Background Cutaneous diphtheria is a skin infection caused by toxigenic and non-toxigenic strains of Corynebacterium diphtheriae. It is characterised by chronic nonhealing ulcers. Diagnosis may be delayed because it is a rare infection in developed countries. Usual treatment is erythromycin or penicillin, although erythromycin is more effective than penicillin.
Purpose To describe a case of cutaneous diphtheria caused by non-toxigenic C. diphtheriae in a Visiting Friends and Relatives (VFR) patient.
Material and methods Data were obtained by a review of the electronic medical records, Pubmed and Uptodate.
Results A 25-years-old female. No known drug allergy. No usual treatment. She is from Guinea Bissau but she has lived in Spain since she was 7-years-old. She has been on holiday in Guinea Bissau from April to May 2017. Two weeks before her return she had a papular lesion in her left leg and subsequently it was ulcerated. Two days after she returned, she went to the hospital. Progressively similar lesions appeared in both legs, right shoulder and back. Exudate samples from ulcers were taken for microbiological culture and biopsy. In addition, we performed a protocol to care for immigrants: serology for strongyloides, treponema pallidum, plasmodium falciparum/vivas/malariae/ovale and HIV-1/2 were negative as well as PCR for Loa-loa and filarias. Skin histology showed eosinophil infiltrates with a central ulceration. PAS/Ziehl–Neelsen stains remained negative. Microbiological culture of ulcer swabs revealed C. diphtheria with Streptococcus pyogenes group A and methicillin-sensitive Staphylococcus aureus superinfection. PCR analysis for C. diphtheria toxin was negative. Pharyngeal swab cultures remained negative for C. diphtheriae. The patient was treated with erythromycin 500 mg/6 hours for 14 days. Topical treatment included daily fusidic acid. Lesions improved progressively with the treatment. Within 2 weeks all skin lesions had completely resolved.
Conclusion Cutaneous diphtheria was caused by non-toxigenic C. diphtheria. It is a highly contagious infection. Due to high vaccination rates it is a quite a rare infection in developed countries, but due to the increase in migration and refugees into Europe, more cases are being seen. Cutaneous diphtheria should be included in the differential diagnosis of patients with skin ulcerations, especially in immigrants.
No conflict of interest
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