Services on Demand
- Cited by SciELO
- Access statistics
- Similars in SciELO
Print version ISSN 0034-8910
Rev. Saúde Pública vol.45 n.6 São Paulo Dec. 2011
Difteria por Corynebacterium ulcerans: una zoonosis emergente en Brasil y en el mundo
Alexandre Alves de Souza de Oliveira DiasI; Louisy Sanchez SantosII; Priscila Soares SabbadiniIII; Cíntia Silva SantosIII; Feliciano Correa Silva JuniorI; Fátima NapoleãoIII; Prescilla Emy NagaoIII; Maria Helena Simões Villas-BôasI; Raphael Hirata JuniorIII; Ana Luíza Mattos GuaraldiIII
de Imunologia. Instituto Nacional de Controle e Controle de Qualidade em Saúde.
Fundação Oswaldo Cruz. Rio de Janeiro, RJ, Brasil
IIPós-Graduação em Ciências Médicas. Faculdade de Ciências Médicas (FCM). Universidade do Estado do Rio de Janeiro (UERJ). Rio de Janeiro, RJ, Brasil
IIILaboratório de Difteria e Corinebactérias de Importância Clínica. FCM-UERJ. Rio de Janeiro, RJ, Brasil
The article is a literature review on the emergence of human infections caused by Corynebacterium ulcerans in many countries including Brazil. Articles in Medline/PubMed and SciELO databases published between 1926 and 2011 were reviewed, as well as articles and reports of the Brazilian Ministry of Health. It is presented a fast, cost-effective and easy to perform screening test for the presumptive diagnosis of C. ulcerans and C. diphtheriae infections in most Brazilian public and private laboratories. C. ulcerans spread in many countries and recent isolation of this pathogen in Rio de Janeiro, southeastern Brazil, is a warning to clinicians, veterinarians, and microbiologists on the occurrence of zoonotic diphtheria and C. ulcerans dissemination in urban and rural areas of Brazil and/or Latin America.
Descriptors: Corynebacterium Infections, epidemiology. Disease Reservoirs, veterinary. Zoonoses. Communicable Diseases, Emerging. Review.
El articulo revisa la literatura sobre la emergencia de infecciones humanas causadas por Corynebacterium ulcerans en diversos países, incluyendo Brasil. Se realizó análisis de artículos publicados entre 1926 y 2011 en las bases Medline/Pubmed y SciELO, así como artículos e informes del Ministerio Brasileño de la Salud. Se presenta un esquema de selección, rápido, económico y de fácil ejecución, capaz de permitir la realización del diagnóstico presuntivo de C. ulcerans y C. diphtheriae en la mayoría de los laboratorios brasileños públicos y privados. La circulación de C. ulcerans en varios países, aliada a los recientes casos de aislamiento del patógeno en Rio de Janeiro (Sureste de Brasil), es un alerta a clínicos, veterinarios y microbiólogos sobre la ocurrencia de difteria zoológica y la circulación de C. ulcerans en regiones urbanas y rurales del territorio nacional y/o de América Latina
Descriptores: Infecciones por Corynebacterium, epidemiología. Reservorios de Enfermedades, veterinaria. Zoonosis. Enfermedades Transmisibles Emergentes. Revisión.
Diphtheria is a disease with acute evolution that shows local and systemic manifestations. It remains an important cause of morbidity and mortality on different continents, even in countries with child immunization programs.4,35,58,82,92 The classical forms of diphtheria are caused mainly by Corynebacterium diphtheriae, which produces diphtheric toxin (DT), and are characterized by the presence of a grayish pseudomembrane at the infection site, due to the effects from multiplication of this bacillus and the host's immune response.40,65,114 DT is a potent exotoxin of protein nature that has the capacity to act on all tissues, with special tropism for the myocardium, nervous system, kidneys and suprarenal glands.40,82,93 Only the samples infected by specific bacteriophages that carry the gene tox are toxinogenic.33
Protection against DT can be acquired through vaccination with diphtheric toxoid (e.g. DTP and other combinations containing the diphtheric component), but not with somatic antigens.6,35,ª The level of immunity diminishes at the end of childhood and adolescence, depending on the vaccination calendar and the reservoir of C. diphtheriae in the population.35,77 Diphtheria may affect partially immunized individuals, independent of age, race or sex. Partial decline in immunity, allied with lack of vaccine boosts and lower exposure to the bacillus, contribute towards sporadic occurrences of epidemics.23,34,69,77
In today's era of vaccination, the various changes observed in the epidemiology of diphtheria14,35,69 can be partially explained by the prevailing low levels of diphtheric antitoxin in the adolescent and adult population.15,29 In the 1990s, in Eastern Europe, the greatest epidemic of diphtheria recorded since the start of mass vaccination occurred, accounting for 80% of the cases notified worldwide. Most of the cases and deaths occurred among adults infected by the epidemic clone of C. diphtheriae subsp. gravis, which still circulates in Russia, Latvia, Lithuania and Belarus.89,90,112,113
In addition to changes in age group, diphtheria cases without pseudomembranes and cases of invasive infection of a variety of origins have been observed in individuals who had previously undergone vaccination. These cases of invasive infection such as endocarditis, osteomyelitis, arthritis, pneumonia and renal abscesses have been predominantly correlated with atoxigenic samples of C. diphtheriae subsp. mitis.17,24,48,53,66,68
The World Health Organization (WHO) has created the Disability-Adjusted Life Year (DALY) index, in which each unit represents one year of healthy life lost through disease, hospitalization or even death (taking into account the life expectancy in each country), per 100,000 inhabitants. The 2002 data on the mortality and incidence of diphtheria correlated the following regions with greater DALY indexes: Central America [Haiti (> 50 DALY units) and the Dominican Republic], Sub-Saharan Africa [Democratic Republic of the Congo and Serra Leone] and Asia [Nepal and Myanmar] (> 15 DALY units).b The current epidemic that has been occurring in India presents DALY > 7 and vaccination coverage less than 80%. Only 56% of the children are protected against diphtheria (> 0.1 UI/ml).4
The countries of South and North America, Western Europe and Oceania present DALY indexes of less than one.b In Brazil, the national immunization program was established at the start of the 1970s.c,d According to data from the Brazilian Ministry of Health, vaccination coverage now reaches 99% of the child population. However, over recent decades, cases of diphtheria have still been occurring in most Brazilian states.48,66,68,e,f, g,h Over the period 2008/09 alone, 89 diphtheria cases were confirmed. In 2010, in three municipalities in the state of Maranhão, where vaccination coverage reaches 56%, 27 diphtheria cases were confirmed, with two deaths, and the majority were in children with complete vaccination schemes. The possibility of underreporting of cases in Brazil and other developing countries cannot be dismissed: there may be unawareness among the population regarding the need to seek medical care and difficulties in obtaining clinical-laboratory diagnoses in cases of diphtheria, especially when patients are partially protected against the action of DT.
Starting in the middle of the 1980s, the number of diphtheria of zoonotic nature caused by C. ulcerans increased in different countries. In England, the number of diphtheria cases due to C. ulcerans exceeded the number reported with the classical etiological agent, C. diphtheriae.5,76,96,107,109,113,115 Although toxigenic C. ulcerans has now been recognized in several industrialized countries as an emerging pathogen, its capacity to cause disease in humans, including among the inhabitants of urban centers, is still often neglected.19,70,108
Thus, the present review had the aim of analyzing aspects of the emergence of C. ulcerans as an etiological agent for zoonotic diphtheria in Brazil and other countries that carry out triple bacterial vaccination (DTP), against diphtheria, tetanus and pertussis, and other combinations containing the diphtheric component.
