To read the full-text of this research, you can request a copy directly from the authors.
Abstract
Background
Corynebacterium diphtheriae may cause respiratory or cutaneous infections, often with the formation of a pseudo-membrane in the tonsils, pharynx, nasopharynx, or larynx.
Case Report
We describe the case of a 42-year-old patient presenting with chronic sinusitis without polyposis with symptoms of forehead and malar pain and pressure that did not abate with conservative therapy. She opted for surgical management and operative cultures taken from the paranasal sinuses grew Corynebacterium diphtheriae Toxin A type. Patient's postoperative course was uneventful, and she completed diphtheria treatment with erythromycin.
Conclusion
Our case report highlights a previously unreported presentation of diphtheria infection of the paranasal sinuses and underlies the importance of considering this rare organism in patients with an unknown vaccination history from endemic areas with tenacious plaques of the oropharynx, nasopharynx, and nasal cavity.
Forty eight patients with a clinical diagnosis of diphtheria, admitted to the Pediatric Intensive Care Unit (PICU) of a tertiary care teaching hospital, from December 1994 to 2002, were analyzed retrospectively with respect to demographic details, clinical features, immunization status, complications and mortality. Several variables were compared among the survivors and non-survivors to define the predictors of outcome More than half 27 (56.3%). of the patients were unimmunized. Complications seen were: airway compromise 34 (70.8%), myocarditis 32 (66.6%), renal failure 17 (35.4%) and thrombocytopenia 15 (31.3%). Out of the 48 patients, 21 survived and 27 died (56.3%). The immediate cause of death was myocarditis 23 (85%), airway compromise 3 (11.1%) and septic shock due to nosocomial sepsis(1). Inadequate immunization, hypotension at admission and presence of any complication like airway compromise, myocarditis and renal failure had a significant (P <0.05) adverse effect on outcome; multiple regression analysis ascertained that, development of myocarditis was the only independent predictor of death (Adjusted OR 0.061; 95% CI 0.009-0.397; P = 0.003).
Diphtheria is a potentially fatal infection mostly caused by toxigenic Corynebacterium diphtheriae strains and occasionally by toxigenic C. ulcerans and C. pseudotuberculosis strains. Diphtheria is generally an acute respiratory infection, characterized by the formation of a pseudomembrane in the throat, but cutaneous infections are possible. Systemic effects, such as myocarditis and neuropathy, which are associated with increased fatality risk, are due to diphtheria toxin, an exotoxin produced by the pathogen that inhibits protein synthesis and causes cell death. Clinical diagnosis is confirmed by the isolation and identification of the causative Corynebacterium spp., usually by bacterial culture followed by enzymatic and toxin detection tests. Diphtheria can be treated with the timely administration of diphtheria antitoxin and antimicrobial therapy. Although effective vaccines are available, this disease has the potential to re-emerge in countries where the recommended vaccination programmes are not sustained, and increasing proportions of adults are becoming susceptible to diphtheria. Thousands of diphtheria cases are still reported annually from several countries in Asia and Africa, along with many outbreaks. Changes in the epidemiology of diphtheria have been reported worldwide. The prevalence of toxigenic Corynebacterium spp. highlights the need for proper clinical and epidemiological investigations to quickly identify and treat affected individuals, along with public health measures to prevent and contain the spread of this disease.
Toxigenic strains of Corynebacterium diphtheriae cause the majority of respiratory diphtheria cases. However, nontoxigenic strains of C. diphtheriae can also cause diseases, and have become increasingly common. Infection that is limited to the anterior nares (nasal diphtheria) is a well-described but rare condition, even for toxigenic C. diphtheriae. We report a case involving chronic carriage of nasal diphtheria caused by nontoxigenic C. diphtheriae, as well as a review of other reported nontoxigenic C. diphtheriae cases in Japan. Mild or asymptomatic nasal diphtheria involving nontoxigenic strains, which can be the source of transmission, may be underrecognized. Our case highlights the importance of awareness regarding nontoxigenic diphtheria among clinicians, especially in the era of improved diphtheria vaccination coverage.