Cutaneous diphtheria in a child.

Abstract

A 2‐year‐old, nonimmunized, lower socioeconomic stratum girl from the rural outskirts of Bangalore, southern India, was brought to the hospital with complaints of nonhealing “kissing ulcers” over the right thigh and inguinal region and fever of 1 month. The lesions started as small pustules. There was no history of respiratory illness or contact with tuberculosis. On physical examination, the child weighed 10 kg, was afebrile, and had mild anemia. The inguinal lymph nodes were enlarged. Systemic examination was essentially normal. Local examination revealed punched out ulcers with grayish slough over the ulcer measuring 3 cm × 4 cm (Fig. 1). The differential diagnosis of cutaneous tuberculosis, ecthyma, tropical ulcer, and mycotic ulcer were considered.Two “kissing ulcers” with adherent sloughimageLaboratory examination revealed the following. Hemoglobin was 10.3 g/dL. White blood cell count (WBC), 13,500/cm2. Differential count: P 58, L 40, E 2. The rest of the routine blood and urine tests were normal. The Mantoux test was negative. An X‐ray of the chest was normal. An electrocardiogram was not taken. Gram stain of the pus from the lesion revealed no pus cells, but many Gram‐positive cocci, Gram‐positive bacilli and Gram‐negative bacilli. Albert stain of the smear was positive for Corynebacterium diphtheria. Bacterial cultures grew organisms morphologically and biochemically characteristic of C. diphtheria and susceptible to ampicillin, erythromycin, gentamycin, co‐trimoxazole, ciprofloxacin, amikacin, vancomycin, and netilmycin. No other pathogens were cultured from the wound. The organisms isolated were confirmed as C. diphtheria (Baren EJ, Peterson LR, Finegold SM. Aerobic, non‐spore‐forming, Gram‐positive bacilli. In: Baily, Scott, eds. Diagnostic Microbiology, 9th edn. Town: C.V. Mosby. 1994: 457–473). Serum antitoxin levels were not measured.With confirmation of the diagnosis of cutaneous diphtheria, the child was treated with 20,000 units of anti‐diphtheria serum and injected intramuscularly with procaine penicillin 400,000 units daily for 10 days. The ulcer healed over a period of 10–12 days without any other complications of diphtheria.