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Letter
Corynebacterium ulcerans
Diphtheria in Japan
Akio Hatanaka,* Atsunobu Tsunoda,* Makoto Okamoto,* Kenji Ooe,* Akira
Nakamura,* Masashi Miyakoshi,* Takako Komiya,† and Motohide Takahashi†
*Asahi General Hospital, Chiba, Japan; and †National Institute of Infectious
Diseases, Tokyo, Japan
Suggested citation for this article: Hatanaka
A, Tsunoda A, Okamoto M, Ooe K, Nakamura A, Miyakoshi M, et al. Corynebacterium
ulcerans diphtheria in Japan. Emerg Infect Dis [serial online] 2003
Jun [date cited]. Available from: URL: http://www.cdc.gov/ncidod/EID/vol9no6/02-0645.htm
To the Editor: Corynebacterium ulcerans causes a zoonotic
infection similar to diphtheria, which is caused by C. diphtheriae.
Studies indicate that signs and symptoms of a diphtheria-like illness
caused by C. ulcerans are milder than those caused by C. diphtheriae.
However, some strains of C. ulcerans produce potent diphtheria
toxin and may cause severe symptoms similar to those caused by C. diphtheriae
(1). We report a case of a diphtheria-like illness caused
by C. ulcerans infection.
A previously healthy 52-year-old woman first noticed hoarseness approximately
3 days before admission to the hospital. On February 16, 2001, severe
dyspnea and fever developed, and the patient was referred to the emergency
room of the Asahi General Hospital by her private practitioner. Physical
examination indicated a large stridor, which could be heard without using
a stethoscope. Cyanosis was not observed. The endoscopic examination showed
a thick white coat covering the nasopharynx and laryngeal vestibulum,
and subglottic constriction was also observed. A chest x-ray showed diffuse
infiltrates in both lungs. Pertinent laboratory findings on admission
included leukocyte count of 16.8 x 103/uL and C-reactive protein
of 20.0 mg/dL. The serum level of liver transaminase was normal, and both
Wassermann reaction and anti-HIV antibody tests were negative. Pharyngolaryngitis
and pneumonia was diagnosed in the patient. Because of severe dyspnea,
intubation was performed, which caused sudden and unexpected exacerbation
of the condition. Severe cyanosis subsequently developed. Extubation was
immediately performed, and a thick white material was found to be filling
the lumen of the endotracheal tube. Reintubation was performed, and dyspnea
subsided. The patient was hospitalized in the intensive-care unit. Sulbactam
sodium/ampicillin sodium (6 g per day) was intravenously administered
for 4 days; however, the symptoms were not much improved. The symptoms
were most consistent with those of diphtheria. Therefore, the patient
was subsequently placed on erythromycin (1.0 g/day) and quickly responded
to this treatment without administration of diphtheria antiserum. Erythromycin
was intravenously administered at 1 g per day for 9 days, then orally
administered at 1,200 mg per day for the next 14 days. Throughout the
hospitalization, no complication occurred, and no abnormalities were noted
in the electrocardiograms or in the patient’s neurologic status. The patient
was discharged uneventfully, and no serious sequelae were noted for 20
months. History of immunization for diphtheria was not known.
After the hospitalization for this acute illness, a laboratory report
showed that C. ulcerans was cultured from the thick white coat
of the throat. No other bacteria were found. The National Institute of
Infectious Diseases in Tokyo later confirmed identification of the bacteria.
By using Elek’s test, Vero cell toxicity, and polymerase chain reaction
for toxigene, this strain of C. ulcerans was proven to produce
diphtheria toxin identical to C. diphtheriae (2-4).
Although administering appropriate antibiotics as well as antitoxin is
a standard of care for patients with diphtheria, antitoxin was not given
to this patient because of her rapid response to the erythromycin therapy.
C. ulcerans infections in humans occur after drinking unpasteurized
milk or coming in contact with dairy animals or their waste (5,6).
However, person-to-person transmission of C. ulcerans has not been
reported, and in some cases, the route of transmission is not clear (7).
Recently, C. ulcerans-producing diphtheria toxin was isolated in
the United Kingdom from cats with nasal discharge (8).
Our patient did not have direct contact with dairy livestock or unpasteurized
dairy products; however, more than 10 dairy farms are scattered around
her home. Moreover, she kept nearly 20 cats in her house and had been
scratched by a stray cat a week before illness developed. This stray cat,
which had rhinorrhea and sneezing, had wandered into her house. The stray
cat died before the patient became ill, and no further investigation could
be made. Stray cats might well be one of the possible carriers of C.
ulcerans and might have transmitted the bacteria to this patient.
To our knowledge, a case of human infection caused by C. ulcerans
has never been reported in Japan. On the basis of current experience,
this bacterium does exist in Japan and can potentially cause a serious
diphtheria-like illness in humans.
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