To the Editor: The dispatch by Izurieta et al. (Emerg Infect Dis 1997;1:65-8) reporting exudative pharyngitis possibly due to Corynebacterium pseudodiphtheriticum was very interesting, especially with the resurgence of diphtheria in the former Soviet Union. However, I was somewhat surprised at the treatment received by the 4-year-old patient whose case is reported. Erythromycin is an effective antibiotic in diphtheria, but it is secondary in importance to diphtheria antitoxin.

The presence of a thick grayish white adherent pseudomembrane, adenopathy and cervical swelling, and low grade fever should certainly provoke a high index of suspicion of diphtheria, especially in a child who has not received pediatric immunization. The diagnosis of diphtheria is primarily made presumptively on clinical grounds and confirmed by the recovery of toxigenic Corynebacterium diphtheriae by the laboratory.

Antitoxin treatment cannot wait for laboratory confirmation. Prompt administration of antitoxin is important because diphtheria toxin binds rapidly and irreversibly to tissue sites. Delay in initiating antitoxin treatment is associated with increased incidence of myocarditis, paralysis, and death. Also, it would have been good practice to have placed this child in isolation until the diagnosis was established by the laboratory. The primary care physician in this case is indeed fortunate that the patient did not have diphtheria; the results could have been tragic.

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