An unusual case of post-trauma polymicrobial cutaneous diphtheria.

We report a rare case of post-traumatic cutaneous diphtheria in a patient referred from a hospital in rural India. The diagnosis of cutaneous diphtheria was confirmed by the isolation of Corynebacterium diphtheriae cultured from the ulcer of the leg, along with Staphylococcus aureus, Streptococcus pyogenes, and Arcanobacterium haemolyticum. The patient was kept on isolation and treated with erythromycin for 14 days without antitoxin. He was discharged when his subsequent cultures turned out to be negative. Chemoprophylaxis was also given to his family members. Such a case highlights the revisiting of vaccination strategies and the role of cutaneous carriers in transmission of this deadly disease.

Preventing the preventable through effective surveillance: the case of diphtheria in a rural district of Maharashtra, India.

BACKGROUND: Epidemic diphtheria is still poorly understood and continues to challenge both developing and developed countries. In the backdrop of poor immunization coverage, non-existent adult boosters, weak case based surveillance and persistence of multiple foci, there is a heightened risk of re-emergence of the disease in epidemic forms in India. Investigating each outbreak to understand the epidemiology of the disease and its current status in the country is therefore necessary. Dhule a predominantly tribal and rural district in Northern Maharashtra has consistently recorded low vaccination coverages alongside sporaidic cases of diphtheria over the last years. METHODS: This study reports the findings of an onsite survey conducted to assess a recent outbreak of diphtheria in Dhule district and the response mounted to it. Secondary data regarding outbreak detection and response were obtained from the district surveillance office. Clinical data were extracted from hospital records of eleven lab confirmed cases including one death case. Frequency distributions were calculated for each identified clinical and non- clinical variable using Microsoft™ Excel® 2010. RESULTS: Our findings suggest a shift in the median age of disease to adolescents (10-15 years) without gender differences. Two cases (18%) reported disease despite immunization. Clinical symptoms included cough (82%), fever (73%), and throat congestion (64%). About 64% and 36% of the 11 confirmed cases presented with a well defined pseudomembrane and a tonsillar patch respectively. Drug resistance was observed in all three culture positive cases. One death occurred despite the administration of Anti-Diphtheric Serum in a partially immunized case (CFR 9%). Genotyping and toxigenicity of strain was not possible due to specimen contamination during transport as testing facilities were unavailable in the district. CONCLUSIONS: The outbreak raises several concerns regarding the epidemiology of diphtheria in Dhule. The reason for shift in the median age despite consistently poor immunization coverage (below 50%) remains unclear. Concomitant efforts should now focus on improving and monitoring primary immunization and booster coverages across all age groups. Gradually introducing adult immunization at ten year intervals may become necessary to prevent future vulnerabilities. Laboratory networks for genotyping and toxigenicity testing are urgently mandated at district level given the endemicity of the disease in the surrounding region and its recent introduction in remote Dhule. Contingency funds with pre- agreements to obtain ADS and DT/Td vaccines at short notice and developing standard case management protocols at district level are necessary. Monitoring the disease, emerging strains and mutations, alongside drug resistance through robust and effective surveillance is a pragmatic way forward.

[The clinical manifestations, diagnosis and treatment of diphtheria in adults]. / Klinicheskie proiavleniia, diagnostika i lechenie difterii u vzroslykh.

Diphtheria morbidity among adult population of Moscow is growing. The tests of different modes and schemes of heterogeneous antidiphtheria serum administration have found out that the highest efficacy of serotherapy was achieved with a single intravenous dose. Another treatment of diphtheria is hemosorption. Widely used in present-day clinical practice hemosorbents provide adequate elimination of the toxin from plasma. The authors analyse the present situation in clinical symptoms, complications, lethality of diphtheria basing on the data provided by S. P. Botkin's Hospital.

[The albumin-binding capacity of the blood serum in diphtheria patients]. / Sviazyvaiushchaia sposobnost' al'bumina syvorotki krovi u bol'nykh difteriei.

Total and effective concentrations of blood serum albumins were measured in 45 patients with various clinical forms of diphtheria. Both parameters were decreased in patients with toxic forms of the disease in comparison with the norm and with those in patients during the period when specific complications develop and in patients with all clinical forms of diphtheria at the beginning of the illness.

[Basic features of diphtheria (author's transl)]. / Grundlagen der Diphtherie

The basic features of diphtheria, especially clinical aspects, differential diagnosis and therapy are set out insofar as they are important for the general practitioner. The doctor, not the bacteriologist, must make the diagnosis. Serotherapy must be begun as rapidly as possible, and in adequate dosage. The patients must be carefully watched over in the interests of early detection of possible complications. Rest in bed is required in every case for at least 3 to 4 weeks, longer if possible. Even mild "localized" forms can lead to toxic damage during the course or subsequently. In infants, diphtheria may run its course as the well-defined clinical picture of "diphtheria intoxication" of infants.

Clinical characteristics and management of 676 hospitalized diphtheria cases, Kyrgyz Republic, 1995.

The Kyrgyz Republic experienced a widespread resurgence of diphtheria during 1994-1998. To describe the clinical characteristics and management of diphtheria patients hospitalized in 1995, a retrospective chart review was conducted. Physician-diagnosed cases of diphtheria were classified according to the system recommended by the World Health Organization and UNICEF. Among 676 patients hospitalized with respiratory diphtheria, 163 (24%) were carriers, 186 (28%) had tonsillar forms, 78 (12%) had combined types or delayed diagnosis, and 201 (30%) had severe forms of diphtheria. The highest age-specific incidence rates occurred among persons 15-34 years old, and 70% of cases were among those >/=15 years of age. Myocarditis occurred among 151 patients (22%), and 19 patients died (case fatality ratio: 3%). Diphtheria antitoxin was administered to 507 patients (75%), and all patients received antibiotics (penicillin or erythromycin). Respiratory diphtheria remains a potentially fatal disease, commonly presenting with a typical membranous pharyngitis. Early diagnosis and treatment of cases with diphtheria antitoxin and antibiotics are the cornerstones of effective treatment.