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| Journal of the New Zealand Medical Association,
24-February-2012, Vol 125 No 1350
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A case of cutaneous diphtheria in New
Zealand
David C R McGouran, Stanley K F Ng, Mark R Jones, David
Hingston
Diphtheria is an acute bacterial disease caused by infection
with toxin-producing strains of Corynebacterium diphtheriae (C.
diphtheriae). Upper respiratory tract infection is the most common
presentation1 with a fatality rate of
5–10%.2
Sore throat, cervical lymphadenopathy (“bull
neck”), a grey membrane obstructing the airway and respiratory distress
predominate in severe infection. Other systemic consequences are well
recognised.
The prevalence of diphtheria has changed over the last three
decades. Having almost disappeared completely by the
1980s,2 a serious outbreak in the Newly
Independent States of the former Soviet Union in the 1990s required a mass
immunisation campaign to stem the outbreak.3
Cutaneous C. diphtheriae infection is less common but acts as a
potential source of respiratory C. diphtheriae infection.
We report the case of an adult male who presented to
Wellington Hospital’s Emergency Department having contracted cutaneous
toxigenic C. diphtheriae whilst visiting Samoa where he acquired a
tattoo.
Case reportWithin days of acquiring the tattoo, the man noticed redness
and swelling overlying the tattoo, spreading to his mid-calf. A week later after
returning to New Zealand he presented to his medical centre with an infected
lesion. Flucloxacillin was prescribed but he was non-compliant with his
medication. Four days later he returned to hospital.
The doctor attending noted a coin-sized erythematous lesion
discharging pus was present within the tattoo on the leg, with peau
d’orange surrounds. Swabs were taken and erythromycin was prescribed. The
patient was again non-compliant. One week later he again presented, with fevers
and rigors where examination of his leg also showed cellulitis. Cultures had
grown Staphylococcus aureus and toxigenic Corynebacterium
diphtheriae var gravis. The patient was referred to our Emergency
Department. He had taken only four doses of erythromycin.
He was admitted to a single negative-pressure room and
nursed with “droplet” precautions. Intravenous erythromycin and
high-dose flucloxacillin were commenced. Within 4 days he was well enough to be
discharged on oral antibiotics. . A Diphtheria-Tetanus booster was given post
discharge. Contact tracing was conducted by the Public Health Service.
DiscussionCutaneous C. diphtheriae infection is common in
developing countries where chronic carriage has long been
recognised.4 It should be considered in any
case of tropical ulcer.
Primary cutaneous diphtheria often begins as an
acutely tender pustule which breaks down and enlarges to form an oval,
punched-out ulcer. This often becomes secondarily infected leading to
surrounding cellulitis.5 Septicaemia and septic
arthritis can occur. Myocarditis is relatively rare. Neurological complications
including Guillain-Barre syndrome have been reported in 3–5% of ulcerated
lesions.6
The performance of a traditional Samoan tattoo is of great
cultural significance. The techniques involved have their origins dating back
thousands of years. Typically the penetrating implement is made from a
pig’s tooth, sliced and fashioned into a series of sharp spikes. This is
bound with nylon fishing line, for example, to a larger piece of bone or
plastic, which, in turn, is bound to a wooden handle. The implement is difficult
to adequately clean and, as a consequence, sterilisation cannot be achieved.
Heat sterilisation using an autoclave is not performed, as the instruments would
break down. At best, the “chemical” treatment of such implements can
only achieve a moderate level of disinfection.
In Samoa, each tattooing session is followed by bathing in
seawater, a procedure that is believed to account for the purportedly low rates
of post-tattoo infections. In New Zealand the rate of post-traditional tattoo
infection is unknown however cases of severe infection have been reported in the
past.7
Learning points:
Author
information: David C R McGouran, Gastroenterology Registrar, Wellington
Hospital, Wellington; Stanley K F Ng, Paediatric SHO, Wellington Hospital,
Wellington; Mark R Jones, Lead Pathologist in Microbiology, Aotea Pathology,
Wellington; David Hingston, General Practitioner, Wellington
Correspondence:
David C R McGouran, Gastroenterology Registrar, Wellington Hospital, Private Bag
7902, Wellington South, New Zealand. Email: d.mcgouran@googlemail.com
References
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