's Story-Diphtheria or Pawn? Part 1

[Guest guest]

I came across this article which I thought was quite an eye opener so I

thought I would share it. It is printed here with the permission of New

Zealand's newsletter called WAVES Volume 12, No 4, pages 21-26. I hope that

y'all read it cuz I just spent alot of time separating the paragraphs (damn

cut and paste) and then had to deal with truncation. This is an example of

how the system is MANIPULATED. You might want to print and then read.

- A Case of Diphtheria? OR Convenient Medico-Political Pawn?

On 30th June 1998, ’s grandparents arrived at his house to take care of

him while his parents and brother went to Bali for a holiday. Because their

oldest son had had a severe reaction to a vaccine, the parents had decided

not to vaccinate . was in the care of his grandparents because

they felt travel was an unnecessary disruption for a 2½-year-old. They

returned to New Zealand on July 13th.

A few days before got tonsillitis, there had been a big rainstorm on

the North Shore. The stormwater drains overflowed into the sewage system and

raw sewage spilled onto a property next door – something too interesting for

a 2-year-old to leave unexplored. Something too uninteresting for the Public

Health people to investigate when brought to their attention later, even

though New Zealand has two historical precedents of diphtheria following raw

sewage flowing onto property.

Eleven days after returning from Bali, ’s father developed an infected

abrasion on his chin, which had spread to his nose and chin by the 28th July

when the doctor started treatment with antibiotics. Dr Baker (ESR,

Porirua), in a published report on , considered this important because

there were no swabs taken from his father’s chin – the unproven implication

is that this infection might have been the primary source of the bacteria

which “infected†. During this time, had developed a cold, which

turned into tonsillitis, and his mother took him to the doctor on the same

day. The doctor did not think he was particularly unwell, but took swabs,

which showed normal flora, and prescribed amoxycillin.

On the 30th, his mother became concerned that there was no improvement.

had become quite hoarse, didn’t want to drink, and was coughing. So in the

late afternoon, her sister took them back to the doctor, who decided to refer

him to Starship. The doctor saw a yellow green exudate on the tonsils,

swollen glands, and a swollen neck. He wondered about diphtheria, because the

parents had been to Bali, the child was unvaccinated, and the antibiotics

weren’t working.

His admission letter gave name and address, and stated: “Problem:

1) Severe tonsillopharyngitis with confluent yellow green exudate.

2) Cervical nodes in swelling.

3) Unvaccinated child.

Many thanks for seeing this young boy. I have swabs off at Diagnostic for CTS

and Diptheria [as spelt by doctor]. Many thanks, with regards….â€

The doctor also rang ahead to let the hospital know that he was querying the

possibility of diphtheria. The parents arrived expecting to be greeted with

masks, white gowns and isolation. Instead they were put into a six-bed room

with unwell children. They were interviewed both by a nurse and student GP,

and on both occasions gave the full story.

During this time, their son played happily with the other children. was

finally seen by Dr Denny at 19.24 p.m. when his first question was “Why

haven’t you immunised ?†’s mother said that right now, they

wanted seen, not their choices questioned. The first line this doctor

wrote in the file was:

“Referral from GP ?Diphtheria.â€

So we know that he knew the referring doctor had alerted the hospital to

this. (This is very important later).

Previous history written into the files included: “cough and fever, four

days… 2½-year-old boy unimmunised (underlined twice)…no others in family

unwell…Alert and happy playing, Temp 37, … throat pus on tonsils – exudate

green, no grey. Confined to tonsillar bed, no pharynx…diagnosis, tonsillitis

in well unimmunised 2-year-old – low likelihood of C. diptheria… explained

above to parents.â€

His parents were told that it was probably some virus, or tonsillitis, but

not diphtheria and that he should continue the amoxycillin that the GP had

thought wasn’t working. They asked what could the hospital do if it was

diphtheria, and he mentioned an ECG, but that he didn’t think it was

necessary. The parents refused to leave until had one. They also

discussed anti-toxin, and the doctor said he didn’t know much about it, if

there was any in the country or where to get it from, but he considered it

academic, since he didn’t think had diphtheria. Just before they left,

he said in an offhand manner – almost as an after-thought – “Oh, I had

better give a swabâ€.

(For some reason, the hospital never gave the parents the results of that

swab – the parents only have the results of the ones from the GP.)

