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CARDIAC COMPLICATIONS OF DIPHTHERIA

Beverly C. Morgan
Pediatrics 1963;32;549

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/32/4/549

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1963 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

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CARDIAC

COMPLICATIONS
Beverly
Station

Heart

and

HE

routine

WIDESPREAD

C. Morgan,

Department

immunization

diphtheria,
and smallpox

pertussis,
has re-

sulted

decrease

the

dence

marked

of these

current

diseases

in the

textbook

United

of pediatric

comments

: Since

the

eliminated

almost

totally

an opportunity

in

is rarely
presented.
world,
however,
and

98

recently
States.2

by

to the
The

In other
even
in

parts
certain

Robert

to

determine

ment,

incidence,

efficacy

prognosis
this disease.

of

of

the

During
1957,

the

cardiac

with
diphtheria
Green
Memorial
county
with

while
history

period,
30,

98

1,

patients

were

evaluated

dead

on

postmortem

There

were

American.
were
and
tion

three

patients;

Negro

the

Forty-nine

male.

Three

rubeola
ranged

of

February

the

98

had

The
months

18; accepted

This study was partially


supported
Grant HTS-5539.
ADDRESS:
(B.C.M.)
Department
5,

three
were

children

concurrenfly.
from
14

(Received

and

remainder

for
study

analysis.
after

95

cases)

had

was

positive
diph-

chest

of
In
x-ray

availadmitted
1960,
(42

to
of

electrocardiograms

day

following

during
tracings

discharge

electrocardiograms

obtained

for

from

The

Cau-

and

patients

all

but

1 month

duration

fever,

several
shortness

diphtheria
age distributo 17 years.

of Pediatrics,

All patients
November
15,
serial

the

the type
available.

had

hospitaliza1, 2, and

from

the

hos-

were

12 or

13

April

from

often

patients

and

ranged

from

FINDINGS

of

symptoms

with

prior
that
swelling

to admission.
of sore
throat
of the

neck;

patients,
in addition,
complained
of
of breath.
On physical
examina-

tion

all

ings

compatible

children

6, 1963.)
the National

University

six

to 5 years.

a few hours
to 11 days
The
usual
history
was

Latin

by a grant

met

nasopharyn-

electrocardiograms

CLINICAL
of

for publication

more

every
other
and
additional

ranged

diphtheria.
casian

able
the

study

regarding
was
not
patient

or

arrival

findings

this
positive

had

patients

lead
tracings
obtained
on a Sanbom
Twin
Beam
photographic
machine
except
for the
bedside
records
which
were
taken
with
a
Cambridge
Simple-Scribe
direct
writing
instrument.
Post-hospitalization
follow-up

at the Robert
B.
a 330-bed
city-

were

each

one

All

in
ap-

two

95

diphtheria,
(2)
Corynebacterium

for

and

pital.

in

in

for

only
The

( 1)

Information
organism

months

and

Ninety-five

included

smear
culture

taken
tion

of these

criteria:

addition,

involve-

January

1962,

booster

theriae.
diptheria

the

three
and

geal
throat

METHODS

were
seen
Hospital,

hospital.

clinically,

were

following

complications

AND

June

who
heart

treatment,

5%-year

through

injection.

reviewed
of

type

modern

MATERIAL

and

of the
areas

school
age;
children

contracted
their
diphtheria
from
siblings.
Only
five patients
had
a basic
series
of three
diphtheria

had

admitted
Hospital.

were

were
of
younger

the

immunizations,

sections
of
5%-year-period,

findings

age

B. Green

been

communicommon.
actually
in-

with

cardiovascular

parently
school
received

immunization,

diphtheria
were
B. Green
Memorial

patients

patients
10 of

States.

a diphtheritic

in some
In the past

Sixty-nine
addition,

mci-

has

of the United
States,
preventable
cable
diseases
remain
relatively
Diphtheria
attack
rates
have
creased
United

Robert
Texas

cardiology

infection

to study

San Antonio,

of

children
against
tetanus,
poliomyelitis,
in

M.D.