Studies and surveys on zoonotic diphtheria were gathered by searching in the Medline/PubMed and SciELO databases. The search terms used were: "diphtheria", "Corynebacterium ulcerans", "zoonotic diphtheria", "laboratorial diagnosis", "diphtheria clinical cases", "molecular epidemiology" and "infected animals", covering the period from 1926 to 2011. Studies focusing on descriptions of diphtheria cases due to C. diphtheriae that occurred outside of Brazil were excluded. In addition, articles available in electronic format in Portuguese and English focusing on the diphtheria situation in Brazil, laboratory procedures and serum levels of diphtheric antitoxin antibodies in adults, were analyzed.
MICROBIOLOGICAL AND CLINICAL CHARACTERISTICS
The genus Corynebacterium belongs to the group of irregular Gram-positive rods, which grow aerobically and are immobile, non-sporulating and catalase-positive. Over the last few years, more than 60 species of corynebacteria have been described, and many of them are related to colonization and/or infection in humans and animals. Phylogenetic analysis on subunits of 16S rRNA sequences has made it possible to identify C. ulcerans, C. diphtheriae and Corynebacterium pseudotuberculosis as distinct species that are potential producers of DT.57,91 C. ulcerans and C. pseudotuberculosis are capable of hydrolyzing urea, which presumptively differentiates them from the type species of the genus, i.e. C. diphtheriae.
The species C. ulcerans, which is gelatinase-positive and nitrate-negative and was described by Gilbert & Stewart in 1926, can produce several clinical conditions, depending on the type and quantity of toxins secreted.8,36 Many studies have investigated pathogenicity mechanisms and DT production in samples of C. diphtheria,13,47,49,69,73,101 but little has been documented about the virulence factors of C. ulcerans. The virulence mechanisms described for C. pseudotuberculosis include toxic lipids associated with the cell wall, which may mediate bacterial to attack by phagocytes.42 Currently, a phospholipase D (PLD) exotoxin is considered to be the main virulence factor produced by C. pseudotuberculosis during cases of infection. PLD presents sphingomyelinase activity and may locally increase the vascular permeability, thereby contributing towards dissemination of the pathogen in the host's tissue.3,50,72 C. ulcerans is also capable of producing PLD, as well as DT.51
Concern regarding the potential for C. ulcerans to emerge as a pathogen capable of carrying the DT-coding bacteriophage, and therefore capable of causing conditions of classical diphtheria, is not new. Studies have shown that some bacteriophages are selective regarding C. ulcerans and do not induce DT production.45 However, it has also been observed that the bacteriophage β has the capacity to infect samples of C. diphtheriae, C. pseudotuberculosis and C. ulcerans, thereby constituting a risk of emergence of conditions of diphtheria caused by this species.1,38,95,99 Variability of the capacity to produce DT, between samples of C. ulcerans, has already been documented.39,116 The majority of clinical cases in humans and animals have been correlated with DT-producing strains (Tables 1 and 2).11,18,56,62
The following DT effects are produced by C. ulcerans: frequent occurrences of nose bleeding during infections; skin lesions that mimic typical cutaneous diphtheria; lesions of the tracheobronchial tree, with pseudomembrane; hemorrhage; compromised cervical lymph nodes; and cell death due to apoptosis.8,17,63,111,115 Occurrences of necrosis, mucosal ulceration and clinical syndromes in the lower respiratory tract, such as pneumonia and granulomatous pulmonary nodules, have been attributed to production of DT and PLD.16,44,52,97
Classically, the species C. ulcerans has been described as the etiological agent of a variety of infectious conditions in animals, especially mastitis in cattle. The first cases of infection in humans have usually been associated with consumption of unboiled or unpasteurized milk and derivatives, along with rural workers who are asymptomatic carriers of C. ulcerans in the nasopharynx. This shows the capacity of this pathogen to circulate between human and animal hosts and cause diphtheria of zoonotic nature.2,7,43,46,52 In a general manner, diphtheric infections caused by C. ulcerans have been correlated with patients who have been partially immunized with diphtheric toxoid, negative results from investigating carriers and contacts and indeterminate infection sources.108
As presented in Table 1, in addition to conditions with characteristics similar to respiratory and cutaneous diphtheria, samples of C. ulcerans have also been correlated with other clinical conditions in humans, such as sinusitis, tonsillitis, pharyngitis, pneumonia and peritonitis. The growing number of cases of infections due to C. ulcerans in cats and dogs since 2006 emphasizes the importance of expanding the knowledge of the epidemiological aspects of this emerging zoonosis. Cases of infection due to C. ulcerans in various animals species such as monkeys, squirrels, otters, orcas, camels, lions, dogs, cats, pigs, goats and cattle have been described in the international literature (Figure 1 and Table 2). 1,17,18,55,62,96,103
Among the 37 studies relating to infections in humans, it was possible to determine the sex of 37 individuals and the age in 32 cases. The majority of the cases (n = 24; 65%) and deaths (n = 5; 71%) were observed in females. Interestingly, most of the infections in animals due to C. ulcerans have also occurred in females (mastitis). Wagner et al113 (2010) conducted a survey of cases of infections due to C. ulcerans and C. diphtheriae in England between 1986 and 2008, and also found that the cases were predominantly in women (76%), as were the deaths (75%). The mean age of the individuals with C. ulcerans (38 years) was higher than the mean age of those with C. diphtheriae (15 years). In addition, Table 1 shows that the individuals with C. ulcerans were older (mean of 53 years), with a large number over 60 years, which contrasts strongly with the age profile of the cases of infection due to C. diphtheriae in Brazil and around the world.
As presented in Table 1 and Figures 1 and 2, C. ulcerans has been a growing cause for concern among the public health authorities in many countries: England,25,113 France,1 Germany,100 Netherlands,108 Italy,110 Switzerland,39,56 Denmark,75 Japan,44 Canada17 and the United States.12,13,107 Only five cases of human infection were documented prior to the 1990s, and these were in England and Denmark. Many cases of human patients who had not presented risk factors associated with infections due to C. ulcerans (such as consumption of untreated milk or contact with farm animals) started to be reported from 1990 onwards. Therefore, the risk of transmission among small animals and among humans has become a cause for concern.1,17,18,55,62,70,96,107
In addition to cattle and goats, dogs and cats have also become responsible for transmitting C. ulcerans to human hosts. In two cases of diphtheria caused by C. ulcerans that were described in France (2005 and 2006), the source of infection was the pet dog.1,62 Ribotyping tests were also been conducted in order to determine the genetic relationship between the microorganisms isolated from these animals and those in humans. In the United Kingdom, it was observed that toxigenic samples isolated from cats with bilateral nasal discharges belonged to the same ribotypes of C. ulcerans that were isolated from infected humans, thus showing these animals' capacity to act as pathogen reservoirs.18,104 Likewise, it was observed that a sample of C. ulcerans isolated from humans in Italy belonged to the same ribotype found in samples isolated in England.110
Although C. diphtheriae is classically considered to be a human pathogen, cases of infection due to C. diphtheriae in cats (severe otitis) and a horse (purulent skin lesions) were reported in 2010,41,64 thus suggesting that zoonotic potential was also emerging with regard to C. diphtheriae (Table 2).
Transmission of C. ulcerans between humans has still not been demonstrated, but several researchers have recommended that infected patients should be isolated.2,7,11,43,60,70,107 In the first and only clinical case of human infection due to C. ulcerans notified in Brazil,70 the patient's vaccination history and the source of infection were unknown. A few days after the patient died, one of the healthcare professionals involved in the case presented a condition of pharyngitis consequent to exposure to the pathogen. He immediately started antibiotic therapy with erythromycin, before material was collected for culturing and identification. Although the culture presented a negative result, the patient presented signs of myocarditis in clinical cardiological examinations, including echocardiograms and repeated electrocardiograms.
