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Weil LM, Williams MM, Shirin T, Lawrence M, Habib ZH, Aneke JS, Tondella ML, Zaki Q, Cassiday PK, Lonsway D, Farrque M, Hossen T, Feldstein LR, Cook N, Maldonado-Quiles G, Alam AN, Muraduzzaman AKM, Akram A, Conklin L, Doan S, Friedman M, Acosta AM, Hariri S, Fox LM, Tiwari TSP, Flora MS. Investigation of a Large Diphtheria Outbreak and Cocirculation of Corynebacterium pseudodiphtheriticum Among Forcibly Displaced Myanmar Nationals, 2017-2019. J Infect Dis 2021; 224:318-325. [PMID: 33245764 PMCID: PMC10846527 DOI: 10.1093/infdis/jiaa729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/20/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Diphtheria, a life-threatening respiratory disease, is caused mainly by toxin-producing strains of Corynebacterium diphtheriae, while nontoxigenic corynebacteria (eg, Corynebacterium pseudodiphtheriticum) rarely causes diphtheria-like illness. Recently, global diphtheria outbreaks have resulted from breakdown of health care infrastructures, particularly in countries experiencing political conflict. This report summarizes a laboratory and epidemiological investigation of a diphtheria outbreak among forcibly displaced Myanmar nationals in Bangladesh. METHODS Specimens and clinical information were collected from patients presenting at diphtheria treatment centers. Swabs were tested for toxin gene (tox)-bearing C. diphtheriae by real-time polymerase chain reaction (RT-PCR) and culture. The isolation of another Corynebacterium species prompted further laboratory investigation. RESULTS Among 382 patients, 153 (40%) tested tox positive for C. diphtheriae by RT-PCR; 31 (20%) PCR-positive swabs were culture confirmed. RT-PCR revealed 78% (298/382) of patients tested positive for C. pseudodiphtheriticum. Of patients positive for only C. diphtheriae, 63% (17/27) had severe disease compared to 55% (69/126) positive for both Corynebacterium species, and 38% (66/172) for only C. pseudodiphtheriticum. CONCLUSIONS We report confirmation of a diphtheria outbreak and identification of a cocirculating Corynebacterium species. The high proportion of C. pseudodiphtheriticum codetection may explain why many suspected patients testing negative for C. diphtheriae presented with diphtheria-like symptoms.
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Affiliation(s)
- Lauren M. Weil
- Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Margaret M. Williams
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tahmina Shirin
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Marlon Lawrence
- Laboratory Leadership Service, Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Zakir H. Habib
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Janessa S. Aneke
- IHRC Inc, Contractor to US Centers for Disease Control and Prevention, Division of Bacterial Diseases, Atlanta, Georgia, USA
| | - Maria L. Tondella
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Quazi Zaki
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Pamela K. Cassiday
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - David Lonsway
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mirza Farrque
- Bangladesh Field Epidemiology Training Program, Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Tanvir Hossen
- Bangladesh Field Epidemiology Training Program, Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Leora R. Feldstein
- Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nicholas Cook
- IHRC Inc, Contractor to US Centers for Disease Control and Prevention, Division of Bacterial Diseases, Atlanta, Georgia, USA
| | - Gladys Maldonado-Quiles
- IHRC Inc, Contractor to US Centers for Disease Control and Prevention, Division of Bacterial Diseases, Atlanta, Georgia, USA
| | - Ahmed N. Alam
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | | | - Arifa Akram
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Laura Conklin
- Global Immunization Division, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Stephanie Doan
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michael Friedman
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anna M. Acosta
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Susan Hariri
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - LeAnne M. Fox
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tejpratap S. P. Tiwari
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Meerjady S. Flora
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
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Infection and colonization by Corynebacterium pseudodiphtheriticum: a 9-year observational study in a university central hospital. Eur J Clin Microbiol Infect Dis 2020; 39:1745-1752. [PMID: 32367215 DOI: 10.1007/s10096-020-03891-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/01/2020] [Indexed: 10/24/2022]
Abstract
Despite constituting part of the human commensal flora, Corynebacterium pseudodiphtheriticum has been recognized as a potentially infectious agent, most frequently in immunocompromised patients or individuals with other morbidity factors, but significant association to comorbid states remains unproven. This study's purpose was to assess clinical significance, risk factors for infection and antimicrobial susceptibility of C. pseudodiphtheriticum isolates. A retrospective observational study was conducted. Relevance of isolation was determined by clinical, laboratory, and imaging criteria. Forty-nine isolates occurred in 47 episodes. Colonization was assumed in 12% and infection in 78%, of which 51% were nosocomial. Patients with infection were older, with male predominance; both age and gender were statistically significant (p < 0.05) between infection and colonization groups. Although dyslipidemia (58%), arterial hypertension (58%), invasive procedures (56%), and chronic lung disease (50%) were prevalent in the infection group, no comorbidity was a significant risk factor for infection compared with colonization. Charlson comorbidity index showed no statistically difference between groups. Mortality rate was 14% in infection. Respiratory samples were the main isolation product; all tested strains were susceptible to amoxicillin/clavulanate and vancomycin. Resistant strains were observed for clindamycin (77%) and erythromycin (48%). C. pseudodiphtheriticum isolation was associated with infection in most cases. Despite the high prevalence of comorbidities and invasive procedures, no factors other than age and gender were significantly associated with infection. Although C. pseudodiphtheriticum may constitute a contaminant or colonizer in clinical samples, positive cultures in patients with signs and symptoms consistent with infection should not be neglected.