of Pediatrics,

Hospital,

Memorial

OF DIPHTHERIA

had

nasopharyngeal

with

Heart

of Washington

diphtheria,

Institute,
School

Public

findincluding

Health

of Medicine,

Service
Seattle

Washington.
PEDIATRICS,

October

1983

549

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1)1 PHTI-IERIA

550
TABLE

peared

ELucraocutDIooItAiuIc

FINDINUN

95 PATIENTS

WITH

Patients
These

with

T-wave

changes

Died

vere myocarditis
Three
of these

ST-segmentshift
Minor
P-wave

more than
abnormality

1 mm

14

Prolonged

QT

interval

Prolonged

PR

interval

in

regularity
during

Atrial premature
contractions
Ventricular
premature
contracatrial

rhythm

rhythm

Left

bundle-branch

Right

bundle-branch
dissociation

A-V

block
block

The

electrocardiographic

in 31 patients,

of whom

had

myocarditis.

significant

scribed
in three
rhythm

abnormalities
27 are

and

not

to

formation;

admission
with
ture
elevation.
cient
respiratory

most

variable
degrees
Fifteen
patients
embarrassment

Six

patients

at or soon
developed

one

transient

ocular

tracheostomy

sis

of

the

left

neurological
No

palsy,

abnormality

against

this disease
All patients
were
penicillin
and many
therapy.

theria

antitoxin

all had
treated
received

All

cularly

in

in mild

six

these

were

deaths

to

The

but

intramus-

and

three

of
ap-

other

de-

with-

was
mur-

children

who

or clinical

evi-

and this
become
was

complete

abnormalities
in Table

one

two

right,

had
and

bundle-branch
In addition
atrioventricular

fourth
had

developed

I.

clinical
evideveloped

block;

block,

tion
while
the
heart
block.
One
patient

the
block

observed.

children
with
myocarditis

a right
to left.
showed

heart

otherwise

bundle-branch
had

on

patient
succumbed.
Two
hypotensive
terminally,

not

bundle-branch

steroid

effect

of the four
of
severe

child

received

apparent
disease;

congestive
despite

anti-congestive

also

electrocardiographic
patients
are summarized

terminally
patients

pa-

and
of these

without

shock

complete

units
after
appropriwas administered
in-

both

The
in 95

from

cardiac

in children

in several

carditis
and

of his

diph-

95

present

One

developed
patients

cardiac

Three

seen

were

or distant
while
gallop
Tachycardia

developed
succumbed

observed.

the

sounds

poor,
children,
in one.

were

with
failure

of

mild
diphtheria.
with
parenteral
additional
an-

among
hospital.

Heart

dren
heart

ranging

deaths
the

patients.

ir-

some
time
in each
of

No child
with carditis
time. Two of the chil-

course

immunized

and

at
illness

dence
of myocarditis.
had a murmur
at any

received

cases

occurred

electrocardiographic

therapy

ones.

There
were
tients
admitted

no

doses

severe

which
course

of the

cardiac

or absence
of heart
murmurs
to be helpful.
Physiologic

were

had

patients

in

se-

findings

was

bradycardia

Each
dence

40,000
units
to 80,000
ate skin
testing;
this
travenously

been

of

auscultatory

as indistinct,
of these
four
was observed

measures.

other

examination.

had

electro-

evidence

carditis

digitalization

paralyno

evidence

physical

who

tibiotic

one

were

had

on

children

admission.
paralysis,

hemi-diaphragm;

initially

on

of temperahad
suffito require

and

the

presence
not found

have

febrile

after
palatal

complications

patient

five

were

developed

(case reports
in appendix).
patients
succumbed
while

with

four

murs
membrane

occurred
illness.

out other
evidence
of carditis
as frequently
as in those
who had this complication.
The

occurred

considered

of

pathological
eviover-all
mortality

clinical

frequent

patients

history

diagnostic

survived.

most

these

patients
and

fourth
The

block

heart

Complete
*

the

tions
Nodal

95

cardiographic

18

Low

of

bradycardia

with

findings

64
leads

Sinus

additional

arrival

or more

in

Three

on

postmortem

Four
electrocardiogram

dead

9 of 98 cases)
was 9%. All deaths
within
the first fourteen
days
of

Findings*

Normal

respiratory.

diphtheria
but
without
dence
of myocarditis.
The

Findings

Surrived

be

were

and

DIPHTHERIA

Electrocardiographic

to

patients

IN

left
one

shifting
three

of these
dissociacomplete

electrocardiographic

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551

ARTICLES
findings

of particular

evidence

of
girl

Negro

vealing

had
leads

l)lane;
interval.

in

1960,

1962.