The causes contributing towards the increase in the number of cases of infection due to C. ulcerans in humans and animals have still not been fully elucidated. Given that similar ribotypes have been observed in human and animal infectious processes, it is possible that some samples of C. ulcerans may present additional virulence factors resulting from selective pressure, associated with unfavorable socioeconomic conditions, especially in overpopulated areas in which inadequate sanitary and hygiene conditions prevail. In addition, in some countries like the United States, the number of domestic animals living inside homes and circulating in areas such as kitchens and bedrooms, is very high,i thus favoring the process of transmission of various agents and zoonoses to humans, possibly including C. ulcerans. 20
PRESENT SITUATION IN BRAZIL AND EMERGING COUNTRIES
As illustrated in Figure 1, the number of cases notified in emerging countries is very small. In Latin America, cases in animals have been described in Argentina74 and Brazil,19 but in humans, only in Brazil70 (Tables 1 and 2). There are no records in the literature of isolation of samples of C. ulcerans in India, China, Oceania or the entire African continent. The hypothesis that circulation of this pathogen really occurs in all continents also needs to be put forward, and that there may be underreporting of cases because of lack of availability of laboratories qualified to isolate and identify the pathogen. Other than the United Kingdom, few countries present established laboratory routines and require compulsory notification of human infection due to C. ulcerans and isolation of atoxigenic samples.
In August 2010, the Brazilian Ministry of Health issued a warningj about the diphtheria situation in this country. This document gave information about changes to the clinical-epidemiological profile of the disease, such as the absence of pseudomembranes, deviation of the age group, occurrences of zoonotic diphtheria and circulation of C. ulcerans and C. diphtheriae in Brazil. Other points that were highlighted included: adoption of the same control measures as recommended for the species C. diphtheria, in confirmed cases of diphtheria due to C. ulcerans; and notification, treatment and monitoring of all suspected cases of diphtheria, with isolation of non-toxin-producing strains, by healthcare professionals.
In Brazil, a single human case of fatal infection caused by C. ulcerans was described in 2008,70 and subsequently (2010), a dog was found to be an asymptomatic carrier. Both of these cases were in the metropolitan area of the city of Rio de Janeiro (Southeastern Brazil).19 In summary, an elderly women presented several skin lesions on her legs, covered by pseudomembranes, and she died of cardiorespiratory complications despite antibiotic therapy serum therapy. The microorganism isolated from the patient's lower respiratory tract, which produced an exotoxin presenting differences in subunit A of the molecule, was shown to be resistant to the antimicrobials penicillin G (MIC 0.19 mg/l) and clindamycin (MIC 1.5 mg/l). Variations in sensitivity profiles had previously been observed by other authors.15,37 In the same way as found on other occasions, like in the United States,11,107 Switzerland,39 Germany,54,111 England8,63,105 and Japan,59,61,76,96 the origin of the infection was not elucidated (Tables 1 and 2).
According to Pesavento et al84 (2007), several diseases are reemerging. Hypotheses raised to explain these occurrences include the sanitary status of the population, migrations, adaptation by pathogens to new environmental conditions and factors, among others. According to those authors, animal shelters present many conditions that predispose towards this phenomenon: stress, immunosuppression, overpopulation, high exposure, high turnover of animals, malnutrition and indiscriminate use of antibiotics, thereby becoming a risk factor for the human and animal populations.
Such findings were the motivation for conducting a microbiological survey among apparently healthy dogs at an animal shelter. Out of a group of only 60 dogs from which nasal and ocular secretions and skin lesions were analyzed, one female dog that was an asymptomatic carrier of C. ulcerans was detected.19
Findings of C. ulcerans in the environment, infecting and/or colonizing humans and/or dogs19,70 suggests that the scarcity of epidemiological data in Brazil may be related to clinicians' and microbiologists' lack of attentiveness regarding the possibility of infection and a lack of awareness of the clinical and microbiological characteristics of infectious processes caused by C. ulcerans. Moreover, there are no routine procedures that enable isolation and identification of this pathogen in clinical laboratories.
BACTERIOLOGICAL DIAGNOSIS: TRIAGE SCHEME
The diphtheria epidemics that have occurred over recent decades have forced a generation of clinicians, laboratory scientists and epidemiologists in different parts of the world to recall old lessons and develop new methods for microbiological diagnosis, prevention, control and treatment of diphtheria.6,17,21,26,27-29,35 In emerging countries, in which the incidence of diphtheria remains relatively high and the vaccination coverage continues to be insufficient, laboratory support should be implemented in the light of the recurrent deficiencies in this segment.30
It is essential to have accurate, rapid, economical and easily performed triage, with the capacity to make a presumptive diagnosis of diphtheria cases caused both by C. ulcerans and by C. diphtheriae, in the majority of Brazilian laboratories. This would have the aim of reducing the underreporting that results from false negative laboratory results.
In Figure 3, the proposed algorithm enables isolation of Gram-positive rods that are potential DT producers, using culturing media (blood agar and tellurite chocolate agar) and biochemical tests routinely used in clinical bacteriological laboratories, i.e. deoxyribonuclease (DNAse) activity, urea hydrolysis and the reverse CAMP reaction using a beta-lysine-producing strain of Staphylococcus aureus. If it is possible to use Tinsdale medium, the samples of cystinase-negative Gram-positive rods can be discarded. Cystinase-positive and H2S-producing samples are identified through the presence of a brown halo around the colony.30,36
Positive results from the DNAse test88 suggest that C. diphtheriae and C. ulcerans are present. Unlike C. diphtheriae, samples of C. ulcerans are urease-positive and undergo the reverse CAMP reaction.35 On rare occasions, samples of C. pseudotuberculosis that are potential DT producers may be isolated. These present negative results from DNAse tests and positive results in the cystinase, urease and reverse CAMP tests. Cystinase-negative and DNAse-negative samples should be considered to be "other coryneform bacteria".
In addition to conventional biochemical tests, the semi-automated API Coryne system (BioMérrieux, Lyon, France) is also capable of identifying these pathogens, including the atypical sucrose-fermenting samples of C. ulcerans and C. diphtheriae that are often isolated in Brazil.33,67
Laboratories that do not have any resources available for carrying out toxigenicity tests should send the strains for complementary analyses to the Central Public Health Laboratory of their region and/or the National Reference Laboratory and the Collaborating Center for diphtheria. Laboratories that do have resources available for conducting molecular techniques capable of identifying C. diphtheriae and C. ulcerans and determining the presence of the tox gene9,79,80,86,87 should also send the strains for epidemiological control procedures, to the same laboratories, which have this capacity.
Considering the short incubation period of this disease (between one and six days), it is recommended that material for investigating C. ulcerans and C. diphtheriae should be collected from nasal and oropharyngeal mucosa and skin lesions of people and animals that have been in contact with the case (suspected or confirmed) over the last 10 to 14 days.
ROLE OF DIPHTHERIC TOXOID IN PREVENTION
The concentration of protective antibodies in adult individuals decreases by 10% every year.98 The importance of vaccination booster programs has been proven in Finland.78 Data on vaccination coverage among adolescents and adults in Brazil are scarce in the literature.15,20,22,85,102 In the city of Rio de Janeiro, only 30% of the adults are completely protected against the action of DT,15 similar to what has been observed in other countries like Turkey.10 These data emphasize the importance of applying reinforcement doses of diphtheric toxoid every ten years, in order to avoid decreased antibody levels in the population.10,20
However, the efficacy of diphtheric toxoid against the zoonotic diphtheria caused by C. ulcerans still remains unknown. The studies listed in Table 1 showed that the majority (approximately 75%) of the cases of zoonotic diphtheria have occurred in adult patients who had been fully or partially vaccinated with diphtheric toxoid.
