The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Chana A. Sacks, M.D., Editor

Cutaneous Diphtheria
A B

A 
5-year-old, fully vaccinated girl was brought to the emergency Isabel E. Wilson, M.B., B.S.,
department with pruritic lesions on both legs. She had recently returned  D.T.M.&H.
from a trip to Sierra Leone. The lesions had appeared 3 weeks into her stay Esse N. Menson, M.B., Ch.B.,
there and had increased in size and ulcerated. On presentation, she was afebrile,  D.Phil.
and an area over the medial aspect of the left lower leg was ulcerated and bleeding Evelina London Children’s Hospital
(Panel A). The C-reactive protein level was mildly elevated, and the white-cell count London, United Kingdom
was normal. Empirical treatment with oral floxacillin was initiated, and a skin swab isabel​.­wilson@​­doctors​.­org​.­uk

was sent for culture, which grew Staphylococcus aureus, group A streptococcus, and
Corynebacterium diphtheriae. Gram’s staining showed predominantly gram-positive
bacilli characteristic of corynebacterium (Panel B). An immunodiffusion test
(Elek’s test) was positive, indicating that this diphtheria was toxin-producing.
Early manifestations of cutaneous diphtheria can appear as nonhealing, well-
demarcated ulcers. After the detection of diphtheria in this patient, the antibiotic
agent was changed to clarithromycin. Contact tracing was undertaken, and chemo-
prophylaxis was given to household contacts. At follow-up 1 week after the change
in antibiotics to clarithromycin, the skin lesions had fully healed.
DOI: 10.1056/NEJMicm1701825
Copyright © 2018 Massachusetts Medical Society.

n engl j med 378;13 nejm.org  March 29, 2018 e17

The New England Journal of Medicine
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