CASE REPORTS

UNUSUAL LOCALISATION OF DIPHTHERIA

IN AN INFANT*

P. C. B^RAL,

Calc~tfa

A. K. R., a boy, aged I year 4 months was admitted into the Medical College Hospital on the x2th January, i936, for the following complaints:

(I) Intermittent fever ranging between 98CF. and Ioo~ for about a month. (2) Convulsive twitching, and (3) Drowsiness for two days.

Examination- The child was in a stuporous condition. There were convulsive twitchings specially of the right superior extremity.

The size of the head appeared disproportionately large as compared to the general development of the body.

There was an eczematous ulcer with irregular margins just above the left ear extending in fr6nt and behind. Its size was I " x ~". No discharge from the ears was noticed. A certain amount of rigidity of the neck was present.

Kernig's signnNegative. Knee jerksl-Absent. Plantar reflexu Extensor response. Throat Tonsils hypertrophied but no patch was seen. Heart--First sound short and sharp; no other abnormality. Lungs---A few scattered rhonchi. Liver Not palpable. SpleenDNot palpable. Bowels--Loose yellow motions. Temperature was 98-4~

Pulse rate--i48 per minute. Volume--Feeble. Respirationu34 per minute.

A lumbar puncture was done and 8 c.c. of clear cerebrospinal fluid drawn under slight pressure.

Laboratory investigation---Blood: Hb.D5o %. R. B. C.~2,8oo,ooo per cubic mm. Polymorphonuclear---68%. Lymphocytes--32%: Large mononuclears--Nil. Eosinophiles--Nil. Throat swab---A throat swab was taken and examined by ordinary staining methods. Nothing abnormal was found.

*From the Medical College Hospital, Calcutta. Submitted for publication, February i2, i936.

BARAL--DIPHTHERIA 95

A throat-swab and a swab from the eczematous ulcer were sent'for culture on the I3th January, i936, and the report showed the presence of B. Diphthcrice in the swab from the ulcer but not in the throat-swab.

Course and Treatment : The patient was comatose and on the morning of the I3th January, i936, he was having Cheyne-Stokes type of respiration. The right half of the diaphragm was moving definitely less than the left half during respiration. Suction of the ribs was present. Temperature ranged from 99*F. to Ioo~ Respiration rate was 32 per minute.

ThroatmNothing suspicious was noticed. The left tonsil appeared to be a little congested. No patch could be found.

An injection of anti-diphtheritic serum IO, OOO units was given.. Continuous oxygen inhalation was started.

On the I4th January, i936, the child was having hurried respira- tion, the rate being 86 per minute. Temperature was Ioo~

An injection of anti-diphtheritic serum IO,OOO units and anti- streptococcic serum IO c.c. was given in the morning.

The child died at i o'clock the same day. No autopsy was permitted.

COMMENT

The salient features of the case, name ly (I) his tory of slight fever for one m o n t h ; (2) gradual wast ing; (3) diarrhoea, (4) size of the head, a n d (5)r igidi ty of the neck, at first suggested a chronic meningitis, possibly of tuberculous origin.

I t was ascertained f rom the mother tha t the size of the head was ra ther big even before the illness started.

F r o m the very beginning the child was evident ly suffering f rom a mi ld a t tack of diphther ia . No suspicious pa tch or m e m b r a n e could be found in the usual sites of invasion by diphtheria bacillus.

T h e first hint of the real m a l a d y was obta ined f rom what was appa ren t ly a r ight-sided d iaphragmat ic paresis and this was af terwards conf i rmed by positive cul ture repor t of the swab taken f rom the ulcer beh ind the ear.

I am indebted to Dr. A. K. Bose, .Hony. Add. Physician, Medical College Hospital, for his kind permission to publish the case note, and for his valuable suggestions.