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Letter
Imported Cutaneous Diphtheria,
Germany, 1997–2003
Andreas Sing*
and Jürgen Heesemann*
*Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie,
Munich, Germany
Suggested
citation for this article
To the Editor: The March 2004 report by de Benoist et al. on the
incidence of imported cutaneous diphtheria in the United Kingdom (1)
prompted us to describe the situation of cutaneous diphtheria in Germany
and to analyze the cases reported to the German Consiliary Laboratory
on Diphtheria since its establishment at our institute in 1997. The laboratory
provides advisory and diagnostic services mainly to microbiologic laboratories
throughout Germany.
From 1997 to 2003, 6 cases of cutaneous infections caused by toxigenic
Corynebacterium diphtheriae were documented (Table).
None of these was accompanied by secondary diphtheria infection. Toxigenicity
was determined by both dtx polymerase chain reaction and Elek test
(2). As in the United Kingdom, all cases for which clinical
information was available (N = 5) were imported. Three were found in tourists
who had traveled to tropical countries: a 20-year-old diver had injured
her heel after stepping on coral in Thailand; a 60-year-old tourist had
a chronic ulcer in the thigh after a trip to Indonesia (no history of
an insect bite); and a 39-year-old traveler to Kenya returned with a purulent
ear infection with no memory of trauma or insect bite. The remaining imported
C. diphtheriae skin infections were reported in 2 Angolan children,
5 and 10 years of age, who were brought to Germany by a humanitarian organization
for surgery on severe gun wounds to their lower extremities (foot and
thigh with chronic osteomyelitis, respectively). To our knowledge, these
reports are the first of cutaneous diphtheria in gunshot wounds in recent
years. Moreover, in the patient with the thigh wound, C. diphtheriae
was also isolated from a deep fistula, which suggests involvement of C.
diphtheriae in the chronic osteomyelitis.
As in the United Kingdom, all cases of diphtheria reported since 1997
were caused by C. diphtheriae mitis. In 4 of 5 cutaneous diphtheria
patients who had an available medical history, mixed infections with Staphylococcus
aureus and Streptococcus pyogenes were found; 3 of 5 patients
were not sufficiently vaccinated against diphtheria as recommended. Systemic
symptoms, such as malaise and general weakness, developed in the 20-year-old
Thailand tourist, although she had received a booster dose just before
her travel. Cutaneous diphtheria must be expected even in vaccinated patients;
for instance, among serum samples of 287 healthy German adults with a
complete record of basic immunization against diphtheria, only 42.2% showed
full serologic protection as indicated by antitoxin levels >0.1
IU/mL (3).
As de Benoist et al. outline, cutaneous diphtheria might be difficult
to diagnose because of its unspecific clinical appearance and the presence
of mixed infections in chronic nonhealing skin lesions. Because of the
nearly complete disappearance of cutaneous diphtheria in many parts of
the western world, microbiologists lack experience in identifying C.
diphtheriae grown from specimens. From 1997 to 2003, approximately
one fifth of the strains sent to our Consiliary Laboratory on Diphtheria
for species identification and toxin testing were either nondiphtheria
Corynebacterium spp. or noncoryneform bacteria of different genera
(including lactobacilli, Dermabacter hominis, and Propionibacterium
acnes).
Clinicians (4) and microbiologists (5)
should be aware of the possibility of cutaneous diphtheria in chronically
infected skin lesions in patients returning from disease-endemic regions.
Medical personnel should include this in civilian as well as military
health services, since our cases indicate that toxigenic C. diphtheriae
might affect not only travel-related skin injuries caused by leisure or
tourist activities but also wounds in patients from war regions in diphtheria-endemic
areas.
References
- De Benoist AC, White JM, Efstratiou A, Kelly C, Mann
G, Nazareth B, et al. Imported
cutaneous diphtheria, United Kingdom. Emerg Infect Dis. 2004;10:511–3.
- Sing A, Hogardt M, Bierschenk S, Heesemann J. Detection
of differences in the nucleotide and amino acid sequences of diphtheria
toxin from Corynebacterium diphtheriae and Corynebacterium
ulcerans causing extrapharyngeal infections. J Clin Microbiol.
2003;41:4848–51.
- Hasselhorn HM, Nubling M, Tiller FW, Hofmann F. Factors
influencing immunity against diphtheria in adults. Vaccine. 1998;16:70–5.
- Bonnet JM, Begg NT. Control
of diphtheria: guidance for consultants in communicable disease control.
Commun Dis Public Health. 1999;2:242–9.
- Efstratiou A, George RC. Laboratory
guidelines for the diagnosis of infections caused by Corynebacterium
diphtheriae and C. ulcerans. Commun Dis Public Health.
1999;2:250–7.
| Table.
Cutaneous diphtheria cases caused by toxigenic Corynbacterium diphtheriae
in Germany, reported to the German Consiliary Laboratory, 1997–2003 |
|
|
Y
|
Sex*
|
Age (y)
|
Biotype
|
Localization
|
Country
|
Vaccination status
|
|
|
1997
|
F
|
20
|
mitis
|
Heel
|
Thailand
|
+†
|
|
2000
|
M
|
60
|
mitis
|
Thigh
|
Indonesia
|
+†
|
|
2001
|
M
|
60
|
mitis
|
NR‡
|
NR‡
|
NR‡
|
|
2001
|
F
|
39
|
mitis
|
Ear
|
Kenya
|
(+)§
|
|
2002
|
M
|
5
|
mitis
|
Foot; gun wound
|
Angola
|
–¶
|
|
2002
|
M
|
10
|
mitis
|
Thigh; gun wound
|
Angola
|
–¶
|
|
| *M, male; F, female. |
| † +, vaccination status as
recommended in Germany (basic and booster immunization). |
| ‡ NR, not reported. |
| § (+), vaccination status
only partial as recommended in Germany (only basic immunization). |
| ¶ –, not vaccinated. |
Suggested citation
for this article:
Sing A, Heesemann J.
Imported cutaneous diphtheria, Germany, 1997–2003 [letter]. Emerg Infect
Dis [serial on the Internet]. 2005 Feb [date cited]. Available
from http://www.cdc.gov/ncidod/EID/vol11no02/04-0560.htm
|
