Subcutaneous abscess formation in the upper extremity caused by toxigenic Corynebacterium ulcerans

Abstract

Corynebacterium ulcerans is attracting attention as an emerging zoonosis that causes lymphadenitis, dermatitis and respiratory infections. We report here what appears to be the first case of subcutaneous abscess formation in the upper extremity due to toxigenic C. ulcerans in Japan. Awareness of the fact that C. ulcerans can cause a subcutaneous, elastic-hard, lessmobile mass with heat, redness and pain in the extremities is important for differential diagnosis. IntroductionCorynebacterium ulcerans is known as an emerging zoonosis that causes cutaneous infection, sinusitis, tonsillitis, pharyngitis, pneumonia and peritonitis (Dias et al., 2011). However, to the best of our knowledge, C. ulcerans has not been reported to cause subcutaneous abscess in the extremities. Therefore, clinicians encountering a subcutaneous mass in the extremities are unlikely to consider subcutaneous abscesses due to C. ulcerans as a differential diagnosis. This could lead to a delay in diagnosis and treatment, and in the worst scenario, it may result in a fatal diphtheria-like disease (Mattos-Guaraldi et al., 2008;Putong et al., 2011).Here, we report the diagnosis and treatment of a patient with a subcutaneous abscess in the upper extremity due to C. ulcerans and discuss the clinical characteristics useful for differential diagnosis. Case reportIn December 2011, a 37-year-old Japanese woman was referred to Tsuruoka Municipal Shonai Hospital, in Tsuruoka, Japan, with a painful mass in her right elbow. The patient had no cardiac symptoms. Her past medical history was unremarkable. Three days before the current hospital visit, she experienced swelling and itching on the medial side of her right elbow. Within a few days, a hot, red, painful mass rapidly formed subcutaneously.Physical examination revealed redness and local heat on the surface of the skin over the mass. The mass was approximately 4 cm in size, elastic hard and less mobile, and caused pain and tenderness. No radiating pain was produced on tapping on the mass (Tinel's sign). Laboratory tests revealed an increase in C-reactive protein levels (2.3 mg dl 21) and a white blood cell count in the normal range (7500 mm 23 ). Radiography did not reveal calcification within the lesion. On magnetic resonance imaging, a subcutaneous soft tissue mass (27622626 mm in size) was observed on the medial side of her elbow; it exhibited iso-signal intensity on T1-weighted images (Fig. 1a) and inhomogeneous high-signal intensity on T2-weighted images (Fig. 1b). Following intravenous administration of gadopentetate dimeglumine, ring enhancement was seen on T1-weighted images (Fig. 1c).Fine-needle aspiration biopsy was performed. No pus was aspirated, but small fragments of tissue were obtained. The tissue fragments were sent for pathological analysis and microbiological diagnosis. Histopathological examination showed no malignancy, but neutrophils and histiocytes were present in the specimen. Bacterial cultures were negative under aerobic conditions. In January 2012, the patient underwent surgery...

The detection of toxigenicCorynebacterium ulceransfrom cats with nasal inflammation in Japan

“…The Ministry of Health, Labour and Welfare reported that effective vaccination enables infants to possess high levels of antibodies against diphtheria leading to a marked decrease in antibody prevalence rates in adults aged >45 years [27]. Effectiveness of vaccination for diphtheria has not been fully evaluated [16, 28, 29], and thus further epidemiological surveys of toxigenic C. ulcerans must be conducted to solve this controversial issue. Veterinarians should consider infection with C. ulcerans in cats with purulent disease, particularly upper respiratory tract diseases such as nasal catarrh.…”

“…In recent epidemiological surveys, toxigenic C. ulcerans was isolated from companion animals such as dogs and cats, and livestock such as cows and sheep; thus, these animals were strongly implicated as sources of human infections [7,9,10]. Twelve cases of diphtheria or diphtheria-like disease associated with toxigenic C. ulcerans have been reported in Japan since toxigenic C. ulcerans was first detected in 2001 [11][12][13][14][15][16][17]. In several cases, patients were confirmed as having had direct contact with dogs or cats with/without dermatitis or respiratory symptoms such as rhinitis [11,17].…”

A paediatric case of lymphadenitis by toxigenic Corynebacterium ulcerans

“…This condition requires urgent treatment with diphtheria antitoxin and antibiotics. On the other hand, lymphadenitis by C. ulcerans is curable by antibiotics and drainage (Urakawa et al, 2013). C. ulcerans is a zoonotic agent that infects humans drinking unpasteurized milk or in close contact with infected dogs, cats or various other animal species (Vandentorren et al, 2014).…”

Corynebacterium ulcerans isolates from humans and dogs: fibrinogen, fibronectin and collagen-binding, antimicrobial and PFGE profiles

“…clinical signs is increasing in industrialized and developing countries (Dewinter et al 2005;De Zoysa et al 2005;Mattos-Guaraldi et al 2008a;Wagner et al 2010;Kamada et al 2012;Urakawa et al 2013). Human infections by C. ulcerans may be fatal and mostly occur in adults with close animal contact (Wellinghausen et al 2002;Lartigue et al 2005).…”