Cutaneous infections with rapidly growing mycobacteria

Mesotherapy and cutaneous Mycobacterium fortuitum infection

BACKGROUND

Cutaneous infections caused by Mycobacterium fortuitum usually are a complication of trauma or postsurgical wounds.

CASE REPORT

A 41-year-old woman presented with numerous dusky red nodules, abscesses and sinuses on the right buttock and on the lateral surfaces of both thighs. The lesions developed at the injection sites of mesotherapy treatment. M. fortuitum was cultured from a biopsy specimen and purulent fluid drained from lesions. The lesions had cleared completely with ciprofloxacin 500 mg b.d. for 3 weeks, and then 250 mg b.d. for another 3 weeks.

CONCLUSIONS

This case demonstrates the importance of suspecting mycobacterial etiology in patients with nodules and abscesses in the areas of mesotherapy treatment.

Cutaneous Infection With Rapidly-Growing Mycobacterial Infection Following Heart Transplant: A Case Report and Review of the Literature

Nontuberculous mycobacteria are ubiquitous and infrequently cause disease in humans, most commonly in immunocompromised hosts. One type of nontuberculous mycobacteria is Mycobacterium abscessus. This rapidly growing mycobacterium is a soil or water saprophyte. It was previously classified as a subspecies of Mycobacterium chelonae; however, current taxonomy now designates it as a separate species. Rapidly growing mycobacteria are resistant to the usual antituberculous drugs. This emphasizes the need for tissue diagnosis and obtaining specimens for culture and drug susceptibility testing. M abscessus has been reported to cause infection in renal transplant patients, but is less well described in cardiac transplant recipients. We report the case of a 65-year-old man who presented 5 years after transplantation for heart failure, with a 2-day history of progressive right lower extremity swelling and redness. He recalled no antecedent trauma and denied any unusual epidemiologic exposure. Medical history included diabetes with peripheral neuropathy and renal insufficiency, hypertension, and right-sided heart failure felt to be due to obstructive sleep apnea. A punch biopsy of the area grew M abscessus sensitive only to clarithromycin (MIC not reported), amikacin (30 microg/mL), and kanamycin (30 microg/mL). On subsequent clinic visits, the patient had decreased leg swelling and resolution of the papular lesions. Ten weeks into antimycobacterial therapy, the patient had an increase in creatinine to 4.9 mg/dL from a baseline of 2.0 with fluid overload necessitating discontinuation of aminoglycoside therapy. He completed 6 months of treatment with oral clarithromycin. We describe these findings and review the literature in this report.

Cutaneous Infection with Mycobacterium abscessus in a child

Nontuberculous mycobacteria can cause cutaneous infections in both children and adults. Localized nontuberculous mycobacterial infections of the skin have been reported in children following injections or surgical procedures. We report a child who developed a cutaneous nontuberculous mycobacterial infection after exposure of a skin wound to pond water. Cutaneous infection with the rapidly growing mycobacteria Mycobacterium abscessus was demonstrated by clinical and histologic evaluation on the lower leg of an otherwise healthy 12-year-old Caucasian boy. We describe this as an instance of an unusual acquisition of cutaneous M. abscessus infection in a child.

Mycobacteria other than Mycobacterium tuberculosis are not present in erythema induratum/nodular vasculitis: a case series and literature review of the clinical and histologic findings

Erythema induratum (EI)/nodular vasculitis (NV) is characterized by recurrent crops of tender oedematous nodules on the lower legs. A lobular panniculitis with granulomatous inflammation, vasculitis, focal necrosis and septal fibrosis is present. Mycobacterium tuberculosis DNA has been detected in some lesions by means of polymerase chain reaction (PCR). Ten cases of EI/NV were found. H&E slides were reviewed. PCR assays for M. tuberculosis and mycobacteria other than M. tuberculosis (MOTT) were performed. PCR did not reveal M. tuberculosis (0%) or MOTT (0%) DNA, with positive controls, indicating the reliability of the assays. Among the MOTT, cutaneous infections are most commonly caused by M. marinum. Subcutaneous tuberculoid granulomas may be seen with M. kansasii, M. marinum, M. scrofulaceum and M. avium complex. M. gordonae, M. szulgai and M. malmoense rarely cause cutaneous infections. M. simiae, M. gastri and M. asiaticum are probably not cutaneous pathogens. M. tuberculosis and MOTT DNA was not found in EI/NV. EI/NV has diverse aetiologies with varying pathogeneses leading to similar histologic changes. The cases analysed may not have had an infectious aetiology. However, in EI/NV, performance of PCR for MOTT as well as M. tuberculosis complex may still be beneficial, particularly in cases from immunocompromised hosts.

A case of cutaneous Mycobacterium chelonae abscessus infection in a renal transplant patient

BACKGROUND

Mycobacterium chelonae is an atypical "fast-growing Mycobacteria" that is a rare cause of human infection. There have been several reports of cutaneous infection among immunosuppressed patients, as well as in immunocompetent individuals following trauma. Most cases to date seem to have occurred among renal transplant recipients, raising the possibility that there is something inherent to the renal transplant patient that increases their susceptibility more than other immunocompromised patients.

OBJECTIVE

The differential diagnosis of subcutaneous nodules distributed in a sporotrichoid pattern is extensive, particularly in an immunocompromised host. Although several cases of cutaneous M. chelonae abscessus infection have been reported among both immunosuppressed and immunocompetent patients, the clinical presentation has varied, and few cases have reported the appearance of lesions in a sporotrichoid pattern. We present a case of a renal transplant patient with a reported history of trauma to the lower extremities, who presents with subcutaneous nodules distributed in a sporotrichoid pattern. The patient is found to have M. chelonae abscessus infection, fails several treatment regimens, and presents with a recurrence. The literature of M. chelonae infection is reviewed, and the various treatment options are discussed.

METHODS

An initial skin biopsy was stained with Hematoxylin and Eosin and revealed deep dermal abscesses with acid-fast bacilli in clusters. The culture became positive for Mycobacterium chelonae abscesses in four days and was found to be sensitive to multiple antibiotics. The patient underwent surgical excision of 14 nodules, which revealed findings consistent with the skin biopsy, and was subsequently treated with the appropriate antibiotics.

RESULTS

Despite treatment with a full course of an organism-sensitive antibiotic regimen, the patient returned with persistent and recurrent nodules six weeks later. The patient was then treated as an inpatient with a seven-week course of intravenous antibiotics and was discharged home on a combined intravenous and oral regimen.

CONCLUSION

Although M. chelonae abscessus is an extremely rare cause of infection among humans, there seems to be a predominance of cases reported among renal transplant patients. The explanation for this is not entirely clear; however, the organism must be considered as a cause of infection in any renal transplant recipient who presents with subcutaneous nodules. Eradication of the organism presents a tremendous challenge to the clinician, and, as presented here, even with appropriate antibiotics, there is a high rate of recurrence.

Nontuberculous mycobacterial infections of the skin

Nontuberculous mycobacteria are playing an increasingly important role in human disease owing to higher prevalence of antibiotic resistance and immunodeficiency. These organisms cause a variety of cutaneous findings which are often misdiagnosed by the clinician. Compounding this problem is the fact that most mycobacteria require special culture conditions, which if not specifically requested, are frequently not used. Recognition of susceptible patients is imperative and is not limited to the immunocompromised. Successful treatment of mycobacterial infections requires knowledge of currently available and recommended antibiotics followed by tailoring of the antimicrobial regimen after sensitivity testing is performed.