There are still many issues that require better assessment, not only in relation to clinical-laboratory diagnosis, but also in relation to treating and preventing diseases caused by C. ulcerans. Likewise, better comprehension of the molecular epidemiology and characteristics of C. ulcerans, along with the toxin produced (which resembles the DT of C. diphtheria) is needed.
Recent studies have revealed differences in nucleotide sequences between the tox genes of C. ulcerans and C. diphtheriae, and between the tox genes of different samples of C. ulcerans. Some samples isolated from patients presenting conditions of extrapharyngeal infection have presented differences in DT sequences, predominantly in the domains of translocation and adherence.9,70,80,99,109
These facts may contribute towards situations in which individuals vaccinated with diphtheric toxoid or undergoing serum therapy do not present full protection against infections caused by C. ulcerans. Even if it is considered that the diphtheric toxoid may have a protective effect against diphtheria caused by C. ulcerans (i.e. through the presence of attenuated clinical symptoms), it should be remembered that the vaccination only presents the action of DT and probably does not impede colonization by toxigenic corynebacteria. There is agreement among researchers that, in the absence of a proven vaccine against C. ulcerans, diphtheric toxoid remains a reasonable alternative, especially in cases of convalescence. On the other hand, it is also believed that there is a scarcity of evidence to show that vaccination with diphtheric toxoid, even when kept up-to-date, would impede zoonotic diphtheria or other diseases caused by C. ulcerans.94,107
The circulation of C. ulcerans in many countries, added to the recent cases of infections in humans and animals described in Brazil, make it possible to raise the hypothesis that zoonotic diphtheria is occurring and C. ulcerans is circulating in urban and rural regions of Brazil. There is thus a need to improve the adequacy of the protocols for microbiological diagnosis of both C. ulcerans and C. diphtheriae, using alternative triage methods that could be implemented in public and private-sector laboratories. Implementation of epidemiological and laboratory-based surveillance may contribute towards increasing the number of confirmed cases of classical and zoonotic diphtheria in Brazil.
1. Aaron L, Heurtebise F, Bachelier MN, Guimard Y. Angine diphtérique pseudomembraneuse autochtone liée à Corynebacterium ulcerans. Rev Med Interne. 2006;27(4):333-5. DOI:10.1016/j.revmed.2005.12.011 [ Links ]
2. Barret NJ. Comunicable disease associated with milk and dairy products in England and Wales. J Infec. 1986;12(3):265-72. [ Links ]
3. Bergin Il, Chien CC, Marini RP, Fox JG. Isolation and characterization of Corynebacterium ulcerans from cephalic implants in macaques. Comp Med. 2000;50(5):530-5. [ Links ]
4. Bitragunta S, Murhekar MV, Chakravarti A, Verma V, Namjoshi GS, Parekh SS, et al. Safety and immunogenicity of single dose of tetanus-diphtheria (Td) vaccine among non/partially immune children against diphtheria and/or tetanus, Hyderabad, India, 2007. Vaccine. 2010;28(37):5934-8. DOI:10.1016/j.vaccine.2010.06.047 [ Links ]
5. Bonmarin I, Guiso N, Le Flèche-Matéos A, Patey O, Patrick AD, Levy-Bruhl D. Diphtheria: a zoonotic disease in France? Vaccine. 2009;27(31):4196-200. DOI:10.1016/j.vaccine.2009.04.048 [ Links ]
6. Bonnet JM, Begg NT. Control of diphtheria: guidance for consultants in communicable disease control. Commun Dis Public Health. 1999;2(4):242-9. [ Links ]
7. Bostock AD, Gilbert FR, Lewis D, Smith DCM. Corynebacterium ulcerans infection associated with untreated milk. J Infect. 1984;9(3):286-8. [ Links ]
8. Carpentier JP, Flanagan PM, Singh JP, Timms MS, Nassar WY. Nasopharyngeal Corynebacterium ulcerans: a different diphtheria. J Laryngol Otol. 1992;106(9):824-6. [ Links ]
9. Cassiday PK, Pawloski LC, Tiwari T, Sanden GN, Wilkins PP. Analysis of toxigenic Corynebacterium ulcerans strains revealing potential for false-negative real-time PCR results. J Clin Microbiol. 2008;46(1):331-3. DOI:10.1128/JCM.01251-07 [ Links ]
10. Cavus SA, Oguz VA, Yuce A. The seroprevalence of diphtheria among adults in Izmir-Turkey. Vaccine. 2007;25(19):3851-4. DOI:10.1016/j.vaccine.2007.01.104 [ Links ]
11. Centers for Disease Control and Prevention. Respiratory diphtheria caused by Corynebacterium ulcerans -Terre Haute, Indiana, 1996. MMWR Morb Mortal Wkly Rep. 1997;46(15):330-2. [ Links ]
12. Centers for Disease Control and Prevention. Three cases of toxigenic Corynebacterium ulcerans infection. Commun Dis Rep CDR Wkly. 2000;10(6):49, 52. [ Links ]
13. Colombo AV, Hirata Jr R , Souza CM, Monteiro-Leal LH, Previato JO, Formiga LC, et al. Corynebacterium diphtheriae surface proteins as adhesins to human erythrocytes. FEMS Microbiol Lett. 2001;197(2):235-9. [ Links ]
14. Coyle MB, Minshew BH, Bland JA, Hsu PC. Erythromycin and clindamycin resistance in Corynebacterium diphtheriae from skin lesions. Antimicrob Agents Chemoter. 1979;16(4):525-7. [ Links ]
15. Damasco PV, Pimenta FP, Filardy AA, Brito SM, Andrade AF, Lopes GS, et al. Prevalence of IgG diphtheria antitoxin in blood donors in Rio de Janeiro. Epidemiol Infect. 2005;133(5):911-4. DOI:10.1017/S0950268805003997 [ Links ]
16. Dessau RB, Brandt-Christensen M. Jensen OJ, Tonnesen P. Pulmonary nodules due to Corynebacterium ulcerans. Eur Respir J. 1995;(4)8:651-3. DOI:10.1183/09031936.95.08040651 [ Links ]
17. Dewinter LM, Bernard KA, Romney MG. Human clinical isolates of Corynebacterium diphtheriae and Corynebacterium ulcerans collected in Canada from 1999 to 2003 but not fitting reporting criteria for cases of diphtheria. J Clin Microbiol. 2005;43(7):3447-9. DOI:10.1128/JCM.43.7.3447-3449.2005 [ Links ]
18. De Zoysa A, Hawkey PM, Engler K, George R, Mann G, Reilly W, et al. Characterization of toxigenic Corynebacterium ulcerans strains isolated from humans and domestic cats in the United Kingdom. J Clin Microbiol. 2005;4(9):4377-81. DOI:10.1128/JCM.43.9.4377-4381.2005 [ Links ]
