Acta Clinica Belgica International Journal of Clinical and Laboratory Medicine
ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20
A FORGOTTEN DISEASE IN A RETURNING TRAVELER FROM THAILAND M Depypere, J Verhaegen, I Derdelinckx & W Meersseman To cite this article: M Depypere, J Verhaegen, I Derdelinckx & W Meersseman (2013) A FORGOTTEN DISEASE IN A RETURNING TRAVELER FROM THAILAND, Acta Clinica Belgica, 68:5, 382-383 To link to this article: http://dx.doi.org/10.2143/ACB.3429
Published online: 06 May 2014.
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Article views: 18
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yacb20 Download by: [Gazi University]
Date: 29 March 2016, At: 12:17
382
A FORGOTTEN DISEASE IN A RETURNING TRAVELER FROM THAILAND
Case Report
A FORGOTTEN DISEASE IN A RETURNING TRAVELER FROM THAILAND Depypere M1, Verhaegen J1, Derdelinckx I2, Meersseman W2 1
Department of Clinical Microbiology, University hospital Leuven, Belgium, 2Department of Infectious Diseases, University hospital Leuven, Belgium
Downloaded by [Gazi University] at 12:17 29 March 2016
Correspondence and offprint requests to: Melissa Depypere, E-mail: [email protected]
ABSTRACT Cutaneous diphteria is a forgotten disease. We must consider this in our differential diagnosis, not only when a patient presents with a cutaneous ulcer and has travelled to tropical areas, but also in patients who subsist in low socio-economic conditions, especially in homeless people and people with a history of alcohol or drug abuse. Vigilance for this forgotten disease is warranted because most physicians in developed countries have never seen one case. In an era of increasing globalisation, we might see more cases in the future. We report a case of a foot infection with a non toxigenic C. diptheriae biovar gravis in a 16 year old girl, who has travelled to Thailand. Figure 1
Key words: cutaneous diptheria, coryne bacteria diptheria
CASE REPORT A 16-year-old girl, living in Belgium for 8 years, travelled to Thailand for two weeks. Patient’s medical history was unremarkable. In May 2012, one month after return, she presented with non-healing sores on both feet. The lesions started as a vesicle in Thailand, probably due to inappropriate footwear. Despite local application of desinfectants, it progressed to an ulcer. The patient never had fever. There was no improvement after 10 days of Amoxicillinclavulanate 875 mg three times a day prescribed by her general practitioner. Consequently she was referred to our hospital. On clinical examination there were punched-out ulcer like lesions on both feet (Figure 1). Painful small glands were palpable in the left groin. No other clinical signs were present. Laboratory tests showed no signs of inflammation, no leucocytosis and a CRP of 0.5 mg/L (ref ≤ 5.0 mg/L). To exclude
Acta Clinica Belgica, 2013; 68-5
any underlying acquired immunodeficiency syndrome, the HIV status was checked, which turned out to be negative. A CT-scan of both feet showed no evidence of osteomyelitis and abcedation. This was confirmed by an ultrasound. Corynebacterium diphtheriae, Streptococcus pyogenes and Staphylococcus aureus were isolated from the wound of the left foot. A diagnosis of cutaneous diphtheria (with streptococcal and staphylococcal superinfection) was made. Clindamycin 600 mg three times a day was initiated because of its susceptibility against the 3 pathogens. Treatment was given for 14 days. Healing occurred after 5 weeks. The National Reference Center (U.H. Brussels) confirmed the identification of a non-toxigenic C. diptheriae biovar gravis. Diphteria was one of the first infectious diseases for which mass vaccination was implemented. Nowadays, it is a very rare disease. Classical disease, mostly transmitted from person-toperson, causes respiratory symptoms with pseudomembranes in the upper respiratory tract (2, 3, 4). In subtropical climates, transmission by fomites may occur and causes cutaneous
doi: 10.2143/ACB.3429
Downloaded by [Gazi University] at 12:17 29 March 2016
A FORGOTTEN DISEASE IN A RETURNING TRAVELER FROM THAILAND
isease (2, 4). The bacteria can enter the skin after injury or act d as co-pathogen in other pre-existing Gram-positive cutaneous infections (1, 3-5). When a patient has travelled to tropical areas and presents with a cutaneous ulcer, C. diphtheriae infection must be considered in the differential diagnosis. It can be caused by toxigenic and non-toxigenic strains (1-5). It can also be seen in patients subsisting in low socio-economic conditions, especially in homeless people and people with a history of alcohol or drug abuse (1, 3-5). Penicillin or erythromycin is considered the first-line treatment of cutaneous diphtheria (2-5). The lesions usually heal completely within 8 weeks. The patient moved eight years ago from Thailand to Belgium. Presumably, the vaccination scheme was not completed in Thailand. In accordance with her mother she received the vaccinations as a baby but no booster at the age of 12. Her general practitioner confirmed the incomplete vaccination status with determination of antibodies. The necessary vaccinations were given, so the vaccination status has been completed. There are case reports of cutaneous diphtheria acting as a reservoir for respiratory diphtheria. Infection with toxin-producing
C. diphtheriae can cause pharyngeal colonisation and the disease diphtheria can occur (1, 2, 3). Vigilance for this forgotten disease is warranted because most physicians in developed countries have never seen one case. In an era of increasing globalisation, we might see more cases in the future.
