Tuesday, January 27, 2015

c. Active immunization and antibiotics.

A 6-year-old girl who recently emigrated from Sri Lanka with her parents complains of severe sore throat, headache, difficulty swallowing, and generalized weakness and malaise. Her previous medical history is not known. Her oral temperature is 103.2◦F. You note prominent cervical lymph nodes and an adherent gray pseudomembrane in her posterior oropharynx. Treatment must include antitoxin therapy plus:

a. Active immunization.
b. Passive immunization.
c. Active immunization and antibiotics.
d. Passive immunization and high-dose acyclovir.
e. Active immunization and steroids.

The answer is c. This patient has a classic case of diphtheria, a respiratory infection caused by Corynebacterium diptheriae. Management should focus on airway protection, limiting additional C. diptheriae growth and toxin production, and minimizing the effects of toxin that has already been produced. Equine serum diphtheria antitoxin should be administered promptly after the clinical diagnosis of respiratory diphtheria. Antitoxin can be obtained by contacting the CDC. The size and location of the membrane, the duration of illness, and the patient’s overall degree of toxicity determine the dosage of antitoxin. The Committee on Infectious Diseases of the American
Academy of Pediatrics (AAP) recommends 20,000–40,000 units for pharyngeal or laryngeal involvement of 48 hours’ duration, 40,000–60,000 units for nasopharyngeal lesions, and 80,000–100,000 units for extensive disease of 3 or more days’ duration or for diffuse swelling of the neck. In addition to antitoxin therapy, antibiotics should be administered for 14 days. Erythromycin, 40–50 mg/kg/d (up to 2 g) IV or orally in divided doses; intramuscular (IM) aqueous crystalline penicillin, 100,000–150,000 U/kg/d in four divided doses; or procaine penicillin,25,000–50,000 U/kg/d in two divided doses for 14 days given IM every 12 hours is acceptable. Patients should be admitted to respiratory isolation.


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