtheriae
• Toxin testing : Positive
Immunisation History • Immunisation Hx:
• All vaccinations not received
Outcome Stable but has developed a new murmur
Worked up for ?Myocarditis
Contact Tracing 3 siblings- Prophylaxis given to all contacts
• All positive for C.diphtheriae- Toxin pending

14. CASE 7 EN (Sibling 2) CONFIRMED
Date of Presentation 04 May 2015
Age 10 year old female (sibling)
Hospital / Area • contact sibling- seen at Port Shepstone –referred to
IALCH
Presenting History • Presented : sore throat, mild submandibular
swelling and drooling. No UAO
Examination • ENT : hyperemic, whitish membrane over soft
palate and tonsils
Clinically stable

15. CASE 7 EN (Sibling 2) CONFIRMED
Antibiotics • Penicillin
Laboratory Results • Throat and Tonsil swab : cultured C.diphtheriae
• Toxin testing : Pending
• Px received anti –toxin on 7/05/2015
• Stable - improving
• D/C from ICU- to ward
Immunisation History • Immunisation Hx:
• All vaccinations not received
Outcome Stable transferred to High care
Contact Tracing 3 siblings- Prophylaxis given to all contacts
• All positive for C.diphtheriae- Toxin pending

16. CASE 8 AN (Sibling 3) PROBABLE
Date of Presentation 10 May 2015
Age 6 years old female
Hospital / Area • Admitted Port Shepstone Hospital
• HD penicillin
SIBLING 4 –REMAINS WELL
Presenting History • Contact sibling – fell sick at home
Examination • Clinically well
• ENT exam –Normal

17. CASE 8 AN (Sibling 3) PROBABLE
Antibiotics Penicillin
Laboratory Results • Swabs : Cultured C. diphtheriae
• Toxin Testing : pending
Immunisation History • Immunisation Hx:
• All vaccinations not received
Outcome Stable in hospital
Contact Tracing Sibling 4 remains stable

18. CASE 9 MK PROBABLE
Date of Presentation 03 May 2015
Age 41 year old female
Hospital / Area Yellow-wood park
Entabeni
Presenting History • Resp distress
• ?UAO
• 5 day Hx –illness
Examination • severely ill, renal fx
• Not seen by ENT

19. CASE 9 MK PROBABLE
Antibiotics • Started on Imipenem and clarithromycin
• Decompensated rapidly- intubated
• Died within 2days
Laboratory Results • Swabs from ETA : Cultured C. diphtheriae
• Toxin testing: Pending
Immunisation History No history
Outcome Died
Contact Tracing • Pending
• Husband admitted in St Augustines- ? Anxiety

20. CASE 10 MN PROBABLE
Date of Presentation 07 May 2015
Age 14 year old ? 9 year old male
Hospital / Area Kwadebeka- RKK
Presenting History • T/F IALCH- ICU Adult
• Presented : Severe sepsis with shock, Respiratory
distress UAO ? Clinical Diphtheria Renal failure
• Difficulty : Taking swabs
Examination • ENT : difficult examination, whitish membrane
laryngeal oedema
• Renal physician
• HD catheter for placement under platelet cover
• Died 4hours after arrival ( 3 am -7 am)

21. CASE 10 MN PROBABLE
Antibiotics • Ceftriaxone but changed to Meropenem
Laboratory Results • Post mortem
• Tonsil swab-Cultured C.diphtheriae
• Toxin Testing : Pending
Immunisation History Not Available
Outcome Died
Contact Tracing Nil positive

22. Case 11 WM CONFIRMED
Date of Presentation 10 May 2015
Age 17 years old male
Hospital / Area Chatsworth- RKK
Presenting History • Seen at emergency
• Resp distress, trismus of jaw unable to examine-
referred to IALCH
Examination • Seen by ENT
• “Slash” Tracheostomy
• ENT : Difficult to examine

23. Case 11 WM CONFIRMED
Antibiotics • Started on Penicillin and Clindamycin
• Received antitoxin
Laboratory Results • Swabs : Cultured C diphtheriae
Toxin Testing : pending
Immunisation History • Immunisation Hx:
6, 10 , 14 weeks , 18 months-received
• Booster at 6 years - not received
Outcome • Clinically stable
• Weaning off ventilator
• For transfer back to base hospital
•
Contact Tracing Nil positive

24. IMMUNISATION
PX 6 W 10 W 14 W 18 M 6 YRS 12 YRS
SM YES YES YES YES NO NO
NM YES YES YES NO NO NO
AS YES YES YES YES NO NO
ZM YES YES YES YES NO NO
AN NO NO NO NO NO NO
MK YES YES YES YES NO NO
MN YES YES YES YES NO NO
WM YES YES YES YES NO NO

25. C.DIPHTHERIAE
CULTURE +
TOXIN +
C.DIPHTHERIAE
CULTURE +
TOXIN PENDING
C.DIPHTHERIAE
CULTURE +
TOXIN NEGATIVE
STRONG CLINICAL
SUSPICION
SM AS- CONTACT 1 ZM SS
NM AS- CONTACT 2 ZM- CONTACT 1
AS AS- CONTACT 3 ZM- CONTACT 2
AN MK
WM
4 CONFIRMED 5 TOXIN PENDING 3 NON TOXIGENIC 1 CLINICAL

26. Acknowledgements
• ID STAFF –Dr Archary
• ENT DEPT-IALCH
• MICRO DEPT - IALCH
• ICU 4 STAFF
• PMMH – STAFF
• RKK- STAFF
• ADDINGTON -STAFF
• PRIVATE HOSPITAL- STAFF + LABORATORY
• KZN-DOH
• NICD TEAM
• GREEN POINT