In

of

for

the

There

of

the

in Novemin August,
of

findings
were
not thought
episode
of diphtheria.

to

no other

normal

other

major

deviations

observed

cases,

bradycardia,

electrocardio-

Minor

were

additional

atrial

transiently

and
premature

premature

in

included

sinus

1:

contractions,

contractions,

ST-segment
shifts,
T-wave
OI
more
leads,
minor
P-wave

minor

changes

in

two

abnormalities,

minimal
prolongation
of the PR or QT
(Table
I). Normal
electrocardio-

and
interval
grains

subsequently
No patient

were

these
cal

at

evidence

abnormalities

ventricular

PR

present

her

were

from

in

a prolonged

were

absence
to

graphic

had

diphtheria
still present

were

these

related

re-

of 1 to 2 mm
frontal
and horizontal

she
findings

addition,

admission

carditis,

26

electrocardiograms

in the

and

other

9-year-old

shifts

These

time
l)er,

without
This

serial

ST-segment

lflulti1)le

l)e

interest

myocarditis.

children.

pathological
significant

or

without

obtained

in

all

developed

evidence

of

clini-

of myocarditis

electrocardiographic

changes.

Each
rubeola

of the three
and diphtheria

who
developed

electrocardiographic

minimal

abnormalties.

prolongation

minor

in

frequent

atrial

leads.

both

QT

T-wave
child

and

third

proST-

who

of

who

had

patient

mild

cardiac

cardiac

severe
myoFigs.
1 &

has

enlargement
other

case.

had

regres-

enlargement.

was

Sig-

not

ob-

patient.

in

diphtheria

is due

to

Anteroposterior

admission,
death

lus

film

and

of

(below)

(increased

the

liberated

and

self.

not

The

to

by
the

It is said
of

the

shortly

heart

chest
before

size).

of 496

of
is

reported

with

servers

place

to

be

the

most

disease.
62%

abnormalities
in

from

16.5%

figure

at

the

comparable

the children
abnormalities

is
this

in

cases.#{176}

reported

patients

it-

in about

and
in

bacii-

organism

clinically

death

Electrocardiographic
been

diphtheria
of the

patients

cause
mortality

series

the

effect

to occur

affected

common

figure

COM MENT
Myocarditis

1.

on

exotoxin

in the
changes

in each

cardiomegaly

surviving

in any

obtained

Case

(above)

10%
were

patients

his

1.

FIG.

de-

concurrently

elevation
T-wave

.:

had

minor

child

diseases

ST segment
leads
and

developed

4). The

served

interval

of these

x-rays

four

carditis

nificant

and

leads.

Chest

sion

had

interval,

contractions,

The

developed
mild
mid
precordial
in three

PR

A second

premature

changes.

veloped

One

the

shifts,

two

of the

segment

The

of

ST-segment

changes
longation

had both
transient

children

to the
in

this
in

series
one
or

to

have
84%

of

all

while

most

ob-

about

25%,,

#{176}
a

32%

(31

of 95)

of

who
developed
more
tracings

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552

DIPHTHERIA

:::

-:

iIrr

iJ:

I:

4:L

A;1It

i-j

tttt

H ffttLt:i

41#{149}

NL

#{149}

vs

/s

,-.
-

TriI1j:
2.

FIG.

Case

1. Electrocardiogram

tion

Table
graphic
sion

I). The most


abnormality
of the

segment

shifts

has

been
1(

have

this

are

probably

of
in

Other

been

6 hours

marked

variation

Prolongation
observed

and

the

the

about

and

ST-

earliest
affected

prolonga-

4$

showing

A-V

dissocia-

tion

of the

low

voltage,

slurring

of the

axis

shift,

bizarre

QT

interval,

sinus

the

more

bradycardia,

QRS

waves,

serious

graphic

abnormalities,

defects

and

arrhythmias

scribed.

Atrial

fibrillation

complexes,

and

have
and

conduction
been
flutter

!i;

L1

-?

I1jl_l

FIG.

3.

Case

2.

#{149}T#{149}

Electrocardiogram

block

extra

electrocardio-

varying

j$

. .