CONFLICT OF INTEREST: None. REFERENCES 1. Gordon CL, Fagan P, Hennessy J, Baird R. Characterization of Corynebacterium diphteriae isolates from infected skin lesions in the Northern Territory of Australia. J. Clin. Microbiol. 2011; 49: 3960-3961. 2. Werdmuller BF, Brakman M, Vreede RW. A tropic ulcer; cutaneous diphteria. Ned Tijdschr Geneeskd. 1996; 140: 2414-2416. 3. Gerald. Mandell, John E. Bennett, Raphael Dolin. Principles and practice of infectious diseases. Sixth edition. 4. Orouji A, Kiewert A, Filser T, Goerdt S, Peitsch WK. Cutaneous diphtheria in a German man with travel history. Acta derma Venereol. 2012; 92: 179-180. 5. Lowe CF, Bernard KA, Romney MG. Cutaneous diphteria in the urban poor population of Vancouver British Columbia, Canada: A 10-year Review. J.Clin. Microbiol. 2011; 49: 2664-2666.
Acta Clinica Belgica, 2013; 68-5
383
ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20
A FORGOTTEN DISEASE IN A RETURNING TRAVELER FROM THAILAND M Depypere, J Verhaegen, I Derdelinckx & W Meersseman To cite this article: M Depypere, J Verhaegen, I Derdelinckx & W Meersseman (2013) A FORGOTTEN DISEASE IN A RETURNING TRAVELER FROM THAILAND, Acta Clinica Belgica, 68:5, 382-383 To link to this article: http://dx.doi.org/10.2143/ACB.3429
Published online: 06 May 2014.
Submit your article to this journal
Article views: 18
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yacb20 Download by: [Gazi University]
Date: 29 March 2016, At: 12:17
382
A FORGOTTEN DISEASE IN A RETURNING TRAVELER FROM THAILAND
Case Report
A FORGOTTEN DISEASE IN A RETURNING TRAVELER FROM THAILAND Depypere M1, Verhaegen J1, Derdelinckx I2, Meersseman W2 1
Department of Clinical Microbiology, University hospital Leuven, Belgium, 2Department of Infectious Diseases, University hospital Leuven, Belgium
Downloaded by [Gazi University] at 12:17 29 March 2016
Correspondence and offprint requests to: Melissa Depypere, E-mail: [email protected]
ABSTRACT Cutaneous diphteria is a forgotten disease. We must consider this in our differential diagnosis, not only when a patient presents with a cutaneous ulcer and has travelled to tropical areas, but also in patients who subsist in low socio-economic conditions, especially in homeless people and people with a history of alcohol or drug abuse. Vigilance for this forgotten disease is warranted because most physicians in developed countries have never seen one case. In an era of increasing globalisation, we might see more cases in the future. We report a case of a foot infection with a non toxigenic C. diptheriae biovar gravis in a 16 year old girl, who has travelled to Thailand. Figure 1
Key words: cutaneous diptheria, coryne bacteria diptheria
CASE REPORT A 16-year-old girl, living in Belgium for 8 years, travelled to Thailand for two weeks. Patient’s medical history was unremarkable. In May 2012, one month after return, she presented with non-healing sores on both feet. The lesions started as a vesicle in Thailand, probably due to inappropriate footwear. Despite local application of desinfectants, it progressed to an ulcer. The patient never had fever. There was no improvement after 10 days of Amoxicillinclavulanate 875 mg three times a day prescribed by her general practitioner. Consequently she was referred to our hospital. On clinical examination there were punched-out ulcer like lesions on both feet (Figure 1). Painful small glands were palpable in the left groin. No other clinical signs were present. Laboratory tests showed no signs of inflammation, no leucocytosis and a CRP of 0.5 mg/L (ref ≤ 5.0 mg/L). To exclude
Acta Clinica Belgica, 2013; 68-5