19. Dias AASO, Silva Jr FC, Pereira GA, Souza MC, Camello TCF, Damasceno JALD, et al. Corynebacterium ulcerans isolated from an asymptomatic dog kept in an animal shelter in the metropolitan area of Rio de Janeiro, Brazil. Vector Borne Zoonotic Dis. 2010;10(8):743-8. DOI:10.1089/vbz.2009.0132 [ Links ]
20. Dinelli MIS, Fisberg M, Moraes-Pinto MI. Tetanus and diphtheria immunity in adolescents from São Paulo, Brazil. Braz J Med Biol Res. 2007;40(2):259-63. DOI:10.1590/S0100-879X2006005000070 [ Links ]
21. Dittmann S, Wharton M, Vitek C, Ciotti M, Galazka A, Guichard S, et al. Successful control of epidemic diphtheria in the State of Former Union of Soviet Socialist Republics: lessons learned. J Infect Dis. 2000;181 Suppl 1:S10-22. DOI:10.1086/315534 [ Links ]
22. Divino-Goes KG, Moraes-Pinto MI, Dinelli MIS, Casagrande ST, Bonetti TC, Andrade PR, et al. Prevalence of diphtheria and tetanus antibodies and circulation of Corynebacterium diphtheriae in São Paulo, Brazil. Braz J Med Biol Res. 2007;40(12):1681-7. DOI:10.1590/S0100-879X2006005000183 [ Links ]
23. DurbacĂ S. Antitetanus and antidiphtheria immunity in newborns. Roum Arch Microbiol Immunol. 1999;58(3-4):267-72. [ Links ]
24. Dzupova O, Benes J, Kriz B, Horová B, Olexová A. [An unusual course of invasive infection due to nontoxinogenic strain of Corynebacterium diphtheria]. Klin Mikrobiol Infekc Lek. 2005;11(6):222-5. [ Links ]
25. Elden S, Coole L, Efstratiou A, Doshi N. Laboratory-confirmed case of toxigenic Corynebacterium ulcerans. Euro Surveill. 2007;12(3)E070329.3 [ Links ]
26. Efstratiou A, Engler KH, Dawes CS, Sadic D. Comparison of phenotypic and genotypic methods for detection of diphtheria toxin among isolates of pathogenic corynebacteria. J Clin Microbiol. 1998;36(11):3173-7. [ Links ]
27. Efstratiou A, George RC. Laboratory guidelines for the diagnosis of infections caused by Corynebacterium diphtheriae and C. ulcerans. Commun Dis Public Health. 1999;2(4):250-7. [ Links ]
28. Efstratiou A, Engler KH, Mazurova IK, Glushkevish T, Vuopio-Varkila J, Popovic T. Current approaches to the laboratory diagnosis of diphtheria. J Infect Dis. 2000;181(Suppl 1):S138-45. DOI:10.1086/315552 [ Links ]
29. Farizo KM, Strebel PM, Chen RT, Kimbler A, Cleary TJ, Cochi SL. Fatal respiratory disease due to Corynebacterium diphtheriae: case report and review of guidelines for management, investigation and control. Clin Infect Dis. 1993;16(1):59-68. DOI:10.1093/clinids/16.1.59 [ Links ]
30. Formiga LCD, Mattos-Guaraldi AL. Diphtheria: current status and laboratory procedures for diagnosis. Rev Bras Patol Clin. 1993;29(3):93-6. [ Links ]
31. Foster G, Patterson T, Howie F, Simpson V, Davison N, Efstratiou A, et al. Corynebacterium ulcerans in free-ranging otters. Vet Rec. 2002;150(16):524. [ Links ]
32. Fox JG, Frost WW. Corynebacterium ulcerans mastitis in a bonnet macaque (Macaca radiata). Lab Anim Sci. 1974;24(5):820-2. [ Links ]
33. Funke G, von Graevenitz A, Clarridge JE 3rd, Bernard KA. Clinical microbiology of coryneform bacteria. Clin Microbiol Rev. 1997;10(1):125-59. [ Links ]
34. Funke G, Bernard KA. Coryneform gram-positive rods. In: Murray PR, Baron EJ, Jorgensen JH, Landry MA, Pfaller MA, editors. Manual of clinical microbiology. Washington (DC): American Society for Microbiology Press; 2007. p.485-514. [ Links ]
35. Galazka AM, Robertson SE. Diphtheria: changing patterns in the developing world and the industrialized world. Eur J Epidemiol. 1995;11(1):107-17. [ Links ]
36. Galazka AM. The changing epidemiology of diphtheria in the vaccine era. J Infect Dis. 2000;181(Suppl 1):S2-9. DOI:10.1086/315533 [ Links ]
37. Gilbert R, Stewart FC. Corynebacterium ulcerans: a pathogenic microorganism resembling C. diphtheriae. J Lab Clin Med. 1926;12:756-61. [ Links ]
38. Gladin DP, Koslova NS, Zaitseva TK, Cherednichenko AS, Khval SA. [Sensitivity of Corynebacterium diphtheriae isolated in Saint Petersburg to antibacterial drugs]. Antibiot Khimioter. 1999;44(5):17-21. [ Links ]
39. Groman N, Schiller J, Russell J. Corynebacterium ulcerans and Corynebacterium pseudotuberculosis responses to DNA probes derived from corynephage beta and Corynebacterium diphtheriae. Infect Immun. 1984;45(2):511-7. [ Links ]
40. Gubler JG, Wüst J, Krech T, Hany A. [Classical pseudomembranous diphtheria caused by Corynebacterium ulcerans]. Schweiz Med Wochenschr. 1990;120(48):1812-6. [ Links ]
41. Hadfield TL, McEvoy P, Polotsky Y, Tzinserling VA, Yakovlev AA. The pathology of diphtheria. J Infect Dis. 2000;181(Suppl 1):S116-20. DOI:10.1086/315551 [ Links ]
42. Hall AJ, Cassiday PK, Bernard KA, Bolt F, Steigerwalt AG, Bixler D, et al. Novel Corynebacterium diphtheriae in domestic cats. Emerg Infect Dis. 2010;16(4):688-91. DOI:10.3201/eid1604.091107 [ Links ]
43. Hard GC. Comparative toxic effect of the surface lipid of Corynebacterium ovis on peritoneal macrophages. Infect Immun. 1975;12(6):1439-49. [ Links ]
44. Hart RJC. Corynebacterium ulcerans in humans and cattle in North Devon. J Hyg (Lond). 1984;92(2):161-4. [ Links ]
45. Hatanaka A, Tsunoda A, Okamoto M, Ooe K, Nakamura A, Miyakoshi M, et al. Corynebacterium ulcerans diphtheria in Japan. Emerg Infect Dis. 2003;9(6):752-3. DOI:10.3201/eid0906.020645 [ Links ]
46. Henriksen SD. Some bacteriophages of Corynebacterium ulcerans and their lack of effect on toxigenicity. Acta Pathol Microbiol Scand. 1955;37(1):65-70. [ Links ]
47. Higgs TM, Smith A, Cleverly LM, Neave FK. Corynebacterium ulcerans infections in a dairy herd. Vet Rec. 1967;81(2):34-5. [ Links ]
48. Hirata Jr R, Napoleão F, Monteiro-Leal LH, Andrade AF, Nagao PE, Formiga LC, et al. Intracellular viability of toxigenic Corynebacterium diphtheriae strains in HEp-2 cells. FEMS Microbiol Lett. 2002;215(1):115-9. [ Links ]
49. Hirata Jr R, Pereira GA, Filardy AA, Gomes DLR, Damasco PV, Rosa ACP, et al. Potential pathogenic role of aggregative-adhering Corynebacterium diphtheriae of different clonal groups in endocarditis. Braz J Med Biol Res. 2008;41(11):986-91. DOI:10.1590/S0100-879X2008001100007 [ Links ]