#{149}#{149}

complexes.

iPIIA

death,

of QRS

__

S
-

before

Among

abnormalities

include

:
:L

systoles.82

PR-interval

5% of

nonspecific

reported

and

:
1-

widening

common
electrocardiois flattening
or inver-

T waves;

findings.9

zi

ksb$

one

day

before

and

A-V

dissociation.

death

showing

left

bundle-branch

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deoccur

553

ARTICLES

but

are

unusual

velopment

in

of

heart

block

tality

with

branch

is ominous
these

block

with

disease.3
or

the

is

of the

is also

es

dle-branch

block,

complication

terminally

from

both

rhythm

disturbances

complete

(Figs.
left

bundle-branch

A-V
other

dissociation;
survived

now

attending

school

dissociation,

have

ical

examination

complete

have

more
and

the

only

had

to

or

the

and

It has

graphic

in

changes

and
P

a variety

who

had

findings

as

exact
significance

suggested

of histologic
infectious

evidence

cause

of

of

these

remain

that

un-

although
disease

can

Anteroposterior
and

be

doubted,

their

considerable
that

lead

myocardial

sults

in

This

has

to

congestive
not

that
block
decade

of diphtheritic
against
this,

of

two
SIZ(

the

days

chest
before

piralysis

Ifl(l

interpretation

re-

caution.

It is possible

believe
heart

film
(below)

increased
heart
of left hemi-diaphragm).

may

sixth

or electrocardio-

3.
admission,

(showing

quires

abnormalities

The

Case
on

scarcely

myocarditis;
these

pathological

in

also

4.

( above)
death

lobar
These
changes

diphtheritic
with

FIG.

of
5

fever,17
and
as diphtheria.

their

been

presence

interpret.

ST-segment
and
abnormal

electrocardiographic

myocarditis.
clear.

marked
without

to

in patients

patient

clinical

changes

less

electrocardiographic

succumbed
no

cardio-

including

occurred

however,

phys-

show

as prolongation

reported

typhoid
as well

severe

findings
on

difficult

variations

diseases

variations

block

as well.

more

been

poliomyelitis,16
pneumonia17

these

generally

or QT interval,
abnormalities,

infectious

heart

of transient
abnormalities

is

waves

abblock,

myocarditis

x-ray

nonspecific
PR

pres-

myocarditis.

with
of

chest

of the
T-wave

the

diphtheritic

The
occurrence
electrocardiographic
Such

is

illness;

persists.

and

and

progression

and
his

bundle-branch

patients

on

the
is

diphtheria,

evidence

megaly

had

while
survivor

regularly

as
of

addition,

developed

electrocardiographic

diagnostic

In

who

both

block

such

also

succumbed

patients

following

evident

normalities

A-V

and

two

bundle-branch

are

dissociation,

one child
died
(Figs.
3 & 6). The

marked

shifted

showed

A-V

block,

In clinically

bun-

these
bundle-branch

block)
the

3 years

of

left

( one

Of

asymptomatic

ence

of

ultimately

heart

2 & 5).

left

to

patients

children
right

one

right

block;
one

Two

developed
and

in

Bundle-

a serious

series

mor-

reported

14

present

de-

complete

prognostically;

findings

a similar

in

The

dissociation

54% to 100%

from

this

A-V

been

diphtheritic

myocarditis

fibrosis

failure

later

proven.

which

in life.19

Some

re20

observers

many
which

of the cases
of complete
are first
noted
in the

of life

and

beyond

myocarditis.21
100 patients
who

are

sequelae

As evidence
had suffered

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DIPHTHERIA

554
from

severe

were

or moderately

examined

15

to

infection;

none

showed

ventricular

or

intraventricular

increasingly
with

complete

genital
this

not

in

unsatisfactory.
used,
the

been

heart

recovery

from

the

myocarditis

to be good.

era

may

of

the

explain

Though
thus

results

is

Digitalis

is recom-

episode

of

the

diph-

prognosis

the

history

of fever,

measures.

the

admission

boy, was admitted

1980,

of the

with

neck,

x-rays

increase
film

in

(Fig.

taken

shortly

heart

size

one-day

and

respira-

before

la,

b). Two

as

grams were obtained.


