CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 2, May/June 2023 AFRICA 117 Diphtheritic myocarditis: a case report, with toxinmediated complications and multi-organ involvement Kumari Naidoo, Mpumelelo Msimang, Mignon du Plessis, Datshana Prakesh Naidoo Abstract The re-emergence of diphtheria in South Africa in recent years warns of incomplete vaccination coverage. Recent outbreaks have been associated with a high mortality rate, due to late presentation, limited access to antitoxin and the occurrence of serious systemic complications. Death due to diphtheria is most commonly associated with diphtheritic myocarditis, which presents with heart failure, cardiogenic shock and conduction abnormalities. This case highlights the key clinical features and systemic complications, and examines the reasons for the return of diphtheria in our community. Keywords: myocarditis, heart block, diphtheria Submitted 10/9/21; accepted 6/6/22 Published online 5/9/22 Cardiovasc J Afr 2023; 34: 117–120 www.cvja.co.za DOI: 10.5830/CVJA-2022-032 The eradication of diphtheria infection in the developed world is a success attributable to widespread and meticulous childhood immunisation. However, in many developing countries in Africa, Asia and South America, this preventable disease remains endemic, with 7 321 cases occurring globally in 2014.1 Re-emergence of diphtheria in KwaZulu-Natal has been associated with a high mortality rate. In the 2015 outbreak in South Africa, the case fatality rate was 27%.2 In 2018 there were three confirmed cases in the eThekwini district of KwaZuluNatal, with two deaths occurring in children with an incomplete immunisation history. Myocardial involvement is the most frequent cause of diphtheria-related mortality,3 as illustrated in the following case study. Case report A nine-year-old boy presented to his local clinic with a threeday history of fever, swelling of the neck and dysphagia. He was previously in good health, and had been appropriately immunised until two years of age. He had an extensive, tender swelling of the anterior neck and face, and was in respiratory distress with audible stridor. Radiographs of the neck confirmed severe laryngeal narrowing (Fig. 1). In view of the compromised airway, the patient was referred to the nearest hospital and required immediate intubation. A white pseudomembrane coated the pharynx and vocal cords, and due to the oedema, it was possible to pass only a small-lumen endotracheal tube. Following intubation, the chest radiograph showed new consolidation/collapse of the right upper lobe, presumed to have resulted from dislodgement of the pseudomembrane, with resultant bronchial obstruction (Fig. 2). Upon arrival at the intensive care unit (ICU), the patient had developed shock (blood pressure 88/50 mmHg, pulse 132 beats/minute) and became anuric and hypoglycaemic. The blood panel (Table 1) confirmed sepsis, with a raised white cell count, C-reactive protein and procalcitonin level. There were features of disseminated intravascular coagulopathy, with anaemia, red cell fragmentation, thrombocytopaenia and a raised international normalised ratio. Blood chemistry showed evidence of acute Department of Internal Medicine, University of KwaZuluNatal, Durban, South Africa Kumari Naidoo, FCP, kumarinaidoo23@gmail.com Department of Histopathology, University of KwaZuluNatal, Durban; National Health Laboratory Service, Johannesburg, South Africa Mpumelelo Msimang, FC Path SA (Anat) National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa Mignon du Plessis Department of Cardiology, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa Datshana Prakesh Naidoo, MD Fig. 1. Radiographs of the neck show severe laryngeal narrowing.
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