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Cutaneous Diphtheria

Cutaneous diphtheria is a bacterial infection of the skin caused by Corynebacterium diphtheria and less commonly Corynebacterium ulcerans. The condition is endemic in the developing countries, but sporadic cases in Europe, Australia and North America, have been documented. The clinical presentation comprises chronic non-healing ulcers that are only rarely accompanied by signs of a systemic infection. The diagnosis rests on clinical criteria and microbiological identification of the bacterial pathogens.


Presentation

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].

Disability
  • […] itemId /content/10.2807/1560-7917.ES2014.19.24.20835&mimeType html&fmt ahah Comment has been disabled for this content Submit comment Close Comment moderation successfully completed This is a required field Please enter a valid email address Approval[eurosurveillance.org]
  • Disability ... is any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. ‎[books.google.de]
Hematochezia
  • Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself[nejm.org]
Myopathy
  • Stay current on the latest anesthetic implications in regards to coexisting diseases, procedures, drugs, and alternative and complementary therapies, including coverage of mitochondrial myopathy, atrial fibrillation ablation, awake craniotomy, stereotactic[books.google.de]
Arthralgia
  • Extracutaneous symptoms, including fever, arthralgia, myalgia, headache and sore throat, were denied. The patient’s medical history was otherwise unremarkable.[medicaljournals.se]
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]
  • The disease is characterized by shallow skin ulcers, which can occur anywhere on the body and are usually chronic. They are often associated with infected insect bites, frequently coinfected with pathogens such as S. aureus and S. pyogenes.[wwwnc.cdc.gov]
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]

Workup

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]
  • Toxigenic Corynebacterium diphtheriae was isolated from a swab of the lesion. The case was treated with antibiotics.[ncbi.nlm.nih.gov]
  • AIM: Diphtheria is an acute bacterial illness caused by toxigenic strains of Corynebacterium diphtheriae (C. diphtheriae).[ncbi.nlm.nih.gov]

Treatment

  • The 2 cases and 1 carrier were placed in consented restriction until antibiotic treatment and 2 clearance swabs were available.[ncbi.nlm.nih.gov]
  • Stay at the forefront of your field with updated treatment methods throughout, as well as an increased focus on patients with skin of color.[books.google.de]
  • 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]
  • Therefore, increased awareness and immediate treatment is warranted. Both toxigenic and non-toxigenic C. diphtheriae are usually susceptible to penicillin and erythromycin.[medicaljournals.se]
  • Limitations in the capacity to confirm toxigenic infections may delay diagnosis, treatment and public health interventions in some EU Member States.[reliefweb.int]

Prognosis

  • 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]

Etiology

Epidemiology

  • 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]
  • We summarise the epidemiology, clinical presentation, microbiology, diagnosis, therapy, and public health aspects of this disease, with emphasis on improving recognition.[ncbi.nlm.nih.gov]
  • We describe two epidemiologically-linked cases of skin infections from which toxigenic C. diphtheriae was isolated, and discuss implications for diphtheria surveillance and management in New Zealand.[ncbi.nlm.nih.gov]
  • Ms. de Benoist works at the Health Protection Agency, Communicable Disease Surveillance Centre, London, United Kingdom, as a fellow of the European Programme of Intervention Epidemiology Training.[wwwnc.cdc.gov]
Sex distribution
Age distribution

Prevention

  • 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]
  • Degraded public health services leave displaced people vulnerable to multiple environmental and infectious hazards including vaccine preventable disease.[ncbi.nlm.nih.gov]
  • , including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs... ‎[books.google.de]
  • Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets[books.google.de]
  • Europe's journal on infectious disease surveillance, epidemiology, prevention and control Home Eurosurveillance Volume 19, Issue 24, 19/Jun/2014 Article Rapid communications Open Access Like 0 Access full text Article A Jakovljev 1 , M Steinbakk 2 , A[eurosurveillance.org]

References

Article

  1. De Benoist A-C, White JM, Efstratiou A, et al. Imported Cutaneous Diphtheria, United Kingdom. Emerg Infect Dis. 2004;10(3):511-513.
  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.

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Last updated: 2019-06-28 11:12