The first, taken
sion, showed
prolongation
of the
nodal rhythm
and right bundle-branch
second,

taken

dissociation
complexes
this

time

6 hours

with

before

marked

(Fig. 2). The


was 8.4 meq./l.

death,

widening

death

compared

to

showed

interval,

block;
revealed

of

serum
potassium
Approximately

the

the
A-V

QRS

value
at
24 hours

2 (7-64-86)

J.
mitted

to

6-day
ceived
lings

Latin
American
boy was adthe hospital
December
9, 1960, with a
history of sore throat and fever. He had reno immunizations
and was one of five siba 6-year-old

T.,

simultaneously

hospitalized

with

ures.

interval

admis-

diphtheria.

Physical
examination
revealed
a moderately
ill boy
with findings
of laryngotracheal
diphtheria.
Ampultatjon
of the heart was unremarkable
on admis-

dilitation.

showed

mono-

interstitial
edema, swelling
and loss of cross-striations
at

levels.

3 (8-67-96)
P.,

an

11-year-old

to the
history

Latin

American

hospital

January

8,

of swelling

of the

neck,

boy
1962,

was

with

sore

throat,

Chest

x-ray

on

admission

revealed

elevation

of the left hemi-diaphragm


with a normal
size
heart;
a second
film
on
the seventh
hospital
day
showed
the development
of cardiomegaly
(Fig. 4).
The initial
electrocardiogram
taken on admission

on
QT

revealed
of the myocardium

and fever. He had received


no immunizations
and
was one of three siblings concurrently
hospitalized
with
diphtheria.
Physical
examination
revealed
a
moderately
ill child
with evidence
of laryngotracheal
diphtheria.
Auscultation
of the heart
was
within normal limits. Treatment
consisted
of diphtheria
antitoxin,
penicillin
and supportive
meas-

electrocardio-

prior to death he developed


cardiac
irregularity
and poor heart
sounds. Despite
all therapy he died
on the fourth
hospital
day.
Permission
for postmortem
examination
was denied.
Case

study

cell infiltration,
the muscular
fibers,

2-day

swelling

Chest

an

cardiac

examination

Microscopic

R.

tory difficulty.
He had received
no immunizations.
Physical
examination
revealed
an acutely
ill child
with evidence
of laryngotracheal
diphtheria.
Amcultation
of the heart disclosed
no abnormalities
on admission.
Treatment
consisted
of tracheostomy,
intravenous
diphtheria
antitoxin,
penicillin
and
chloramphenicol,
digitalization,
and
supportive
revealed

mortem

Reports

22,

when

weakwhich

The
cardiac
arrhythmia
were
poor and terminally
veloped.
He died on the eighth

Case

Caucasian

at a time

of nausea
and
was
obtained

3)

admitted

a 4-year-old
hospital
August

clinically

diph-

and left bundlethe initial


tracing.
persisted;
heart
hypotension
dehospital
day. Post-

of

1 (7-33-85)

F. W.,
to

tracheostomy,

ness. An electrocardiogram
revealed
that A-V dissociation
branch block had developed
since

different

Case

observed

complaining

was

nuclear

APPENDIX

Case

of

sounds

If

acute

consisted

was

child

(Fig.

steroids
far have

failure

Treatment

arrhythmia

con-

myocarditis

occurs,

theritic

appears

The

infants

that

block

encouraging.
when

atrio-

this

suggests

heart

mended

of
of

in some
adults.
for diphtheritic

generally
have
been

their

block.22

care

complete

theria antitoxin,
penicillin,
and supportive
messures. Chest x-ray on admission
was normal,
while a
Later film showed
cardiac enlargement.
An electrocardiogram
taken
on admission
showed
prolongation of the QT interval
and widespread
flattening
of T waves.
On the seventh
hospital
day, a cardiac

block

baby

finding
Treatment

sion.

after

discovery

heart

well

diphtheria

years
evidence

common

routine

severe
20

normal

sinus

rhythm

with

a prolonged

QT

block. The following day, incomplete


atrioventricular
block had
developed
with
prolongation
of
the PR interval
(Fig. 5, above). Auscultation
at that time revealed
tachycardia
with
gallop rhythm.
By the seventh
and

right

bundle-branch

hospital
day, the right
bundle-branch
tern had shifted
to left bundle-branch

block

pat-

block and
complete
heart block was present
(Fig. 5, below).
At this time
he had developed
nausea,
weakness,
and lethargy.
Physical examination
revealed
bradycardia
with
marked
cardiac
irregularity
and
poor
heart
tones. Steroid therapy
was begun.
Hypotension
and evidence
of a moderate
degree
of congestive
was

heart
initiated.

