Cutaneous infection by non-diphtheria-toxin producing and penicillin-resistant strain in a patient with diabetes mellitus.

Diphtheria is a potentially fatal infection, mostly caused by diphtheria toxin (DT)-producing strains. During the last decades, the isolation of DT-producing strains has been decreasing worldwide. However, non-DT-producing strains emerged as causative agents of cutaneous and invasive infections. Although endemic in countries with warm climates, cutaneous diphtheria is rarely reported in Brazil. Presently, an unusual case of skin lesion in a Brazilian elderly diabetic patient infected by a penicillin-resistant non-DT-producing strain was reported. Laboratory diagnosis included mass spectrometry and multiplex PCR analyses. Since cutaneous diphtheria lesions are possible sources of secondary diphtheria cases and systemic diseases and considering that penicillin is the first line of antimicrobial agent for the treatment of these infections, the detection of penicillin-resistant strains of diphtheria bacilli should be a matter of concern. Thus, cases similar to the presently reported should be appropriately investigated and treated, particularly in patients with risk factor (s) for the development of invasive infections, such as diabetes. Moreover, health professionals must be aware of the presence of in cutaneous lesions of lower limbs, a common type of morbidity in diabetic patients, especially in tropical and subtropical countries.