50. Hirata Jr R, Souza SM, Rocha-de-Souza CM, Andrade AF, Monteiro-Leal LH, Formiga LC, et al. Patterns of adherence to HEp-2 cells and actin polymerisation by toxigenic Corynebacterium diphtheriae strains. Microb Pathog. 2004;36(3):125-30. DOI:10.1016/j.micpath.2003.10.002 [ Links ]
51. Hodgson AL, Krywult J, Corner LA, Rothel JS, Radford AJ. Rational attenuation of Corynebacterium pseudotuberculosis: potential cheesy gland vaccine and live delivery vehicle. Infect Immun. 1992;60(7):2900-5. [ Links ]
52. Hogg RA, Wessels J, Hart J, Efstratiou A, De Zoysa A, Mann G, et al. Possible zoonotic transmission of toxigenic Corynebacterium ulcerans from companion animals in a human case of fatal diphtheria. Vet Rec. 2009;165(23):691-2. DOI:10.1135/vr.165.23.691 [ Links ]
53. Hommez J, Devriese LA, Vaneechoutte M, Riegel P, Butaye P, Haesebrouck F. Identification of nonlipophilic corynebacteria isolated form dairy cows with mastitis. J Clin Microbiol. 1999;37(4):954-7. [ Links ]
54. Honma Y, Nakasone N. Pili of Aeromonas hydrophila: purification, characterization and biological role. Microbiol Immunol. 1989;34(2):83-98. [ Links ]
55. Hust MH, Metzler U, Schubert AW, Seuffer RH. Toxische diphtherie durch Corynebacterium ulcerans. Dtsch Med Wochenschr. 1994;119(15):548-52. [ Links ]
56. Katsukawa C, Kawahara R, Inoue K, Ishii A, Yamagishi H, Kida K, et al. Toxigenic Corynebacterium ulcerans isolated from the domestic dog for the first time in Japan. Jpn J Infect Dis. 2009;62(2):171-2. [ Links ]
57. Kaufmann D, Ott P, Ruegg C. Laryngopharyngitis by Corynebacterium ulcerans. Infection. 2002;30(3):168-70. [ Links ]
58. Khamis A, Raoult D, La Scola B. Rpo B gene sequencing for identification for Corynebacterium species. J Clin Microbiol. 2004;42(9):3925-31. DOI:10.1128/JCM.42.9.3925-3931.2004 [ Links ]
59. Khan N, Shastri J, Aigal U, Doctor B. Resurgence of diphtheria in the vaccination era. Indian J Med Microbiol. 2007;25(4):434. DOI:10.4103/0255-0857.37367 [ Links ]
60. Kimura Y, Watanabe Y, Suga N, Suzuki N, Maeda K, Suzuki K, et al. Acute peritonitis due to Corynebacterium ulcerans in a patient receiving continuous ambulatory peritoneal dialysis: a case report and literature review. Clin Exp Nephrol. 2011;15(1):171-4. DOI:10.1007/s10157-010-0346-4 [ Links ]
61. Kisely SR, Price S, Ward T. Corynebacterium ulcerans: a potential cause of diphtheria. Commun Dis Rep CDR Rev. 1994;4(5):63-4. [ Links ]
62. Komiya T, Seto Y, De Zoysa A, Iwaki M, Hatanaka A, Tsunoda A, et al. Two Japanese Corynebacterium ulcerans isolates from the same hospital: ribotype, toxigenicity, and serum antitoxin titre. J Med Microbiol. 2010;59(Pt 12):1497-504. DOI:10.1099/jmm.0.022491-0 [ Links ]
63. Lartigue MF, Monnet X, Le Flèche A, Grimont PA, Benet JJ, Durrbach A, et al. Corynebacterium ulcerans in an immunocompromised patient with diphtheria and her dog. J Clin Microbiol. 2005;43(2):999-1001. DOI:10.1128/JCM.43.2.999-1001.2005 [ Links ]
64. Leek MD, Sivaloganathan S, Devaraj SK, Zamiri I, Griffiths GD, Green MA. Diphtheria with a difference: a rare corynebacterium fatality with associated apoptotic cell death. Histopathology. 1990;16(2):187-9. [ Links ]
65. Leggett BA, De Zoyza A, Abbott YE, Leonard N, Markey B, Efstratiou A. Toxigenic Corynebacterium diphtheriae isolated from a wound in a horse. Vet Rec. 2010;166(21):656-7. DOI:10.1136/vr.b4846 [ Links ]
66. Man P, Montagner C, Vitrac H, Kavan D, Pichard S, Gillet D, et al. Accessibility changes within diphtheria toxin T domain when in the functional molten globule state, as determined using hydrogen/deuterium exchange measurements. FEBS J. 2010;277(3):653-62. DOI:10.1111/j.1742-4658.2009.07511.x [ Links ]
67. Mattos-Guaraldi AL, Formiga LCD. Bacteriological properties of a sucrose-fermenting Corynebacterium diphtheriae strain isolated from a case of endocarditis. Curr Microbiol. 1998;37(3):156-8. DOI:10.1007/s002849900356 [ Links ]
68. Mattos-Guaraldi AL, Formiga LC, Andrade AF. Trans-sialidase activity for sialic acid incorporation on Corynebacterium diphtheriae. FEMS Microbiol Lett. 1998;168(2):167-72. [ Links ]
69. Mattos-Guaraldi AL, Formiga LCD, Marques EA, Pereira GA, Moreira LO, Pimenta FP, et al. Diphtheria in a vaccinated adult in Rio de Janeiro, Brazil. Braz J Microbiol. 2001;32(3):236-9. DOI:10.1590/S1517-83822001000300015 [ Links ]
70. Mattos-Guaraldi AL, Moreira LO, Damasco PV, Hirata Jr R. Diphtheria remains a threat to health in the developing world: an overview. Mem Inst Oswaldo Cruz. 2003;98(8):987-93. DOI:10.1590/S0074-02762003000800001 [ Links ]
71. Mattos-Guaraldi AL, Sampaio JLM, Santos CS, Pimenta FP, Pereira GA, Pacheco LGC, et al. First detection of Corynebacterium ulcerans producing diphtheria-like toxin in a case of human with pulmonary infection in the Rio de Janeiro metropolitan area, Brazil. Mem Inst Oswaldo Cruz. 2008;103(4):396-400. DOI:10.1590/S0074-02762008000400014 [ Links ]
72. May BD. Corynebacterium ulcerans infections in monkeys. Lab Anim Sci. 1972;22(4):509-13. [ Links ]
73. McNamara PJ, Cuevas WA, Songer JG. Toxic phospholipases D of Corynebacterium pseudotuberculosis, C. ulcerans and Arcanobacterium haemolyticum: cloning and sequence homology. Gene. 1995;156(1):113-8. DOI:10.1016/0378-1119(95)00002-N [ Links ]
74. Moreira LO, Andrade AF, Vale MD, Souza SM, Hirata Jr R, Asad LM, et al. Effects of iron limitation on adherence and cell surface carbohydrates of Corynebacterium diphtheriae strains. Appl Environ Microbiol. 2003;69(10):5907-13. DOI:10.1128/AEM.69.10.5907-5913.2003 [ Links ]
75. Morris WE, Uzal FA, Cipolla AL. Pyogranulomatous meningoencephalitis in a goat due to Corynebacterium ulcerans. Vet Rec. 2005;156(10):317-8. [ Links ]
76. Nielsen PB, Scherling B, Scheibel JH, Frederiksen W. [Diphtheria in Denmark 1956-1989. Occurrence of Corynebacterium diphtheriae and other diphtheria toxigenic bacteria]. Ugeskr Laeger. 1991;153(11):769-72. [ Links ]
77. Nureki S, Miyazaki E, Matsuno O, Takenaka R, Ando M, Kumamoto T, et al. Corynebacterium ulcerans infection of the lung mimicking the histology of Churg-Strauss syndrome. Chest. 2007;131(4):1237-9. DOI:10.1378/chest.06-2346 [ Links ]
