We have confirmed three cases of diphtheria in Nepal. They are still admitted in the Pediatric ward of the Tribhuwan University Teaching Hospital (TUTH). The patients were presented in the Pediatric Department, TUTH with clinical sign and symptom of diphtheria. Diphtheria was suspected by the clinicians and I was informed to establish a diagnosis.

1st case was of a 5 year old boy from Janakpur, Dhanusha (Nepal) and was referred by a local doctor to TUTH. Patient had greyish-white membrane over the tonsillar region with bull neck, enlarged lymp nodes and stridor. Tonsillar membrane were scrapped by ENT resident and was sent to me. Gram stain and culture on Tellurite Blood Agar and Loeffler’s Serum slope was performed on the specimen received.

Pleomorphic gram positive bacilli was seen on the gram stain. Due to some unavoidable technical problems, the loeffler’s serum slope culture couldn’t be obseved at exactly eight hours later but was examined on the next early morning along with the Tellurite Blood agar which were incubated at 37 degree Celsius aerobically in CO2 incubator.

On Tellurite Blood agar, black colonies with greyish margin(slate colour) was observed, which was a textbook rule for the diagnosis of Corynebacterium diphtheriae . On Loeffler’s serum slope, mixed colonies were grown. I got excited as we never had the opportunity to culture Corynebacterium diphtheriae in lab.

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‘poached egg’ colony of C. diphtheria

 

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colony of C. diphtheria on Tellurite Blood Agar

 

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colony of C. diphtheria on Tellurite Blood Agar

Then, we performed gram stain on the isolated colonies from Tellurite Blood agar and we discovered pleomorphic gram positive bacilli as Chinese latter pattern and many of them were club shaped too. To confirm our diagnosis, we opted out for Albert’s stain as Diphtheria was supposedly eliminated from Nepal and diagnosis of even single case could be an epidemiological emergency and of National concern. Finally, metachromatic granules with green bacilli was observed on the very Albert’s stain which confirmed that the patient was on real infected with Corynebacterium diphtheriae.

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wet mount of C. diphtheria

 

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Gram stain of C. diphtheria

 

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Gram stain of C. diphtheria

 

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Albert’s stain showing metachromatic granules

And in the end, I informed to my professors and seniors along with all the evidences. After examining them meticulously, they agreed it was indeed a case of Diphtheriae.

[We further processed the specimen to differentiate  upto the sub-species level. It was done so by sub-culturing on blood agar and starch fermentation test. Hemolytic colony were seen on blood agar and starch fermentation test came negative.]

In addition to that, two more cases were admitted in Pediatric Department suspecting diphtheria. They both were brother and sister from the same family. Brother was six years old without having membrane over the tonsillar region and was less toxic but sister who happens to be eleven years old had greyish white membrane over the tonsils and was more toxic with bull-neck and lymphadenopathy. Sister’s greyish-white membrane were processed as first case and brother’s tonsillar swab was taken and processed. Sister then developed myocarditis and neurological symptoms and was transferred to PICU, after few days she died.

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Membrane over the tonsillar region of 11 years old girl

All the doctors, nurses and medical personnel including me who were exposed directly or indirectly with the patient as well as the patient party as had to take the anti-biotic erythromycin 500mg twice a day up-to fourteen days and also had to inject a booster dose of Diphtheriae vaccine. It was really unfortunate and heartbreaking for me that we are able to save only two of them and lost one. One of them succumbed to death due to the development of myocarditis. Bitter truth is that ADS (Anti-Diphtheric serum) was not given to any patient due to unavailability and no one was able to arrange ADS, even higher authorities of our country. I am really afraid about both the patients  because they might develop fatal complications although they are improving  as they too have not received ADS.

Thanks to Dr. Shusila , Dr. Mahesh,  for helping me to established the diagnosis and a big thanks to prof. Dr. Bharat Mani sir, Hari sir and Dr. Sangita to be convinced with all the evidence to make this diagnosis possible.

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