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Chapter 131. Diphtheria and Other Infections Caused by Corynebacteria and Related Species (Part 1)

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Chapter 131. Diphtheria and Other Infections Caused by Corynebacteria and Related Species (Part 1)

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Harrison's Internal Medicine Chapter 131. Diphtheria and Other Infections Caused by Corynebacteria and Related Species Diphtheria Diphtheria is a nasopharyngeal and skin infection caused by Corynebacterium diphtheriae. Toxigenic strains of C. diphtheriae produce a protein toxin that causes systemic toxicity, myocarditis, and polyneuropathy. The toxin is associated with the formation of pseudomembranes in the pharynx during respiratory diphtheria. While toxigenic strains most frequently cause pharyngeal diphtheria, nontoxigenic strains commonly cause cutaneous disease. In the United States and Europe, diphtheria has been controlled in recent years with effective vaccination, although sporadic outbreaks have occurred. ...

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  1. Chapter 131. Diphtheria and Other Infections Caused by Corynebacteria and Related Species (Part 1) Harrison's Internal Medicine > Chapter 131. Diphtheria and Other Infections Caused by Corynebacteria and Related Species Diphtheria Diphtheria is a nasopharyngeal and skin infection caused by Corynebacterium diphtheriae. Toxigenic strains of C. diphtheriae produce a protein toxin that causes systemic toxicity, myocarditis, and polyneuropathy. The toxin is associated with the formation of pseudomembranes in the pharynx during respiratory diphtheria. While toxigenic strains most frequently cause pharyngeal diphtheria, nontoxigenic strains commonly cause cutaneous disease. In the United States and Europe, diphtheria has been controlled in recent years with effective vaccination, although sporadic outbreaks have occurred. Diphtheria is still common in the Caribbean, Latin America, and the Indian subcontinent, where mass immunization programs are not enforced. Large epidemics have occurred in
  2. the independent states formerly encompassed by the Soviet Union. Additional outbreaks have been reported in Algeria, China, and Ecuador. Etiology C. diphtheriae is a gram-positive, unencapsulated, nonmotile, nonsporulating bacillus. C. diphtheriae organisms have a characteristic club- shaped bacillary appearance and typically form clusters of parallel rays (palisades) that are referred to as Chinese characters. In the specific laboratory media recommended for the cultivation of C. diphtheriae, tellurite, colistin, or nalidixic acid is responsible for selective isolation of the organism in the presence of other autochthonous pharyngeal microbes. Human isolates of C. diphtheriae may display nontoxigenic (tox–) or toxigenic (tox+) phenotypes. Corynebacteriophage beta carries the structural gene (tox) encoding diphtheria toxin, and a family of closely related corynebacteriophages are responsible for toxigenic conversion of tox– C. diphtheriae to the tox+ phenotype. Moreover, lysogenic conversion from a nontoxigenic to a toxigenic phenotype has been shown to occur in situ. Growth of toxigenic strains of C. diphtheriae under iron-limiting conditions leads to the optimal expression of diphtheria toxin, and these conditions are believed to be a mechanism of pathogenesis during human infection. Epidemiology
  3. C. diphtheriae is transmitted via the aerosol route, primarily during close contact. There are no significant reservoirs other than humans. The incubation period for respiratory diphtheria is 2–5 days; however, disease can develop as long as 10 days after exposure. Before the vaccine era, most individuals over the age of 10 were immune to C. diphtheriae; infants were protected by maternal IgG antibodies but became susceptible after ~6 months of age. Thus, the disease was seen primarily in children and nonimmune young adults. In temperate regions, respiratory diphtheria occurs year-round but is most common during winter months. The development of diphtheria antitoxin and diphtheria toxoid vaccine led to the near-elimination of diphtheria in Western countries. The annual peak incidence rate was 191 cases per 100,000 population in the United States in 1921; in contrast, since 1980, the annual figure for the United States as a whole has been
  4. in the states of the former Soviet Union, a much larger diphtheria epidemic caused >150,000 cases and >5000 deaths. Clonally related toxigenic C. diphtheriae strains of the ET8 complex were associated with this outbreak. Given that the ET8 complex expressed a toxin against which the prevalent diphtheria toxoid vaccine was effective, the epidemic was attributed to failure of the public health infrastructure to effectively vaccinate the population. Beginning in 1998, the epidemic was controlled by mass vaccination programs. During the epidemic, the incidence rate was high among individuals from >15 years of age up to 50 years of age. Socioeconomic instability, migration, deteriorating public health programs, frequent vaccine shortages, delays in implementation of vaccination and of treatment in response to cases, and lack of public education and awareness were contributing factors in that outbreak. Cutaneous diphtheria is usually a secondary infection that follows a primary skin lesion due to trauma, allergy, or autoimmunity. Most often, isolates from cases of cutaneous disease lack the tox gene and therefore do not express diphtheria toxin. In tropical regions, cutaneous diphtheria is more common than respiratory diphtheria. In contrast to respiratory disease, cutaneous diphtheria is not a reportable disease in United States. Nontoxigenic strains of C. diphtheriae have also been associated with pharyngitis in Europe. Outbreaks have occurred among homosexual men and IV drug users.

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