78. Ölander RM, Auranen K, Härkänen T, Leino T. High tetanus and diphtheria antitoxin concentrations in Finnish adults: time for new booster recommendations? Vaccine. 2009;27(39):5295-8. DOI:10.1016/j.vaccine.2009.06.080 [ Links ]
79. Olson ME, Goemans I, Bolingbroke D, Lundberg S. Gangrenous dermatitis caused by Corynebacterium ulcerans in Richardson ground squirrels. J Am Vet Med Assoc. 1988;193(3):367-8. [ Links ]
80. Pacheco LG, Pena RR, Castro TL, Dorella FA, Bahia RC, Carminati R, et al. Multiplex PCR assay for identification of Corynebacterium pseudotuberculosis from pure cultures and for rapid detection of this pathogen in clinical samples. J Med Microbiol. 2007;56(Pt 4):480-6. DOI:10.1099/jmm.0.46997-0 [ Links ]
81. Pallen MJ, Hay AJ, Puckey LH, Efstratiou A. Polymerase chain reaction for screening clinical isolates of corynebacteria for the production of diphtheria toxin. J Clin Pathol. 1994;47(4):353-6. [ Links ]
82. Panaitescu M, Maximescu P, Michel J, Potorac E. Respiratory pathogens in non-human primates with special reference to Corynebacterium ulcerans. Lab Anim. 1977;11(3):155-7. [ Links ]
83. Pappenheimer AM Jr. The story of a toxic protein, 1888-1992. Protein Sci. 1993;2(2):292-8. DOI:10.1002/pro.5560020218 [ Links ]
84. Pers C. Infection due to Corynebacterium ulcerans, producing diphtheria toxin: a case report from Denmark. Acta Pathol Microbiol Immunol Scand B. 1987;95(6):361-2. [ Links ]
85. Pesavento PA, Bannasch MJ, Bachmann R, Byrne BA, Hurley KF. Fatal Streptococcus canis infections in intensively housed shelter cats. Vet Pathol. 2007; 44(2):218-21. DOI:10.1354/vp.44-2-218 [ Links ]
86. Pimenta FP, Damasco PV, Cerbino Neto J, Lopes GS, Hirata Jr R, Milagres LG, et al. Diphtheria-neutralizing antibody levels in healthy adults from Rio de Janeiro, Brazil. Mem Inst Oswaldo Cruz. 2006;101(4):459-62. DOI:10.1590/S0074-02762006000400018 [ Links ]
87. Pimenta FP, Hirata Jr R, Rosa AC, Milagres LG, Mattos-Guaraldi AL. A multiplex PCR assay for simultaneous detection of Corynebacterium diphtheriae and differentiation between non-toxigenic and toxigenic isolates. J Med Microbiol. 2008;57(Pt 11):1438-9. DOI:10.1099/jmm.0.2008/000414-0 [ Links ]
88. Pimenta FP, Matias GA, Pereira GA, Camello TC, Alves GB, Rosa AC, et al. A PCR for dtxR gene: application to diagnosis of non-toxigenic and toxigenic Corynebacterium diphtheriae. Mol Cell Probes. 2008;22(3):189-92. DOI:10.1016/j.mcp.2008.01.001 [ Links ]
89. Pimenta FP, Souza MC, Pereira GA, Hirata Jr R, Camello TC, Mattos-Guaraldi AL. DNase test as a novel approach for the routine screening of Corynebacterium diphtheriae. Lett Appl Microbiol. 2008;46(3):307-11. DOI:10.1111/j.1472-765X.2007.02310.x [ Links ]
90. Popovic T, Kombarova S, Reeves MW, Nakao H, Mazurova IK, Wharton M, et al. Molecular epidemiology of diphtheria in Russia, 1985-1994. J Infect Dis. 1996;174(5):1064-72. DOI:10.1093/infdis/174.5.1064 [ Links ]
91. Popovic T, Mazurova IK, Efstratiou A, Vuopio-Varkila J, Reeves MW, De Zoyza A, et al. Molecular epidemiology of diphtheria. J Infect Dis. 2000;181 (Suppl 1):S168-77. DOI:10.1086/315556 [ Links ]
92. Riegel P, Ruimy R, de Briel D, Prévost G, Jehl F, Christen R, et al. Taxonomy of Corynebacterium diphtheriae and related taxa, with recognition of Corynebacterium ulcerans sp. nov. nom. rev. FEMS Microbiol Lett. 1995;126(3):271-6. [ Links ]
93. Saikia L, Nath R, Saikia NJ, Choudhury G, Sarkar M. A diphtheria outbreak in Assam, India. Southeast Asian J Trop Med Public Health. 2010;41(3):647-52. [ Links ]
94. Salyers AA, Whitt DD. Bacterial pathogenesis: a molecular approach. Washington (DC): American Society for Microbiology Press; 1994. Diphtheria; p.113-21. [ Links ]
95. Schuhegger R, Kugler R, Sing A. Pitfalls with diphtheria-like illness due to toxigenic Corynebacterium ulcerans. Clin Infect Dis. 2008;47(2):288. DOI:10.1086/589575 [ Links ]
96. Schuhegger R, Schoerner C, Dlugaiczyk J, Lichtenfeld I, Trouillier A, Zeller-Peronnet V, et al. Pigs as source for toxigenic Corynebacterium ulcerans. Emerg Infect Dis. 2009;15(8):1314-5. DOI:10.3201/eid1508.081568 [ Links ]
97. Seto Y, Komiya T, Iwaki M, Kohda T, Mukamoto M, Tanahashi M, et al. Properties of corynephage attachment site and molecular epidemiology of Corynebacterium ulcerans isolated from humans and animals in Japan. Jpn J Infect Dis. 2008;61(2):116-22. [ Links ]
98. Siegel SM, Haile CA. Corynebacterium ulcerans pneumonia. South Med J. 1985;78(10):1267. [ Links ]
99. Simonsen O, KlÆrke M, KlÆrke A, Bloch AV, Hansen BR, Hald N, et al. Revaccination of adults against diphtheria. II: Combined diphtheria and tetanus revaccination with different doses of diphtheria toxoid 20 years after primary vaccination. Acta Pathol Microbiol Immunol Scand C. 1986;94(5):219-26. [ Links ]
100. Sing A, Hogardt M, Bierschenk S, Heesemann J. Detection of differences in the nucleotide and amino acid sequences of diphtheria toxin from Corynebacterium diphtheriae and Corynebacterium ulcerans causing extrapharyngeal infections. J Clin Microbiol. 2003;41(10):4848-51. DOI:10.1128/JCM.41.10.4848-4851.2003 [ Links ]
101. Sing A, Bierschenk S, Heesemann J. Classical diphtheria caused by Corynebacterium ulcerans in Germany: amino acid sequence differences between diphtheria toxins from Corynebacterium diphtheriae and C. ulcerans. Clin Infec Dis. 2005;40(2):325-6. DOI:10.1086/426687 [ Links ]
102. Souza SMS, Hirata Jr R, Moreira LO, Gomes ML, Andrade AFB, Bernardo-Filho M, et al. Influence of stannous chloride on the adhesive properties of Corynebacterium diphtheriae strains. Int J Mol Med. 2003;12(4):657-61. [ Links ]
103. Speranza FAB, Ishii SK, Hirata Jr R, Mattos-Guaraldi AL, Milagres LG. Diphtheria toxin IgG levels in military and civilian blood donors in Rio de Janeiro, Brazil. Braz J Med Biol Res. 2010;43(1):120-3. DOI:10.1590/S0100-879X2009007500032 [ Links ]
104. Sykes JE, Mapes S, Lindsay LL, Samitz E, Byrne BA. Corynebacterium ulcerans bronchopneumonia in a dog. J Vet Intern Med. 2010;24(4):973-6. DOI:10.1111/j.1939-1676.2010.0491.x [ Links ]
105. Taylor DJ, Efstratiou A, Reilly WJ. Diphtheria toxin production by Corynebacterium ulcerans from cats. Vet Rec. 2002;150(11):355. [ Links ]
