The widespread vaccination against diphtheria toxin produced by Corynebacterium diphtheriae has led to a profound decrease in the number of infections caused by this gram-positive bacteria throughout the world. However, cutaneous diphtheria is still considered endemic in tropical countries and other developing parts of the world, including the Philippines, Thailand, Vietnam, Bangladesh, Nepal, Malaysia, Indonesia, Afghanistan, India, and China [1] [2]. Additionally, a growing number of reports show both imported and domestic cases of cutaneous diphtheria in the United Kingdom, France, Austria, Norway, Canada, and Australia [1] [2] [3] [4] [5] [6]. Although respiratory infections are the primary focus when it comes to Corynebacterium spp. (due to their life-threatening nature), cutaneous diphtheria is also important, not only due to its potential to cause a systemic infection (although they are rarely seen, particularly in vaccinated individuals), but because it is able to spread from person-to-person rapidly and lead to outbreaks [1] [3] [6]. Infection usually occurs after an insect bite or trauma of the skin that exposes the subcutaneous tissue to the bacterial pathogen [1] [7]. The clinical presentation is characterized by the presence of shallow ulcers on the skin that may develop on virtually any site of the body [1] [4]. The ulcers are chronic in nature and do not heal spontaneously, and coinfections of the ulcers by other bacteria (eg. Staphylococcus aureus and Streptococcus pyogenes) is common [1] [4] [6] [7].

• Lymphadenopathy

  Neck: Extensive anterior and submandibular cervical lymphadenopathy imparts a bull's neck appearance. The patient may hold his or her head in extension. It can occasionally also be associated with dysphonia. [emedicine.medscape.com]

  There were no signs of lymphadenopathy, no lesions of the oropharyngeal mucosa, and no pathological findings of other organ systems. [medicaljournals.se]

  Cutaneous diphetheria Complications/Sequelae Myocarditis/Neuritis (only if toxin gets into the bloodstream) *Bacteria colonizes pharyngeal tissue: damage due to exotoxin activity (lysogenized phage) Pt presents with fever, chills, mlaise, sore throat, LYMPHADENOPATHY [quizlet.com]

  The largest one measured 5.5 × 3.4 cm on the ventral aspect of the shaft of the penis [Figure - 1] along with ipsilateral, nontender, inguinal lymphadenopathy with lymph nodes each measuring about 2 × 1.5 cm in size. [ijdvl.com]

  Patients with severe pharyngeal disease may develop massive lymphadenopathy, giving a characteristic ‘bull neck’ appearance. [www2.health.vic.gov.au]

• Wound Infection

  C. diphtheriae infection was not clinically suspected in any of the patients; treating institutions detected the organism through matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI-TOF) testing of wound-derived coryneform [ncbi.nlm.nih.gov]

  Depending on the route of infection, several forms can be differentiated: first by heteroinoculation, second after autoinoculation (e.g., pharyngeal diphtheria), and third wound diphtheria when a preexisting wound is infected by C. diphtheriae. [karger.com]

  In these cases, the bacterial infection is spread through contact with the infected wound rather than by breathing in infected droplets. [your.md]

• Infectious Mononucleosis

  The membrane bleeds when swabbed, unlike that in typical streptococcal pharyngitis or infectious mononucleosis. The onset is insidious, with early symptoms of malaise, sore throat, anorexia and low-grade fever (rarely >39.1 °C). [www2.health.vic.gov.au]

  The disease may also resemble infectious mononucleosis, streptococcal or viral tonsillitis, peritonsillar abscess, oral thrush, epiglottitis, herpes simplex and impetigo. [patient.info]

• Pathologist

  Perez, MD, Associate Pathologist, Department of Pathology and Laboratory Medicine, Wellington Regional Medical Center, West Palm Beach Click here for Patient Education Diphtheria is an acute pharyngeal or cutaneous infection caused mainly by toxigenic [msdmanuals.com]

• Respiratory Distress

  She presented with a fever, severe sore throat, bull neck (Panel A), hoarse voice, and respiratory distress for 8 days. [canada.ca]

  Respiratory distress manifesting as stridor, wheezing, cyanosis, accessory muscle use, and retractions. Cardiac toxicity typically occurs after 1-2 weeks of illness following improvement in the pharyngeal phase of the disease. [emedicine.medscape.com]

• Dyspnea

  It may manifest as follows: Myocarditis is seen in as many as 60% of patients (especially if previously unimmunized) and can present acutely with congestive heart failure (CHF), circulatory collapse, or more subtly with progressive dyspnea, diminished [emedicine.medscape.com]