That this doctor saw no clinical evidence to lead him to believe that there

was diphtheria is confirmed by the discharge letter sent to the GP, dated

August 8th, in which the Clinical Director of the Children’s Emergency

Department signed off the following:

Under “Reason for attendance (Primary diagnosis)†was written

“tonsillitisâ€. Under “Medications†was written “Amoxycillinâ€. Under

“Disposition from the Emergency Department and Follow up†was written,

“Discharge No Follow-upâ€. Under “Other commentsâ€: “Concern re

?Corynebacterium diphtheriae in unimmunised child. Well in CED. No ‘mousy’

breath, Exudate confined to tonsils. ECG normal.â€

The doctor also told the parents that the child could return to playcentre.

The swab taken by the GP for some reason went walk-about for a week, during

which time returned to playcentre, and to his normal bouncy self.

On August 7th at around 10.00 a.m. the doctor received notification that the

swab taken on 30th July had grown a heavy growth of Streptococcus group A

(pyogenes), a common cause of tonsillitis and sensitive to amoxycillin, and a

heavy growth of Corynebacterium diphtheria (usually treated with

Erythromycin). The doctor wrote and faxed the mother the test results with an

urgent letter for readmission to Starship for review, which states on the

last line:

“It may be appropriate to notify staff who saw the patient whilst last in

Starship.â€

He advised that all family members go to Starship straight away, and that

they would be looked after, swabbed and given booster shots.

They arrived and were again made to wait with other people, even after the

father pointed out that their son had had a positive test result for

diphtheria. Meanwhile, was having great fun playing in the playhouse

with other children. They were very surprised that such a lax attitude

existed. This was supposed to be very serious – the first case in however

many years. A nurse from Public Health came and asked them who they had seen,

and where they had been. The father again pointed out that diphtheria was

supposed to be serious, and why were they still in a public area, and

shouldn’t all staff and families in the same ward as they had been be

notified?

While the staff knew who had been admitted as patients on that night, they

had no idea which rooms they had been put in, and didn’t seem much concerned.

They certainly didn’t notify staff in contact with . The same staff

member did all ECG’s and was only told about the test results by the parents

after the last ECG. No-one had swabbed her, or offered her antibiotics or a

booster. The father had, in the previous week, travelled north and south

seeing lots of customers and friends, as well as friends that went overseas

in that one week. The parents were more concerned about that than anyone

else, because they thought it was their duty to be concerned, even though

nothing seemed to be wrong with their child.

The hospital staff then decided to put into isolation – finally – and

when he was seen, it was by people in NASA-type suits who could find nothing.

The notes from that day show nothing of any sort of infection, but say under

“parental perception of illnessâ€:

“1/52 throat infection, drinking down and fever. ? Diptheria.â€

Staff dropped the “NASA†suits in a wheelchair next to reception, gave

another ECG, said he was fine and sent them home at 5.40 p.m.

However, one doctor who did not see the first day decided to write in

the file records at 1700:

“Presented 7 – 10 days ago with clinical naso-pharyngeal diphtheria –

green

membrane on tonsils Rx Amoxyl… Now back to self.â€

Yet according to the doctor who wrote the “presenting notes†had

tonsillitis with a green EXUDATE, no signs representing clinical diphtheria,

no mousy breath, no MEMBRANE – and no follow-up. How odd.

They were on their way home when their brother-in-law, who had gone to the

doctor’s to check on them, phoned to see how the family was doing, and was

told nothing was happening. The doctor then phoned back, and asked them to

come back to the surgery instead of going home. Just as they got into his

room, the doctor had to attend to a phone call. The husband asked for a

drink, and as he was drinking the doctor came in and accidentally spilled the

water down his front. This was the last straw, because the children were

tired, fed up, thirsty and hungry, having not been offered anything in

hospital, and everyone had had enough of being pushed from pillar to post

with no-one seeming to know what to do next.

That night on Television, the Minister of Health appeared, nationwide,

declaring that the Ministry of Health had taken over, since these derelict

parents had not attended an appointment, implying negligence, etc. And the

media continued camping at the front and rear of their house.

On the 8th (Saturday) the family decided that the whole management had been

atrocious, and that if anyone wanted to do anything further they could come

to their house, since they had done everything asked of them. The father

repeatedly rang Grant Close at the Starship to discuss the matter, but he

would not return the call. However, the supervisor at the hospital did ring

back twice. The first time was to say that they didn’t have any antitoxin in

the country. The second time was to say that it was on a plane from

Australia, and could they bring back the next day to be evaluated by

infectious disease specialists. At 3 p.m. that same day, the Public Health

people went to their home, took swabs from everyone and wanted to give them

all diphtheria boosters.

The next day, the parents took back to Starship for specialist review.

At midday they were seen, and the written purpose of the visit was:

1) Clinical Review

2) Throat swabs

3) ECG.

