Garud B^1*, Chavan S², Agarkhedkar R³, Salunkhe S⁴, Gaiwale S D⁵

 

{¹Assistant Professor ²Professor, ³Professor & HOD, Department of Paediatrics} {⁴Associate Professor ⁵Associate Professor, Forensic Medicine And Toxicology} Dr. D.Y. Patil Medical College, Hospital And Research Centre, Pimpri, Pune, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra 411018, INDIA.

Email: balkrishna860@gmail.com

 

OBSERVATIONS AND RESULTS

In this study total 36 Confirmed cases of Diphtheria in the paediatric age group were studied, of which 5 cases died, 1 case had palatal palsy and 4 patients developed myocarditis.

 

Table 1: Age wise distribution of the Diphtheria cases

 

Table 2 :              Gender wise distribution of the Diphtheria cases.

Age in years	Gender of the case		Percentages (%)
	Boys	Girls
1 – 5	8 (22.2%)	4 (11.11%)	33%
6 – 10	5 (13.8%)	10 (27.7%)	41.6%
11 – 15	5 (13.8%)	4 (11.11%)	25%
Total	18	18	100%

(chi square test = 3.11, df = 1, p>0.05)

Among the 36 cases;15 cases (41.6%) were of the age group of 6-10 yrs. of which females were more contributing to 10 cases (27.7%).

 

 

 

Table 3: Analysis of presenting complaint (Symptoms)

Fever was the commonest presenting symptom contributing in 91.1% of cases

 

Table 4: Table showing age wise contribution of mortality in diphtheria cases

Maximum number of deaths occurred in 1-5 years age group (25%) followed by 6-10 years age group (13.3%).

 

Table 5: Distribution of cases according to Gender and Gender-specific case fatality

(Z= 0.16, p>0.05)

There is no statistically significant difference between no. of cases in male and female. Although mortality rates were higher in female patients.

 

Table 6: Rural – Urban incidence with relative mortality in each group

(Z= 0.55, p>0.05, Z= 0.014, p>0.05)

 Statistically there is no significant difference between incidence as well as deaths in Urban and Rural cases of diphtheria. (Z= 0.014, p>0.05)

               Total 7: Correlation between Immunization status and of Diphtheria cases incidence and proportionate mortality

(X2= 6.45, df= 1, p<0.01)

Statistically there is significant association found between immunization status and incidence of diphtheria cases. Out of the 36 cases, only 4 (11%) cases were immunized, 63.88% were unimmunized. That shows importance of immunization on the incidence and prognosis of diphtheria.

 

Table 8: Correlation between immunization status and morbidity

All the patients who had developed complications were unimmunized except one who developed myocarditis and was partially immunized.

Total 9: Anatomical type of diphtherial patch and mortality

Extensive: Tonsillar + Posterior pharyngeal + Uvular + Palatal. The incidence of involvement of both tonsils by diphtherial patch was maximum i.e. 41.5%. Out of the total 5 deaths, that occurred during the study, 3 had extensive Diphtheria, contributing 33.3% to total mortality. Followed by bi-tonsillar diphtherial patch having 13.3% mortality.

 

Table 10: Occurrence of myocarditis in diphtheria and its relation with mortality

11% of the cases in this study showed evidence of myocarditis. Patients with myocardial involvement contributed 50% of the deaths that occurred in the study population.

 

Table 11: Correlation between anatomical type of diphtherial patch and the occurrence of myocarditis

This table clearly shows the increased incidence of diphtheritic myocarditis in the patients who had extensive involvement of diphtherial patch. Out of 4 cases of diphtherial myocarditis, 2 (50%) cases had anatomically extensive involvement contributing maximum 22.22% of deaths out of remaining 50% cases each had unilateral and bilateral tonsillar involvement.

Table 12: ECG abnormalities in diphtheria myocarditis

ECG’s were taken in all cases suspected to have myocarditis. All cases (4), showed. ECG changes s/o myocarditis. Prolonged QTc was the commonest change noticed.

 

DISCUSSION

In our prospective study, the peak incidence was found in the age group of 6 to 10 years contributing 41.6% of the total cases followed by 1 to 5 years age group contributing 33.3% of the total cases. This agrees with findings of K. Basappa (1962,46) who showed 25% and 24% contribution by above groups in his study. Similar observation was found by S.R. Sengupta, A.G. Joshi in their study in Aurangabad20 which showed 50% contribution by 2-5 yrs. age group. Theodore et al.. (1962) reported the highest incidence in 5 to 9 years age group. This and studies by other western workers indicate an age shift in incidence of diphtheria from preschool to early school age. This disparity can be explained on the basis of extensive immunization during infancy protecting, the preschool children, where as waning immunity in older children making them more susceptible to diphtheria.19 Most of the studies agree on a peak incidence in the age group of 1 to 5 years. Bhargava et al.. (22,53,54,55) have found a maximum incidence in the age group of 2 to 5 years which is correlated well in our study. It is well known that the age of child has an important bearing in determining the mortality from diphtheria, being more fatal in the early years of life. Generally, in infants, symptoms of cold and cough are ignored, and it is only when the child begins to get difficulty in respiration, refuses to take feeds or develops swelling of neck that he is brought to the paediatrician. It is also probable that some cases pass undetected in the early part of illness due to incomplete examination and lack of high index of suspicion on the part of medical attendant.

