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Clinical Opal #16 - Vaccine preventable disease

Jose is a 9 year unvaccinated child with a 5 day history of a low grade fever, cough and sore throat...

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.

diptheria


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:

diphtheria test 2

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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References:

https://www.health.gov.au/diseases/diphtheria

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/

Washington C., Issaranggoon na ayuthaya S., Makonkawkeyoon K., Oberdorfer P. (2014) A 9 year old boy with severe diphtherial infection and cardiac complications BMJ Case Reports  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4244344/

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Grace Larson

Grace Larson

Grace Larson, RN, BN, CertIV(TAE), GradDipClinNurs(PaedCritCare), MAdNursPrac(PaedCritCare), has extensive experience in paediatric nursing, with 13 years in Paediatric Intensive Care Units (PICU). She’s published journal articles in the specialty area of pain and sedation in PICU, and has presented at national and international conferences on the area of pain and sedation in paediatrics. Grace has previously worked with the ACCCN delivering Paediatric Advanced Life Support in Victoria, bringing a wealth of experience into her clinical teaching on paediatric resuscitation. She has also consulted with NSW Health on quality and safety delivering within PICU, and has been contracted with the ANMF to develop nursing programs for nurses who require additional education as part of their practice requirements.

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