Postmortem

failure
He

developed
died

examination

on

and
the

revealed

ninth

digitalization
hospital
cardiac

day.
dilata-

tion; the myocardium


grossly
showed
pallor
was of flabby consistency.
Microscopic
studies
the heart showed
interstitial
edema,
mononudear
cell infiltrates,
and
foci of degeneration
in
myocardium.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on August 20, 2014

and

of
the

555

ARTICLES

vad

--v-

_J_
____ ____

FIG.

5.

Case

3.

Electrocardiogram

tion

of

PR

interval

and

(lay,

days

before

death,

showing

G.C.,

the

history

of

fever

Physical

Latin

hospital
and

examination

penicillin,

and

hospital
ness,

day,

time

revealed

compared

with

oxalacetic
40)

and

ad-

with

compatible

an

were

said

measures.

substernal
irregular
to

significant
his

erythrocyte

evidence
of
antitoxin,
On the second
pain, weak-

be

pulse
fair.

was

film.
78

sedimentation

heart

Chest

increase

admission

with

x-ray

in heart

Serum
units

size

rate

was

at
as

noted

(Fig.
though

tamic

oxaiacetic

mained

elevated

left

charge

on

physical

to

the

subsequently

62

of disblock

findings

within

returned
in

and

fell

normal.

1962,

he

entirely

electrocardiographic

block

at

slightly

was

(Fig.

but

time of
day;
this

When

the

attending
of

6,

dishas

patient

school

asymptomatic,

abnormality

persisted

to

gin-

the

hospital
to

was

were

rate returned
day; his serum

units

thirty-sixth

examined

branch

bundle-

At the time
bundle-branch

transaminase

but

his

left

bundle-

the

were obcardiac

below).

SUMMARY

40

mm/hour.
At this time
his electrocardiogram
revealed normal
sinus
rhythm
with
left bundle-branch
block.
On the
thirteenth
hospital
day,
he had
developed
A-V dissociation
which
persisted
briefly,
and
an occasional
premature
ventricular
contrac-

and

limits.
His sedimentation
by the tenth
hospital

10was

left

6, above).

rhythm

present,

normal
normal

was

prolongahospital

block.

sinus

regularly

glutamic

(normal

were

abnormalities,

heart

charge

duration.

findings

developed

and

transaminase
the

of 8 days

revealed

was

1959,

ST-T

complete

diphtheria
without
consisted
of diphtheria

he

which

boy

11,

throat

supportive

nausea,

sounds

American

August
sore

with nasopharyngeal
carditis.
Treatment

this

and

tion

a 9-year-old
to

hospital
day, showing
(below)
on seventh

and

widespread

block,

4 (6-24-54)

mitted

third

block;

bundle-branch

branch

Case

on

(above)

right

Ninety-eight
cases of diphtheria
served
in a 5% year period,
and
findings
deaths.

were

evaluated.

Three

patients

There
were

were
dead

nine
on

ar-

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on August 20, 2014

DIPHTHERIA

556

,jc

.%

L
I__

showing

6.

Case
4. Electrocardiogram
A-V dissociation,
premature

1)ranch

l)lOCk;

FIG.

rival

at

the

evidence
of

of

hospital

and

(below)

and

persistence

(without

myocarditis)

diphtheritic

and

three
three

who

succumbed

had

been

immunized

diphtheria.

Four

patients

developed

against

complications.

electrocardiographic
of myocarditis,
27 children
graphic
nificance.
logical
sence

and
and
showed

clinical

of

patient

evidence

of

had

transient

ographic

abnormalities

block.

significance

remains

questionable

myocarditis

child

are

showing

normal

trocardiographic

sigthe

ab-

heart
in

rhythm

unclear.

Marked

block

patients

A-V

are
with

elec-

such

as bun-

dissociation,
diagnostic

and
of myo-

diphtheria.

