An unexpected case of diphtheria—the need for vigilance
We report a case of diphtheria, an infection that has not been encountered in Singapore for the past 25 years, the last case being reported in 1992. The patient, a Bangladeshi foreign construction worker, previously well, who was in Singapore for the last 10 months, came to the Emergency Department with worsening neck pain and odynophagia. His neck was swollen and extremely tender on palpation. As there was impending airway collapse, the patient was immediately sent to the Operating Theatre to secure his airway. Awake fibreoptic bronchoscopy was attempted but there was poor visualization so tracheostomy was performed under local anaesthesia. Pseudomembranes were seen and a diagnosis of diphtheria was made clinically. Pan-endoscopy and biopsy of tonsillar tissue were subsequently performed. After securing the airway, the patient was sent to Surgical Intensive Care Unit. He was started on intravenous piperacillin-tazocin empirically. After consulting Infectious Diseases, intravenous erythromycin, amoxicillin-clavulanate acid and diphtheria anti-toxin were given. Cultures of tonsillar tissue also confirmed the diagnosis of diphtheria. After 27 hours of presentation, he developed severe acute respiratory distress syndrome. Ventilatory support was escalated and patient was turned prone. Blood pressure was supported with triple inotropes. Meanwhile, the patient was referred for extra-corporeal membrane oxygenation support. However, the patient continued to deteriorate. He developed pulseless electrical activity from hypoxia and severe metabolic acidosis, and eventually succumbed to the disease 2 days after presentation to hospital. This case highlights the need to be vigilant for rare infectious diseases and the rapidly progressive and lethal sequelae of diphtheria.