106. Taylor J, Saveedra-Campos M, Harwood D, Pritchard G, Raphaely N, Kapadia S, et al. Toxigenic Corynebacterium ulcerans infection in a veterinary student in London, United Kingdom, May 2010. Euro Surveill. 2010;15(31):1-3. [ Links ]
107. Tejedor Mt, Martin JL, Lupiola P, Gutierrez C. Caseous lymphadenitis caused by Corynebacterium ulcerans in the dromedary camel. Can Vet J. 2000;41(2):126-7. [ Links ]
108. Tiwari TS, Golaz A, Yu DT, Ehresmann KR, Jones TF, Hill HE, et al. Investigations of 2 cases of diphtheria-like illness due to toxigenic Corynebacterium ulcerans. Clin Infect Dis. 2008;46(3):395-401. DOI:10.1086/525262 [ Links ]
109. Van Dam AP, Schippers EF, Visser LG, Peek N, Swaan CM, Kuijper EJ. A case of diphtheria in the Netherlands due to an infection with Corynebacterium ulcerans. Ned Tijdschr Geneeskd. 2003;147(9):403-6. [ Links ]
110. Vertiev YuV, Ezepchuk YuV, Souckova A, Soucek A. Purification and some properties of exotoxin from Corynebacterium ulcerans strain ATCC 9015. Zentralbl Bakteriol Mikrobiol Hyg A. 1981;249(4):527-37. [ Links ]
111. Von Hunolstein C, Alfarone G, Scopetti F, Pataracchia M, La Valle R, Franchi F, et al. Molecular epidemiology and characteristics of Corynebacterium diphtheriae and Corynebacterium ulcerans strains isolated in Italy during the 1990s. J Med Microbiol. 2003;52(Pt 2):181-8. DOI:10.1099/jmm.0.04864-0 [ Links ]
112. Wagner J, Ignatius R, Voss S, Höpfner V, Ehlers S, Funke G, et al. Infection of the skin caused by Corynebacterium ulcerans and mimicking classical cutaneous diphtheria. Clin Infect Dis. 2001;33(9):1598-600. DOI:10.1086/322969 [ Links ]
113. Wagner KS, White JM, Crowcroft NS, De Martin S, Mann G, et al. Diphtheria in the United Kingdom, 1986-2008: the increasing role of Corynebacterium ulcerans. Epidemiol Infect. 2010;138(11):1519-30. DOI:10.1017/S0950268810001895 [ Links ]
114. Wagner KS, White JM, Neal S, Crowcroft NS, Kupreviciene N, Paberza R, et al. Screening for Corynebacterium diphtheriae and Corynebacterium ulcerans in patients with upper respiratory tract infections 2007-2008: a multicentre European study. Clin Microbiol Infect Dis, 2011;17(4):519-25. DOI:10.1111/j.1469-0691.2010.03269.x [ Links ]
115. Wang J, London E. The membrane topography of the diphtheria toxin T domain linked to the a chain reveals a transient transmembrane hairpin and potential translocation mechanisms. Biochemistry. 2009;48(43):10446-56. DOI:10.1021/bi9014665 [ Links ]
116. Wellinghausen N, Sing A, Kern WV, Perner S, Marre R, Rentschler J. A fatal case of necrotizing sinusitis due to toxigenic Corynebacterium ulcerans. Int J Med Microbiol. 2002;292(1):59-63. [ Links ]
117. Wong TP, Groman N. Production of diphtheria toxin by selected isolates of Corynebacterium ulcerans and Corynebacterium pseudotuberculosis. Infect Immun. 1984;43(3):1114-6. [ Links ]
Correspondence: Received: 11/25/2010 The authors declare
that there were no conflicts of interest.
Alexandre Alves de Souza de Oliveira Dias
Departamento de Imunologia
Instituto Nacional de Controle e Controle de Qualidade em Saúde
Fundação Oswaldo Cruz
Av. Brasil, 4365
21040-900 Rio de Janeiro, RJ, Brasil
Study funded by the Research Support Foundation of the State of Rio de Janeiro (FAPERJ - Procedural nos. E-26/101519/2010; E-26/11.278/2010; E-26/102.146/2010; E-26/110.339/2010); by the National Council for Scientific and Technological Development (CNPq - Procedural nos. 470357/2009-6;302897/2007-0; 502090/2010-3); by the Coordination Office for Advancement of University-level Personnel (Capes - Procedural no. 0370088); and by the National Institute for Healthcare Quality Control, Oswaldo Cruz Foundation (INCQS/FIOCRUZ - Procedural nos. 403626/2008-0; 03621/2008-9).
Santos LS and Silva Júnior FC were supported by the Sub-Rectory for Postgraduate programs and Research, State University of Rio de Janeiro (Scientific Initiation bursary holders).
a Secretaria de Saúde do Estado do Rio de Janeiro. Proporção de casos e óbitos por difteria segundo faixa etária, 1978-2002. Rio de Janeiro: Assessoria de Doenças Imunoprevisíveis; 2002.
b Wikipedia: The Free Encyclopedia. Diphtheria World Map - DALY - WHO2002 [cited 2010 Nov 15]. Available from: http://en.wikipedia.org/wiki/File:Diphtheria_world_map_-_DALY_-_WHO2002.svg
c Ministério da Saúde, Fundação Nacional de Saúde, Centro Nacional de Epidemiologia. Evolução temporal das doenças de notificação compulsória no Brasil de 1980 a 1998. Bol Epidemiol.1999; 3 Ed Espec:1-48.
d Ministério da Saúde, Fundação Nacional de Saúde. Difteria: situação atual da doença [cited 2002 Mar 23]. Available from: http://www.funasa.gov.br/guia_ epi/htm/doencas/difteria/index.htm
e Ministério da Saúde, Fundação Nacional de Saúde, Centro Nacional de Epidemiologia. Guia de vigilância epidemiológica. 4. ed. Brasília (DF); 1998 [cited 2010 Mar 10]. Difteria; capítulo 5.6. Available from: http://www.cro-rj.org/biosseguranca/Guia de%Vigilancia Epidemiologica.pdf
f World Health Organization. Diphtheria. Geneva; 2010 [cited 2010 Sep 7]. Available from: http://www.who.int/topics/diphtheria/en/index.html
g Santos LS, Sant'Anna LOS, Cosme LMSS, Hirata Jr RH, Mattos-Guaraldi AL. Perfis fenotípicos e genotípicos de amostras de Corynebacterium diphtheriae isoladas em recente surto epidêmico ocorrido no Maranhão. In: 44º Congresso Brasileiro de Patologia Clínica; 2010; Rio de Janeiro, Brasil. J Bras Patol Clin, 2010;46:4.
h Ministério da Saúde, Sistema de Informação de Agravos de Notificação - SINAN. Casos confirmados de difteria: Brasil e Grandes Regiões, 1997-2006. Brasília (DF); 2007 [cited 2010 Mar 10]. Available from: http://portal.saude.gov.br/portal/arquivos/pdf/casos_difteria.pdf
i Marquezi D. Algo novo no reino dos humanos. Galileu. 2007;(197):41-53.
j Ministério da Saúde, Secretaria de Vigilância em Saúde, Coordenação de Vigilância das Doenças de Transmissão Respiratória e Imunopreveníveis. Informe sobre a difteria no Brasil: alerta sobre o cenário atual [nota técnica]. Brasília (DF); 2010 [cited 2010 Nov 17]. Nota técnica. Available from: http://portal.saude.gov.br/portal/arquivos/pdf/nt_difteria_29_09_2010.pdf
The authors declare
that there were no conflicts of interest.