Sex wise distribution of cases:

In our prospective study equal number of cases of Boys as well as girls were equal. This observation correlates with study by Basappa (1963,46) which found almost equal incidence of cases among males and females.Some authors Suri and Khosla 1964, Chandra et al.. (197118) reported higher predilection of female sex. Thus, there is no unanimous opinion in this regard. But a significant difference in the occurrence of disease in males and females in different age groups is established by most of the studies. Basappa (1960,46) described a sex ratio of M:F 1:1.3. Brooks et al.. 31 in United States also reported a slightly higher attack rate for males in the birth to 4 years age group, but it was higher for females in all other age groups. Immunization rates were also more in female i.e. 36.11% as compared to male i.e. 25%. Which is well correlated with Patel VV, Patel BH et al... Indian Journal of community medicine April (2013,53)

Rural-Urban Incidence:

Diphtheria is found to have higher incidence in rural than Urban community. In this study also, out of 36 patients, 77% belonged to rural community and 23% belonged to urban community. Thus, a higher incidence is noted in the rural population. This higher incidence among rural cases in this study are primarily referred from Karnataka and Maharashtra border area, this high endemicity represents situation in border area this may be due to less immunization coverage in rural area as compared to the urban area.

Incidence in immunized Vs unimmunized children:

Brooks et al.. (1974. 31) has quoted the incidence based on national immunization survey in 1967 and 1968, in United States. The attack rate for unimmunized children was 70 times higher than the rate for children with three or more injections. The rate for children who had received 1 or 2 doses of toxoid was six times the rate or those who had received 3 or more doses. In the study carried by Guha Mazumdar et al.. (1968,45) only 3.1% patients were immunized cases, however, the course of the disease was mild. Dutta and Ayyagiri 45 found 3.01% children out of total patients were stated to have received 3 doses of DPT and yet they fell victim of disease. In our study, out of 36 cases, 4 cases were fully immunized contributing (11%), 9 patients (25%) were partially immunized. All these cases developed diphtheria 2 to 5 years after the last dose. Thus, the incidence 63.88% among unimmunized children was 6 times that in completely immunized cases. These observations go in conformity with the findings of various workers. Immunisation significantly alters the clinical severity of diphtheria. Brooks et al.. (1974,31) described that the entire spectrum of clinical severity in immunized patients was significantly shifted towards mild disease. In his study, only 1.5% (3 patients) of 203 who had 3 or more injections of toxoids died. In contrast, 12.8% (167 patients) of the 1300 unimmunised patients expired. This difference is highly significant (P0.0005). Mazumdar’s 1968 study in Calcutta 45 found that whenever diphtheria occurred in immunized children (3.1% of total cases), the disease was mild in nature in all of them and no fatality took place.

All the cases who had developed myocarditis and diphtheritic neurological complication were unimmunized. Except one case of myocarditis who is the partially immunized. The partially immunized cases included those who had missed the second or third DPT doses of primary immunization.

Clinical Presentation And Duration of illness at the time of presentation:

Bhargava and Bhatta 196022 showed that when specific treatment is carried out on the first day of disease, death rate is 0.3% on the 3rd day 4% on 4th day 12% and on subsequent days 25%. Also the classic textbook description11 states “If specific treatment is provided on the first day of disease, mortality may be reduced to less than 1%, delay in treatment until 4th day may be associated with a 20 fold increase in mortality”.  The present study shows the majority of patients (59.19%) presenting with history of illness dating 1 to 4 days. The case fatality was more among the patients who had presented within 1 to 4 days of illness. Specific antitoxin was administered to all the patients on admission itself, the increase in duration of illness directly represents the delay in administration of antitoxin. Almost all studies on diphtheria have described the progressive rise in mortality with delay in ADS administration.

Analysis of presenting symptoms:

Fever was the commonest symptom in this study 91.1% cases presented with it. Other common complaints at presentation were difficulty or pain in swallowing, pain in throat 66.66%, difficulty in swallowing 61.1%. In our study well correlated with Bhargava et al..22 have described the common presenting symptoms as fever 89% cough 62%, pain in throat 36%, difficulty in breathing33%.  The frequency of bullneck and stridor in the present study was 19.4% and 5%. Thus the bullneck indicate an ominous prognostic sign in diphtheria patients. The poor prognosis suggested by Bullneck and stridor were highlighted in the studies of Bhargava (1960.22) and Shrivastava (1968.19)

Analysis of Cardiac Complications in Diptheria patients

11% of the cases in this study showed evidence of myocarditis. Patients with myocardial involvement contributed 50% of the deaths that occurred in the study population. The increased incidence of diphtheritic myocarditis in the patients who had extensive involvement of diphtherial patch. Out of 4 cases of diphtherial myocarditis, 2 (50%) cases had anatomically extensive involvement contributing maximum 22.22% of deaths out of remaining 50% cases each had unilateral and bilateral tonsillar involvement. ECG’s were taken in all cases suspected to have myocarditis. All cases (4), showed. ECG changes s/o myocarditis. Prolonged QTc was the commonest change noticed. The Sunil Samdani et al.. 2017 study shows, the ECG changes were sinus tachycardia (68.3%), T wave inversion (20%), ST segment depression (13.3%), right bundle branch block (5%), multiple atrial ectopics (3.3%). The case fatality rate in our study was 25% (15 patients). Present study Shows similar result as ECG’s were taken in all cases suspected to have myocarditis. All cases (4), showed ECG changes s/o myocarditis. Prolonged QTc was the commonest change noticed. And ST-T change seen in 1 case.

 

CONCLUSION

Cardiac involvement is a common complication of infection with C. diphtheria and is associated with high mortality. As diphtheria can be prevented by adequate vaccination, efforts should be maximized for high vaccine coverage with booster doses.

 

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