• Skin Ulcer

  The case presented with a skin ulcer on her toe. Toxigenic Corynebacterium diphtheriae was isolated from a swab of the lesion. The case was treated with antibiotics. [ncbi.nlm.nih.gov]

  The man had been in Mozambique since autumn 2013 and had experienced persistent skin ulcer infections. His was in good general health. Toxin-producing Corynebacterium diphtheriae was grown from a wound specimen. [eurosurveillance.org]

  • Skin ulcers should be tested for diphtheria especially in returning travellers and in individuals coming from endemic countries. [reliefweb.int]

  There is no need to carry out clearance swabs or to trace contacts of these individ.uals. 4 Skin ulcers not responding to conventional antibiotic treatment should be investigated for rarer causes such as cutaneous diphtheria. [adc.bmj.com]

  Pneumonia, endocarditis and septicemia are the most common complications, whereas skin infections (slowly progressive painful skin ulcers), meningitis or central venous catheter infections are rare [ 9 - 11 ]. [karger.com]

• Insect Bite

  Infection usually occurs after an insect bite or trauma of the skin that exposes the subcutaneous tissue to the bacterial pathogen. [symptoma.com]

  They are often associated with infected insect bites, frequently coinfected with pathogens such as S. aureus and S. pyogenes. Systemic toxic manifestations are uncommon among immunized persons. [wwwnc.cdc.gov]

• Seizure

  A family history of seizures is not a contraindication to immunisation. When there is a personal or family history of febrile seizures, there is an increased risk of these occurring after any fever, including that caused by immunisation. [pcouk.org]

  This can result in seizures or hives, which will later go away. Vaccines only last for 10 years, so your child will need to be vaccinated again around age 12. [healthline.com]

  The following situations do not prohibit diphtheria vaccination: History of a stable neurological condition, seizures or febrile convulsions (without neurological deterioration). [patient.info]

  Rarely, the DTaP vaccine causes serious complications in a child, such as an allergic reaction (hives or a rash develops within minutes of the injection), seizures or shock — complications that are treatable. [drugs.com]

• Guillain-Barré Syndrome

  If there are neurological symptoms and a lumbar puncture is performed, elevated protein in the cerebrospinal fluid may lead to a false diagnosis of Guillain-Barré syndrome. [patient.info]

• Peripheral Neuropathy

  Other cranial nerves may also be affected (3rd, 6th, 7th, 9th, 10th) and a peripheral neuropathy (mainly motor) may appear many months after infection. [tmb.ie]

When suspicion of cutaneous diphtheria arises, the diagnostic workup should start with a thorough history taking during which the patient should be asked about recent travel (or if the patient is a resident in any of the endemic countries mentioned previously) and previous vaccination for diphtheria. Some studies have shown that a poor socioeconomic status, even in developing cities and countries, is an important risk factor [4], implying that sociodemographic characteristics must also be covered in the interview. A detailed clinical examination, including a complete inspection of the skin, should follow. If a chronic non-healing ulcer has been detected, microbiological studies need to be employed. A swab of the tip of the ulcer is tested by gram-staining or by culturing the organism, which are usually the first methods used for detecting Corynebacterium spp., although the presence of various microbiological organisms that are a part of the skin flora (or responsible for co-infections) may compromise the results [1] [7]. For this reason, selective cultivating media or more advanced methods, such as polymerase chain reaction (PCR), must be used to confirm cutaneous diphtheria. PCR amplification is the method of choice when it comes to identifying C. diphtheriae and C. ulcerans, but even more superior procedures, for example matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS), provide more reliable and faster results [3] [7] [8].

• Corynebacterium Diphtheriae

  Cutaneous diphtheria is an infection of the skin by Corynebacterium diphtheriae. It is also known as "desert sore". Diphtheria Skin lesion [en.wikipedia.org]

  Cutaneous diphtheria is a bacterial infection of the skin caused by Corynebacterium diphtheria and less commonly Corynebacterium ulcerans. [symptoma.com]

  Corynebacterium diphtheriae is endemic in Vancouver's urban core, with strains of multilocus sequence type (MLST) 76 predominating. [ncbi.nlm.nih.gov]

  Resistance against toxigenic Corynebacterium diphtheriae in rabbits following injections of non-toxigenic diphtheria bacilli. Am. J. Hyg. 37, 53. Gulasekeran, J., Gunaratna, V. T. H. & Somasunderan, S. J. ( 1956 ). [cambridge.org]