1. Keith,
J. D., Rowe, R. D., and Viad, P. : Heart
Disease
in Infancy
and
Childhood.
New
York, Macmillan,
1958, p. 704.
2. Doege,
T. C., Heath,
C. \V., Jr., and Sherman,
I. L. : Diphtheria
in the United
States,
19591960.

3. Friedberg,

electrocardifrequent,

day

bundle-

REFERENCES

or pathoin

sinus

block,

complete

left

abnormalities

dle-branch

carditis

abnormalities.

nonspecific

left

evidence

clinical

of electrocardiographic

Although

bundle-branch

three
died.
In addition,
minor
electrocardio-

abnormalities
No

No

hospital

and

later

as

of respiratory

thirteenth

contraction,

years

died

result

on

of

postmortem

while

myocarditis

(above)

ventricular

2.

their

PEDIATRICS,

30: 194,

C. K. : Diseases

Philadelphia

and London,

1962.
of

the

Heart,

Saunders,

p. 906.

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Ed.
1956,

557

ARTICLES
4.

C. :

Wesselhoeft,

diphtheria.

Cardiovascular

New

Engi.

disease

J.

Myocardial
changes
in fatal
diphtheria.
Amer.
J. Med. Sci., 215:257, 1948.
6. Hoyne,
A., and Welford,
N. T. : Diphtheritic
myocarditis,
a review
of 496 cases.
J. Pediat.,
5:642,
1934.
7. Ball, D. : Diphtheritic
myocarditis.
Amer. Heart
J., 29:704,
1945.
8.

I.:

Begg,

N.

D. :

Diphtheritic

myocarditis:

electrocardiographic
study.
857, 1937.
9. Burkhardt,
E. A., Eggleston,
L.
W. : Electrocardiographic

peripheral
Amer.

10.

Altshuler,

an

Lancet,
C.,

232:

and

Smith,

changes

and

nerve palsies in toxic diphtheria.


J. Med. Sci., 195:301,
1938.
S.

S.,

Hoffman,

K.

M.,

and

gerald,
P. J. : Electrocardiographic
in diphtheria.
Ann.
Intern.
Med.,

Fitz-

changes
29:294,

15.

of

bundle

Heart
12.

13.

H.:

Cookson,

Heart

block

branch

block

J., 7:63,

the simulation
in diphtheria.
Brit.

and

16.

Neubauer,

and

Auricular

M.,

L.:

Electrocardiographic

Weinstein,

fibrillation

studies

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Boyer,

from complete
Pxawrsucs,
N.

H.,

and

J. Pediat.,
Shelokov,

L.,
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manifestations
Engi. J. Med.,

during

46:30,
A. :

the

1955.

Cardiovas-

cause

22.

acute

1958.

N. : Progressive
myocardial
damrecovery
from
diphtheria.
Amer.
J. Cardiol.,
9:790,
1982.
Butler,
S., and
Levine,
S. A.: Diphtheria
as a

Claman,

age

21.

in

heart
3:222,

Weinstein,

changes

of measles.

48:146,
20.

Thompson,
P. D.:

severe
auricu-

J., 7:59,

Heart

poliomyelitis.
244:281,
1951.
17. Fine,
I., Brainerd
H., and Sokolow,
N.: Myocarditis
in acute
infectious
diseases.
Circulation,
2:859,
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18. Nadas,
A. S.: Pediatric
Cardiology,
Philadelphia and London,
Saunders,
1957, p. 228.
19. Sayers,
E. G. : Diphtheritic
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heart damage.
Ann. Intern.
Med.,

5:592,

Acta

C.:

1949.
Goldfleld,

cular
New

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Andersen,
M. S.: Electrocardiographic
on diphtheritic
myocarditis.
Scand., 84:268,
1934.

Brit.

Engle,
M. A.: Recovery
block
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course

1948.
11.

in diphtheria.

1945.
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1940.

5. Gore,

lar flutter

in

223:57,

Med.,

H.

following

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heart

block.

Amer.

Heart

J.,

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W.

P.,

The heart
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Golden,

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Amer.

S. E.,

to twenty
Heart

and White,
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J.,

13:534,

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CARDIAC COMPLICATIONS OF DIPHTHERIA


Beverly C. Morgan
Pediatrics 1963;32;549
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1963 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

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