any underlying acquired immunodeficiency syndrome, the HIV status was checked, which turned out to be negative. A CT-scan of both feet showed no evidence of osteomyelitis and abcedation. This was confirmed by an ultrasound. Corynebacterium diphtheriae, Streptococcus pyogenes and Staphylococcus aureus were isolated from the wound of the left foot. A diagnosis of cutaneous diphtheria (with streptococcal and staphylococcal superinfection) was made. Clindamycin 600 mg three times a day was initiated because of its susceptibility against the 3 pathogens. Treatment was given for 14 days. Healing occurred after 5 weeks. The National Reference Center (U.H. Brussels) confirmed the identification of a non-toxigenic C. diptheriae biovar gravis. Diphteria was one of the first infectious diseases for which mass vaccination was implemented. Nowadays, it is a very rare disease. Classical disease, mostly transmitted from person-toperson, causes respiratory symptoms with pseudomembranes in the upper respiratory tract (2, 3, 4). In subtropical climates, transmission by fomites may occur and causes cutaneous
doi: 10.2143/ACB.3429
Downloaded by [Gazi University] at 12:17 29 March 2016
A FORGOTTEN DISEASE IN A RETURNING TRAVELER FROM THAILAND
isease (2, 4). The bacteria can enter the skin after injury or act d as co-pathogen in other pre-existing Gram-positive cutaneous infections (1, 3-5). When a patient has travelled to tropical areas and presents with a cutaneous ulcer, C. diphtheriae infection must be considered in the differential diagnosis. It can be caused by toxigenic and non-toxigenic strains (1-5). It can also be seen in patients subsisting in low socio-economic conditions, especially in homeless people and people with a history of alcohol or drug abuse (1, 3-5). Penicillin or erythromycin is considered the first-line treatment of cutaneous diphtheria (2-5). The lesions usually heal completely within 8 weeks. The patient moved eight years ago from Thailand to Belgium. Presumably, the vaccination scheme was not completed in Thailand. In accordance with her mother she received the vaccinations as a baby but no booster at the age of 12. Her general practitioner confirmed the incomplete vaccination status with determination of antibodies. The necessary vaccinations were given, so the vaccination status has been completed. There are case reports of cutaneous diphtheria acting as a reservoir for respiratory diphtheria. Infection with toxin-producing
C. diphtheriae can cause pharyngeal colonisation and the disease diphtheria can occur (1, 2, 3). Vigilance for this forgotten disease is warranted because most physicians in developed countries have never seen one case. In an era of increasing globalisation, we might see more cases in the future.
CONFLICT OF INTEREST: None. REFERENCES 1. Gordon CL, Fagan P, Hennessy J, Baird R. Characterization of Corynebacterium diphteriae isolates from infected skin lesions in the Northern Territory of Australia. J. Clin. Microbiol. 2011; 49: 3960-3961. 2. Werdmuller BF, Brakman M, Vreede RW. A tropic ulcer; cutaneous diphteria. Ned Tijdschr Geneeskd. 1996; 140: 2414-2416. 3. Gerald. Mandell, John E. Bennett, Raphael Dolin. Principles and practice of infectious diseases. Sixth edition. 4. Orouji A, Kiewert A, Filser T, Goerdt S, Peitsch WK. Cutaneous diphtheria in a German man with travel history. Acta derma Venereol. 2012; 92: 179-180. 5. Lowe CF, Bernard KA, Romney MG. Cutaneous diphteria in the urban poor population of Vancouver British Columbia, Canada: A 10-year Review. J.Clin. Microbiol. 2011; 49: 2664-2666.
Acta Clinica Belgica, 2013; 68-5
383
