A 15-year-old girl is brought to the emergency department due to a 3-day history of fever, chills, malaise, and sore throat. The patient has had difficulty swallowing because of severe throat pain. She has also had hoarseness and dry cough. She has no chronic medical problems and takes no medications. The patient has not received recommended childhood vaccinations due to religious beliefs. Temperature is 38.3 C (101 F), blood pressure is 110/60 mm Hg, pulse is 120/min, and respirations are 20/min. Oropharyngeal examination shows pharyngeal erythema with several spots of grey exudate that have nearly coalesced into a membrane. Scraping of the membrane causes bleeding. There are several enlarged and tender cervical lymph nodes. Breath sounds are normal. Throat swab cultures and PCR for a bacterial toxin are positive. This patient is at greatest risk for which of the following due to complications of her current condition?

Question

A 15-year-old girl is brought to the emergency department due to a 3-day history of fever, chills, malaise, and sore throat.  The patient has had difficulty swallowing because of severe throat pain.  She has also had hoarseness and dry cough.  She has no chronic medical problems and takes no medications.  The patient has not received recommended childhood vaccinations due to religious beliefs.  Temperature is 38.3 C (101 F), blood pressure is 110/60 mm Hg, pulse is 120/min, and respirations are 20/min.  Oropharyngeal examination shows pharyngeal erythema with several spots of grey exudate that have nearly coalesced into a membrane.  Scraping of the membrane causes bleeding.  There are several enlarged and tender cervical lymph nodes.  Breath sounds are normal.  Throat swab cultures and PCR for a bacterial toxin are positive.  This patient is at greatest risk for which of the following due to complications of her current condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c16e_b067_8f63_c1789747402e_MD0005_00 This young patient who did not receive age-appropriate vaccinations has fever, sore throat, and pharyngeal grey patches coalescing into a pseudomembrane, suggesting diphtheria infection. Diphtheria is caused by toxigenic strains of Corynebacterium diphtheriae, a gram-positive bacillus transmitted via respiratory secretions that largely affects children age <15. Exotoxin released by the bacteria is absorbed systemically and can result in dose-dependent damage to the heart, nervous system, and kidneys. Myocarditis occurs in up to two-thirds of patients; severe cases are associated with complete heart block and heart failure. Vaccination with diphtheria toxoid significantly reduces the likelihood of infection with toxigenic strains of diphtheria; this not only reduces the risk of developing active infection but also limits asymptomatic carriage of toxigenic strains (causing population-wide declines in prevalence). (Choice A) Guillain-Barré syndrome (GBS) is an acute immune-mediated neuropathy that typically occurs 2-4 weeks after a respiratory (eg, Mycoplasma pneumoniae) or gastrointestinal (eg, Campylobacter) infection. Morbidity with diphtheria is toxin mediated (not immune-mediated) and is not associated with GBS. (Choice B) Hemolytic uremic syndrome causes microangiopathic hemolytic anemia, thrombocytopenia, and renal damage. Most cases arise in children and are associated with Shiga toxin-producing Escherichia coli. Diphtheria is not associated with hemolytic uremic syndrome. (Choice C) Diphtheria may cause toxin-mediated damage to the nervous system, leading to peripheral or cranial neuropathies. Meningoencephalitis is not associated with diphtheria. (Choice D) Septic arthritis may be seen as a consequence of disseminated gonococcal infections. Although gonococcal pharyngitis may occur after oral sexual practices, grey pseudomembranes would be atypical. Diphtheria is usually not associated with joint issues. Educational objective: Diphtheria is caused by toxigenic strains of Corynebacterium diphtheriae. Manifestations of respiratory infection include systemic symptoms (eg, fever), sore throat, and pharyngitis with grey exudates that may coalesce into a pseudomembrane. Systemic absorption of exotoxins may cause toxin-mediated damage to the heart (myocarditis), nervous system, and kidneys.

A 15-Year-Old Girl Is Brought to the Emergency Department Due