• Gram-Positive Bacteria

  The widespread vaccination against diphtheria toxin produced by Corynebacterium diphtheriae has led to a profound decrease in the number of infections caused by this gram-positive bacteria throughout the world. [symptoma.com]

The lesions start as vesicles and quickly form small, clearly demarcated ulcers. 3 Symptomatic infections with non-toxigenic C. diphtheria are rare but when identified needs appropriate treatment. [adc.bmj.com]

Post Diphtheria - Treatment What was the treatment for your diphtheria disease? Post CONTINUE SCROLLING FOR RELATED ARTICLE [emedicinehealth.com]

Epinephrine should be kept at hand during these test doses, as well as during treatment. [infectiousdiseaseadvisor.com]

Treatment: Analgesics (relief from pain) 7. [quizlet.com]

What is the prognosis of diphtheria? The prognosis of diphtheria ranges from good to poor, depending upon how early in the infection the patient is treated, and how the patient responds to treatment. [medicinenet.com]

The prognosis for diphtheria depends on the severity of the disease and the presence of systemic involvement. Cardiac involvement and bacteremia ( blood infection ) are especially associated with a poor prognosis. [emedicinehealth.com]

Prognosis Overall there is a 5-10% mortality rate, but it is up to 20% in those younger than 5 years and older than 40 years. [ 5 ] Recovery is slow and particular caution should be advised after myocarditis. [patient.info]

Etiologic Agent Toxin-producing strains of Corynebacterium diphtheriae. [meningitis-angels.org]

Descriptive Epidemiology 587 Mechanisms and Routes of Transmission 7 Pathogenesis and Immunity 590 Patterns of Host Response 591 Control and Prevention 592 References 593 Suggested Reading 595 Rocky Mountain Spotted Fever Theodore E Woodward and J Stephen [books.google.de]

These cases constituted an epidemiologic focus from which the other cases were infected. [ncbi.nlm.nih.gov]

The Changing Epidemiology of Diphtheria in the Vaccine Era. The Journal of Infectious Diseases, Vol. 181, Issue. s1, p. S2. CrossRef Google Scholar Rastogi, A. Kumar, L. Ayyagari, A. Kumar, V. and Dhar, V. 1982. [cambridge.org]

Descriptive Epidemiology 587 Mechanisms and Routes of Transmission 7 Pathogenesis and Immunity 590 Patterns of Host Response 591 Control and Prevention 592 References 593 Suggested Reading 595 Rocky Mountain Spotted Fever Theodore E Woodward and J Stephen [books.google.de]

Prevention: DPT (toxoid) vaccine series followed by boosters (even for adults) Muy Importante! [quizlet.com]

Degraded public health services leave displaced people vulnerable to multiple environmental and infectious hazards including vaccine preventable disease. [ncbi.nlm.nih.gov]

[…] about people who have suffered or died from vaccine-preventable diseases Video of the Week IAC's weekly selection of PSAs and videos that raise awareness of immunization issues [immunize.org]

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2. Abdul Rahim NR, Koehler AP, Shaw DD, Graham CR. Toxigenic cutaneous diphtheria in a returned traveller. Commun Dis Intell Q Rep. 2014;38(4):E298-300.
3. Cassir N, Bagnères D, Fournier PE, Berbis P, Brouqui P, Rossi PM. Cutaneous diphtheria: easy to be overlooked. Int J Infect Dis. 2015;33:104-105.
4. Lowe CF, Bernard KA, Romney MG. Cutaneous Diphtheria in the Urban Poor Population of Vancouver, British Columbia, Canada: a 10-Year Review. J Clin Microbiol. 2011;49(7):2664-2666.
5. Queensland Health. Diphtheria Queensland Health Guidelines for Public Health Units. Updated 23 January 2012. Accessed on 17 April 2017. Available from: http://www.health.qld.gov.au/cdcg/index/diphtheria.asp#ana
6. Huhulescu S, Hirk S, Zeinzinger V, et al. Letter to the editor: cutaneous diphtheria in a migrant from an endemic country in east Africa, Austria May 2014. Euro Surveill. 2014;19(26).pii:20845.
7. Jakovljev A, Steinbakk M, Mengshoel AT, et al. Imported toxigenic cutaneous diphtheria in a young male returning from Mozambique to Norway, March 2014. Euro Surveill. 2014;19(24).pii:20835.
8. Seng P, Drancourt M, Gouriet F, La Scola B, Fournier PE, Rolain JM, et al. Ongoing revolution in bacteriology: Routine identification of bacteria by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Clin Infect Dis. 2009;49(4):543-551.