Household transmission of non-toxigenic diphtheria toxin gene-bearing following a cluster of cutaneous cases in a specialist outpatient setting.

Combination of PCR and Elek testing to identify toxigenic corynebacteria has revealed organisms described as non-toxigenic toxin-gene bearing (NTTB) or (i.e. PCR positive; Elek negative). These organisms carry part or all of , but are unable to express diphtheria toxin (DT) and present a challenge to clinical and public health case management. There are few data on the theoretical risk of NTTB reversion to toxigenicity. This unique cluster and subsequent epidemiologically linked isolates allowed the opportunity to determine any change in DT expression status. To characterize a cluster of infections due to NTTB in a skin clinic and subsequent cases in two household contacts. Epidemiological and microbiological investigations were carried out according to existing national guidance at the time. Susceptibility testing used gradient strips. The operon analysis and multi-locus sequence typing (MLST) was derived from whole-genome sequencing. Alignment of the operon and phylogenetic analyses were performed using clustalW, mega, the public core-genome MLST (cgMLST) scheme and an in-house bioinformatic single nucleotide polymorphism (SNP) typing pipeline. Isolates of NTTB were recovered from four cases (cases 1 to 4) with epidermolysis bullosa attending the clinic. Two further isolates were subsequently recovered from case 4, >18 months later, and from two household contacts (cases 5 and 6) after a further 18 months and 3.5 years, respectively. All eight strains were NTTB biovar mitis, belonged to the same sequence type (ST-336) with the same deletion in . Phylogenetic analysis showed relatively high diversity between the eight strains with 7-199 SNP and 3-109 cgMLST loci differences between them. The number of SNPs between the three isolates from case 4 and two household contacts (cases 5 and 6) was 44-70 with 28-38 cgMLST loci differences. We report a cluster of NTTB cases in a skin clinic and evidence of onward household transmission. We conclude the deletion in the was responsible for the non-expression of DT. There was no evidence of reversion to DT expression over the 6.5 year period studied. These data informed revision to guidance in the management of NTTB cases and their contacts in the UK.