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Yang K, Kruse RL, Lin WV, Musher DM. Corynebacteria as a cause of pulmonary infection: a case series and literature review. Pneumonia (Nathan) 2018; 10:10. [PMID: 30324081 PMCID: PMC6173903 DOI: 10.1186/s41479-018-0054-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 09/18/2018] [Indexed: 11/23/2022] Open
Abstract
Background In most cases of community-acquired pneumonia (CAP), an etiologic agent is not determined; the most common report from the microbiological evaluation of sputum cites “normal respiratory flora.” Non-diphtheria Corynebacterium spp., a component of this flora, is commonly viewed as a contaminant, but it may be the cause of pneumonia and the frequency with which it causes CAP may be underestimated. Case presentations This report present 3 cases of CAP in which Corynebacterium spp. was clearly the predominant isolate; identification was confirmed by matrix-assisted laser desorption ionization time of flight (MALDI-TOF) mass spectrometry. Two cases were caused by C. propinquum and one by C. striatum. Two patients had a tracheostomy and one was on hemodialysis. Patients who received an appropriate antibiotic responded well. Conclusion When identified as the predominant isolate in sputum from a patient with CAP, Corynebacterium spp. should be considered as a potential cause of the infection. In cases with patients who have compromised airway clearance or who are immunocompromised, microaspiration may be responsible. While some Corynebacterium spp. are suspectible to antibiotics usually prescribed for CAP, others are susceptible only to vancomycin or aminoglycosides. Vancomycin is thus the appropriate empiric antibiotic, pending speciation and susceptibility test results. The number of reported cases with result of antibiotic susceptibility testing, however, remains limited, and further investigation is needed. Non-diphtheria Corynebacterium spp. represent a noteworthy clinical cause of pneumonia. Identification by Gram stain and as a predominant organism on culture demands careful consideration for management.
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Affiliation(s)
| | | | - Weijie V Lin
- 1Baylor College of Medicine, Houston, TX 77030 USA
| | - Daniel M Musher
- 1Baylor College of Medicine, Houston, TX 77030 USA.,2Infectious Disease Section, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030 USA
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Gutiérrez-Rodero F, Ortiz de la Tabla V, Martínez C, Masiá MM, Mora A, Escolano C, González E, Martin-Hidalgo A. Corynebacterium pseudodiphtheriticum: an easily missed respiratory pathogen in HIV-infected patients. Diagn Microbiol Infect Dis 1999; 33:209-16. [PMID: 10212746 DOI: 10.1016/s0732-8893(98)00163-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite being a well-known respiratory pathogen for immunocompromised patients, Corynebacterium pseudodiphtheriticum has uncommonly been reported to occur in persons with infection attributable to HIV virus. We report three cases of respiratory tract infection attributable to C. pseudodiphtheriticum in HIV-infected patients and review the four previous cases from the medical literature. All of them were male with a median CD4 lymphocyte count of 110 cells/mm3 (range, 18-198/mm3); five of the seven cases occurred in persons for whom AIDS was diagnosed previously. The onset of symptomatology was usually acute and the most common radiographic appearance was alveolar infiltrate (six patients) with cavitation (two patients) and pleural effusion (two patients). In five of the seven cases, C. pseudodiphtheriticum was isolated from bronchoscopic samples and in the remaining two cases was recovered from lung biopsy (one patient) and sputum (one patient). In the three patients reported herein and in one previous case from the medical literature, quantitative culturing of bronchoscopic samples obtained through either bronchoalveolar lavage or protected brush catheter procedures yielded more than 10(3) CFU/mL. All the strains tested were susceptible to penicillin and vancomycin. Resistance to macrolides was common. Recovery was observed in six of the seven patients. C. pseudodiphtheriticum should be regarded as a potential respiratory pathogen in HIV-infected patients. This infection presents late in the course of HIV disease and it seems to respond well to appropriate antibiotic treatment in most of the cases. This easily overlooked pathogen should be added to the list of organisms implicated in respiratory tract infections in this population.
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Affiliation(s)
- F Gutiérrez-Rodero
- Servicio de Medicina Interna, Hospital General Universitario de Elche, Alicante, Spain
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