ENG: A 5-year-old girl complains of sore throat when swallowing. On the next day at the doctor's examination, a slight hyperemia of oropharyngeal mucosa, white-grey plaques on the surface of tonsils, enlargement of regional submandibular lymph nodes were noted. Body temperature 37.5*C. Lacunar tonsillitis was diagnosed, antibacterial therapy and bacteriological examination of tonsil washings were prescribed. From anamnesis it is known that the child was vaccinated in violation of the vaccination schedule. In the following days the child's condition did not worsen, the temperature normalised on the fifth day of the disease, but the plaques on the tonsils remained, they were not removed with a spatula. The results of bacteriological examination showed the growth of Corynebacterium diphtheriae gravis. CBC: Hb-136 g/l; erythrocytes-4.5x1012/l; leukocytes-9.6x109 /1; neutrophils-69%; lymphocytes-19%; monocytes-8%; ESR 16 mm/hour. 1) Поставьте предварительный диагноз? Болжам диагноз қойыңыз?/ Make a preliminary diagnosis? 2) Проведите дифференциальную диагностику/ Дифференциалды диагностика жүргізіңіз/ Маке а differential diagnosis 3) Составьте план обследования ребенка/ Тексеру жоспарын жасаныз/ Make an examination plan for the child 4) Составьте план лечения/ Емдеу жоспарын жасаңыз Маake a treatment plan 5) Проведите профилактика и противоэпидемические мероприятия/ Профилактика және эпидемияға карсы іс-шаралар жүргізіңіз/ Prophylaxis and anti-epidemic measures
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Clinical Case Analysis: 5-year-old girl with membranous tonsillitis and C. diphtheriae gravis
1. Preliminary Diagnosis
Diphtheria, oropharyngeal (tonsillar) form, localized, mild course.
Justification:
- White-grey plaques on tonsils that cannot be removed with a spatula (fibrinous pseudomembrane — a hallmark of diphtheria)
- Regional submandibular lymphadenopathy
- Low-grade fever (37.5°C), mild general toxicity
- Violation of vaccination schedule (under-immunized child)
- Bacteriological confirmation: Corynebacterium diphtheriae gravis biotype
- Plaques persisted and did not resolve despite antibiotic therapy for lacunar tonsillitis
The gravis biotype is classically associated with more severe systemic toxicity, though in this case clinical course is relatively mild (localized form), which may reflect partial immunity from incomplete vaccination.
2. Differential Diagnosis
| Condition | Features Shared | Distinguishing Features |
|---|---|---|
| Lacunar tonsillitis (streptococcal) | Tonsillar plaques, fever, lymphadenopathy | Plaques are easily removed with spatula; high fever (38–39°C); pronounced pain; leukocytosis; responds rapidly to antibiotics |
| Follicular tonsillitis | Tonsillar lesions, fever | Yellow-white follicular plugs on tonsil surface, not forming a membrane; easily removable |
| Infectious mononucleosis | Tonsillar exudate, lymphadenopathy | Splenomegaly, hepatomegaly, generalized lymphadenopathy; atypical lymphocytes on CBC; positive monospot/EBV serology |
| Peritonsillar abscess | Sore throat, unilateral tonsillar change | Uvula deviated, trismus, high fever, severe dysphagia; unilateral bulging |
| Fungal tonsillitis (Candida) | White plaques on mucosa | Immunocompromised host; plaques on tongue/buccal mucosa; easily wiped off; KOH positive for hyphae |
| Vincent's angina (fusobacterial) | Membrane on tonsil | Unilateral ulcerative-necrotic lesion; very foul odor; mixed fusiform bacteria on smear |
| Simanovsky-Plaut-Vincent | Ulcerative-membranous tonsillitis | Putrid odor, ulceration beneath membrane, smear shows fusobacteria + spirochetes |
Key distinguishing feature of diphtheria: The pseudomembrane is tough, fibrinous, grey-white, extends beyond the tonsil margin, bleeds when forcibly removed, and cannot be wiped off — distinguishing it from all other forms of exudative tonsillitis.
3. Examination Plan
Mandatory (confirmatory and for complications):
| Investigation | Purpose |
|---|---|
| Bacteriological culture of throat/nasal swabs (already done — positive) | Confirm C. diphtheriae; determine toxigenicity (Elek test / PCR for tox gene) |
| Toxigenicity testing (Elek gel diffusion or PCR for tox gene) | Critical — determines need for antitoxin; gravis biotype is commonly toxigenic |
| Complete blood count (done) | Leukocytosis, neutrophilia in severe disease; CBC here: mild leukocytosis, ESR 16 — consistent with mild course |
| ECG | Screen for myocarditis/heart block (can appear in days 1–2 of toxic forms) |
| Urinalysis | Renal involvement (acute tubular necrosis from toxin) |
| Biochemical blood test | ALT, AST, creatinine, urea — hepatic and renal function |
| Coagulogram | DIC risk in severe/toxic forms |
| Throat smear microscopy | Gram-positive pleomorphic rods, "Chinese character" arrangement; Löffler/Neisser staining |
| Echocardiography | If ECG changes or clinical signs of myocarditis appear |
| Neurological assessment | Early palatal palsy (nasal voice), oculomotor palsy — early neurological complications |
| Anti-diphtheria antibody titer | Assess immune status |
CBC interpretation here: Hb 136 g/L, RBC 4.5×10¹², WBC 9.6×10⁹/L (mild leukocytosis), neutrophils 69%, ESR 16 mm/h — mild inflammatory response consistent with localized form without severe toxemia.