The notes state that: “Dr Lennon and I explained the rarity of this disease

and that throat swabs are not usually cultured in such a way as to detect it.

As strep A pyogenes was also cultured as a much more common cause of

tonsillitis which fitted the clinical picture, the C. diphth could (emphasis

hospital) have been carried, not causing disease, but having been found,

illness and contacts have to be managed as such.â€

Illness? What illness? There was no presenting illness.

What to do now? Dr continued on to explain to the parents that to use

anti-toxin with no sign of infection ( so where was the illness?) could be

dangerous and cause quite nasty, serious side-effects which you wouldn't want

in a healthy child. She reports this in the records: “However, there are no

clear guidelines for its use so far into illness (resolved) and antibiotics

and in mild disease which this must qualify as, as the exudate had gone by

Friday. The antitoxin is only effective prior to absorption by cells so is

unlikely to affect outcome now.â€

Little wonder the parents were now somewhat confused... a viral infection,

just tonsillitis, go back to playcentre and now “Mild disease which this must

qualify as?†There are certain things which should be done to decide whether

clinical disease has occurred. For instance, could have had serial

blood tests from the start which if he had had absorption by the cells of

anti-toxin from the bacteria in the throat, would show up, over a period of 4

weeks, as a 40-fold increase in anti-toxin antibodies. But this was never

done. Dr appears to have considered the presence of an exudate on

tonsils as proof that there was disease – even though she had admitted in the

previous paragraph that the symptoms were also what you would expect with

tonsillitis from Strep A pyogenes.

In my opinion, Dr talked herself into believing that something she

didn’t see was diphtheria. And this is where things get very blurry, because

at no time did staff observe any clinical illness compatible with clinical

diphtheria, nor did they initiate the tests which would have separated an

“isolate†from “clinical diseaseâ€. The only hospital doctor to actually

see

anything was so sure it wasn’t diphtheria that a letter was sent to the GP

stating so.

At no time was this child treated with the antibiotics used for diphtheria,

or antitoxin, so was it a case of diphtheria?

None of ’s symptoms or clinical work-up conforms to either international

diagnosis of a case (as opposed to a laboratory isolate), or New Zealand’s

definition of disease.

Take Baker’s article “A case of diphtheria in Auckland –

implications for disease control†in The New Zealand Public Health Report,

Vol. 5, No. 10 October 1998 pg. 73:

“The first notified case of respiratory diphtheria in New Zealand for 19

years occurred in Auckland in August 1998. The case was an unimmunised

32-month-old European male who presented with pharyngitis from which

toxigenic Corynebacterium diphtheriae was isolated.

However, he defines respiratory diphtheria as: “In the respiratory tract,

infection causes patches of thick, adherent greyish membrane.â€

didn’t have any.

Baker then classifies pharyngotonsillar diphtheria this way: “May result in a

sore throat, enlarged cervical nodes, and swelling of the neck in severe

cases.â€

“Laryngeal and tracheobronchial diphtheria may cause dyspnoea, stridor, and

progressive respiratory obstruction, particularly in young children and

infants.â€

The symptoms had could fit pharyngotonsillar diphtheria with a great

deal of imagination - which clearly the doctor didn't have, but as Dr

admitted, also fitted the clinical picture of Strep A tonsillitis. And other

problems, such as bronchiolitis. Indeed, was sent for a radiology

report, which stated that: “…the mild bronchial wall thickening with

hyperinflation…was consistent with bronchiolitis.â€

Even Dr Baker states on pg. 75: “Membranous pharyngitis is, however, also

associated with infection by other organisms, such as Streptococci, Epstein

Barr virus, Adenovirus and Corynebacterium pseudodiphtheriticum. In a

non-endemic country such as New Zealand, diagnosis of mild cases of

diphtheria will remain difficult… Patients with suspected respiratory

diphtheria should be isolated and treated on the basis of their clinical

presentation rather than waiting for laboratory confirmation which takes a

few days. Antitoxin should be administered promptly with the dose based on

the site and size of the diphtheritic membrane, the degree of toxicity, and

the duration of illness.â€

And that is precisely why wasn’t isolated, or treated – because there

was no clinical presentation compatible with diphtheria. There were no

membranes, no " mousy breath, and no signs of toxicity that led anyone in the

hospital to consider clinical diphtheria seriously.

But Dr Baker goes beyond credibility on pg. 74 when he states: “Based on the

extent of the tonsillopharyngeal membrane and resolution within a week, this

case would be classified as mild.â€

There was no tonsi