1. Letter to the Author: response to "Multidisciplinary approach to the management of a case of classical respiratory diphtheria requiring percutaneous endoscopic gastrostomy feeding"

    Dear Editor,

    We read with interest the work by Haywood et al.[1] dealing with the treatment of a 67 years old Caucasian woman with a 4-day history of sore throat, dysphagia, fever and nasal blockage. During the examination it was revealed a swollen neck and pharyngeal pseudomembranes, positive on culture for Corynebacterium ulcerans after a throat swab, with toxin expression confirmed on PCR and Elek testing. The patient was diagnosed of classical respiratory diphtheria, and the diagnosis was later confirmed on the patient's domesticated dog, which was thought to be the source of infection. The dog had recently been attacked by a wild badger and was being treated for an ear infection. The patient made a good recovery with intravenous antimicrobial and supportive therapy; however, she subsequently developed a diphtheritic polyneuropathy in the form of a severe bulbar palsy with frank aspiration necessitating percutaneous endoscopic gastrostomy feeding. A mild sensorimotor peripheral neuropathy was also diagnosed. The patient eventually made an almost complete recovery.

    Zoonotic infections are defined, in general, as infections transmitted from animal to man (and, less frequently, vice versa), either directly (through direct contact or contact with animal products) or indirectly (through an intermediate vector, such as an arthropod)[2]. Zoonotic disease may affect ENT districts. Unfortunately, literature is often limited to single case reports from different countries and does not allow adequate appreciation of the problem.

    Otorhinolaryngologists often lack in-depth knowledge of zoonotic diseases, which complicates etiological identification and treatment and control strategies.

    In our study we already considered, examining a total of 164 articles, that larynx was the most commonly involved ENT organ. Otherwise, bacteria were the most representative microorganisms involved[2]. As read on another study examined by us, a Corynebacterium ulcerans infection can be responsible for a more aggressive involvement of the ENT district, being capable of involving the total upper airway[3], with the subsequent need to ensure a proper nutrition via a percutaneous endoscopic gastrostomy feeding, as Haywood at al. did facing their case[1].

    Another interesting thing to point out is that the ENT manifestations in most of the zoonoses are often produced in immunosuppressed patients, being responsible of disseminated forms which can lead to death rapidly if misdiagnosed[1]. Albeit this, We want to point out, thanks to the work of Vlachogianni et al., a case in which a zoonotic infection caused by Mycobacterium avium was diagnosed in an immunocompetent 78 years-old woman. She presented with a 6-month reddish, oedematous and painless lesion with fine scaling in the right ear. Histology showed numerous granulomas, composed of epithelioid histio-cytes without central necrosis. Cultures grew Mycobacterium avium. An unusual accidental ear injury was the portal of microbial entry. The patient's lesion fully regressed after a 9-month course of antibiotics[4].

    This two cases brought to Our attention the fact that the kind of diseases are still of difficult diagnosis for most of the ENT specialists, and need to be more pointed out by the Scientific Community, paying particular attention during the anamnesis.

    1. Haywood MJ, Vijendren A, Acharya V, Mulla R, Panesar MJ. Multidisciplinary approach to the management of a case of classical respiratory diphtheria requiring percutaneous endoscopic gastrostomy feeding. BMJ Case Rep. 2017 Mar 6;2017. pii: bcr2016218408. doi: 10.1136/bcr-2016-218408.

    2. Galletti B, Mannella VK, Santoro R, Rodriguez-Morales AJ, Freni F, Galletti C, Galletti F, Cascio A. Ear, nose and throat (ENT) involvement in zoonotic diseases: a systematic review. J Infect Dev Ctries. 2014 Jan 15;8(1):17-23. doi: 10.3855/jidc.4206.

    3. Aaron L, Heurtebise F, Bachelier MN, Guimard Y. Pseudomembranous diphtheria caused by Corynebacterium ulcerans. Rev Med Interne. 2006 Apr;27(4):333-5. Epub 2006 Jan 6.

    4. Vlachogianni P, Volosyraki M, Stefanidou M, Krueger-Krasagakis S, Evangelou G, Haniotis V, Kofteridis D, Maraki S, Krasagakis K. Mycobacterium avium Auricular Infection in an Apparent Immunocompetent Patient: A Case Report. Folia Med (Plovdiv). 2016 Apr-Jun;58(2):131-5. doi: 10.1515/folmed-2016-0012.

    Conflict of Interest:

    None declared

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