He commenced broad spectrum antibiotics on day 3 of his illness and has been taking regular paracetamol.
He is now 5 days into his illness and has presented with neck swelling, dyspnoea and dysphagia. His tonsils are inflamed on examination and he has an inspiratory stridor and poor air entry bilaterally.
What preventable disease do you suspect Jose has presented with, and how will you best manage his airway?
It is likely that Jose is suffering from Diphtheria. Until recently there were no reported cases of Diphtheria in Australia since 1992, with increased numbers of incomplete and unvaccinated children and adults, cases may be on the rise.
The following investigations have been completed on Jose:
Corynebacterium diphtheria releases a toxin that infects the upper airways causing a membrane to grow across the pharynx occluding the trachea. Upper airway obstruction has been reported in ~40% of cases in countries where Diphtheria is common. Intubation is difficult in these patients as there is a risk of pushing the membrane deeper into the lungs spreading infection and further complications.
If this child is at the stage where his airway is compromised it is unlikely that endotracheal intubation will be successful due to the difficult nature of the airway, even if successful, endotracheal intubation may dislodge the membrane and introduce the toxin into the lower airway. We should be prepared to perform an emergency tracheostomy along with commencing antibiotics and managing shock and other organ dysfunction.
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Gidding H., Burgess M., Gilbert G. (2000) Diphtheria in Australia, recent trends and future prevention strategies . Current issues in Immunisation 24(6) https://www1.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-cdi-2000-cdi2406-cdi2406f.htm
Singh S., Gupta N., Saple P. (2020) Diptheritic myocarditis: A case series and review of the Literature Journal of Family Medicine and Primary Care Nov 9 (11) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7842443/
Varghese M., Ramakrishnan S., Kothari S., Parashar A., et al (2013) Complete heart block due to diptheritic myocarditis in the present era Annals of Pediatric Cardiology 6(1) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3634244/