4. Treatment Plan
A. Hospitalization
Immediate compulsory hospitalization in an infectious diseases department (diphtheria is a quarantine infection). Strict bed rest.
B. Specific Therapy — Antidiphtheria Antitoxin (ADA)
This is the cornerstone of treatment — neutralizes circulating exotoxin.
| Form | ADA Dose (IU) | Route |
|---|---|---|
| Localized (oropharyngeal, mild) | 10,000–30,000 IU | IM (after desensitization test) |
| Common/widespread | 40,000–60,000 IU | IM or IV |
| Toxic grade I | 60,000–80,000 IU | IV |
| Toxic grade II–III | 100,000–150,000 IU | IV |
For this child (localized, mild): 10,000–20,000 IU IM as a single dose. Antitoxin must be given as soon as diphtheria is clinically suspected — do not wait for bacteriological confirmation.
Pre-injection Bezredko desensitization protocol (intradermal test with diluted serum, then subcutaneous, then full dose).
C. Antibacterial Therapy
Eradicates the organism (does not replace antitoxin, but eliminates the carrier state):
- Penicillin G (benzylpenicillin) 100,000–150,000 IU/kg/day IV/IM in 4 doses × 14 days, OR
- Amoxicillin orally if mild, OR
- Erythromycin (macrolide) 40–50 mg/kg/day × 14 days — alternative for penicillin allergy
D. Supportive / Pathogenetic Therapy
- IV infusion therapy: 5–10% glucose, saline — for detoxification (moderate volume)
- Corticosteroids (prednisolone 1–2 mg/kg/day): indicated in toxic forms with severe edema/laryngeal involvement — not required in localized mild form unless signs of allergy to antitoxin or local spread
- Antihistamines (desloratadine, chloropyramine): reduce hypersensitivity reactions
- Vitamins: C, B-group for tissue repair
- Bed rest throughout febrile and early post-febrile period
- Soft/liquid diet to minimize trauma to pseudomembrane
- ECG monitoring daily for the first 2–3 weeks (myocarditis can occur even in mild forms)
E. Criteria for Discharge
- Clinical recovery
- Two consecutive negative bacteriological cultures from throat and nose (taken 24 hours apart, no earlier than 3 days after completion of antibiotic therapy)
5. Prophylaxis and Anti-Epidemic Measures
A. Isolation and Quarantine
- Patient: compulsory hospitalization until two consecutive negative cultures
- Contacts (family, kindergarten/school): quarantine for 7 days with daily medical observation and thermometry
- Contacts must be examined bacteriologically (throat + nose swabs) and assessed for vaccination status
B. Contact Management
- All contacts: bacteriological examination (culture for C. diphtheriae)
- Unvaccinated or incompletely vaccinated contacts: emergency prophylactic vaccination with DTP/DT toxoid + benzylpenicillin or erythromycin for 7 days
- Immune contacts (fully vaccinated): single booster dose of diphtheria toxoid (AD-M toxoid)
- Carriers identified among contacts: antibiotics for 7–10 days + toxoid
C. Disinfection
- Current disinfection: ongoing in the patient's room throughout hospitalization
- Final disinfection: in the home/kindergarten after patient removal — wet cleaning with 0.5% chloramine solution; boiling of linen, dishes, toys
D. Vaccination (Active Immunization)
- The key preventive measure — DTP (diphtheria-tetanus-pertussis) vaccine
- Standard schedule: primary series at 2, 3, 4 months + booster at 18 months, then revaccination at 6–7 years (ADS-M) and 14–16 years
- This child was vaccinated on a violated schedule — upon recovery, the vaccination schedule must be corrected and completed according to the catchup immunization plan
E. Notification
- Immediate mandatory notification to the local sanitary-epidemiological service (diphtheria is a Class 1 notifiable disease)
- Report to healthcare authorities within 12 hours of diagnosis
Summary: This is a case of localized oropharyngeal diphtheria (tonsillar form, mild) caused by C. diphtheriae gravis, confirmed bacteriologically. The child's incomplete vaccination status predisposed her to disease. The distinguishing pseudomembrane (non-removable grey-white plaque), mild fever, and regional lymphadenopathy are characteristic. Management centers on antidiphtheria antitoxin + 14-day penicillin/erythromycin course, with strict anti-epidemic measures including contact tracing, disinfection, and correcting the child's vaccination schedule upon recovery.
— Red Book 2021: Report of the Committee on Infectious Diseases, pp. 526–528; Harrison's Principles of Internal Medicine 22E, pp. 1265–1270
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