Imported laryngeal and cutaneous diphtheria in tourists returning from western Africa to Sweden, March 2012.

In March 2012 a 68-year-old woman was diagnosed with laryngeal diphtheria in a hospital in Västra Götaland Region, Sweden. Six days before symptom onset she had returned from a trip to western Africa where she had travelled accompanied by her husband. During the investigation, the 76-year-old husband was diagnosed with cutaneous diphtheria. Both patients were incompletely vaccinated against diphtheria. On 27 March 2012, a 68-year-old woman presented to the Ear, Nose and Throat (ENT) department in a hospital in Västra Götaland Region, western Sweden, with a five-day history of fever, coughing, hoarseness and increasing pain in the throat. She had a medical history of adult-onset diabetes mellitus and was under investigation for thrombocytopenia and suspected liver cirrhosis. Six days prior to the onset of fever and throat symptoms she had returned from a two-week holiday in western Africa where she had travelled together with her husband and a friend. Upon hospital admission, she presented with fever (38.1°C), swelling of her soft palate and severe pain in the throat. A laryngoscopy was performed on the same day and revealed greyish membranes on and surrounding the vocal cords and the base of the tongue, and swollen larynx. These changes could not be seen by ordinary throat examination. Upon admission, the blood count was only mildly affected with slight decrease of the platelet count of 119 x 10 9 / L, (norm: 165–387 x 10 9 / L) and a total white blood cell count of 6.0 x 10 9 / L, (norm: 3.5–8.8 x10 9 / L) neutrophils 75%. C-reactive protein was 46 mg/L (norm: < 5 mg/L) and serum creatinine, 76 μmol/L (norm: 45–90 μmol/L). She had been referred to the ENT ward from the primary care clinic with an initial suspicion of a viral or fungal infection. On initial examination, the ENT physician suspected diphtheria although she had never encountered a case. Throat, nasal swabs and blood samples were sent for culture and sensitivity and the possibility of diphtheria was mentioned to the microbiology laboratory. However, the main suspected condition was fungal infection, and initially anti-fungal treatment was started. The condition of the patient remained stable but due to the fever and throat pain symptoms antibiotic treatment with intravenous benzylpenicillin for a 14-day period was initiated three days after admission when the diphtheria was reconsidered as diagnosis because of primary treatment failure. The Figure shows the laryngoscopy of the case …