Mycobacterium kansasii osteomyelitis of the scaphoid

Nonmarinum, Nontuberculous Mycobacterial Infections of the Upper Extremity: A Multi-Institutional Descriptive Report

PURPOSE

We analyzed patient demographic factors involved in the development of nonmarinum, nontuberculous mycobacterial infections (NTMI) involving the upper extremity, and assessed diagnostic and prognostic values of commonly used preoperative laboratory and imaging studies, as well as factors related to recurrence of disease and patient outcomes.

METHODS

Patients from 2 academic, tertiary facilities with culture-proven, nonmarinum NTMI involving the upper extremity were reviewed. Patient-related factors and clinical outcomes were extracted. The analysis was based on pathogen identification (rapid- vs slow-growing subspecies) and immune status.

RESULTS

Our 76 patients had a mean age of 59 years, and 65% were male. Forty-eight percent reported an injury, and hands were frequently involved (58%). Forty-one percent were immunosuppressed (19% organ transplant recipients). The mean symptom duration prior to presentation was 203 days. The culture identification took a mean of 33 days, with 25 different species identified (subcategorized as rapid or slow growers). Seventy-seven percent had solitary lesions, with a cutaneous or subcutaneous location most common. Immunosuppressed patients were treated longer with antibiotics (243 vs 155 days in immunocompetent patients) and experienced higher rates of side effects, complications, and recurrence. All patients underwent debridement to control infection, including 4 individuals who required amputations. One-third experienced complications and/or recurrence, regardless of the organism type.

CONCLUSIONS

Upper-extremity nonmarinum NTMI is often misdiagnosed, causing management delays. Early consideration in differential diagnoses of chronic, painful swelling, nodular or inflammatory lesions, or septic arthritis is crucial. Tissue biopsy with specimens for histopathology and microbiological analysis (mycobacterial smear, cultures, and broad range polymerase chain reaction) and early involvement with an infectious disease specialist are recommended. Empiric antibiotic therapy is not standard. Debridement and prolonged, directed combination antimicrobial therapy is required; however, adverse reactions are commonly encountered.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Mycobacterial Infections in the Hand and Wrist

Mycobacterial hand infections are uncommon. These infections have an indolent course and are marked by variable and nonspecific presentations, often leading to diagnostic and treatment delays. The pathogens involved in mycobacterial hand infections include Mycobacterium tuberculosis complex, atypical mycobacteria, and M leprae. Initial treatment involves a combination of long-term antibiotics and surgical débridement to cure the infection. Reconstructive procedures aid in restoring hand function lost secondary to the disease.

Atypical Mycobacterial Septic Arthritis of the Wrist: A Report of Two Cases

CASES

Two patients with human immunodeficiency virus (HIV) developed wrist pain following the initiation of antiretroviral treatment, and were diagnosed with chronic atypical mycobacterial septic arthritis. Aggressive operative debridement led to clinical improvement, provided tissue samples for diagnosis, and allowed for a targeted long-term antibacterial regimen.

CONCLUSION

Clinicians should consider atypical mycobacterial organisms as a cause of joint infection in patients with HIV. Symptoms may become apparent after patients experience immune system recovery following antiretroviral treatment.

Mycobacterium kansasii osteomyelitis - a masquerading disease

Introduction

Non-tuberculous mycobacteria (NTM) are environmental bacteria capable of causing an opportunistic myriad of infections. Mycobacterium kansasii, one such NTM, is responsible for causing pulmonary disease in immunocompromised patients. Rare extrapulmonary manifestations such as lymphadenitis, osteoarticular manifestations, and skin and soft tissue infections are also observed.

Case presentation

Here, we report an unusual case of sternoclavicular joint and elbow joint infection with M. kansasii in a relatively immunocompetent patient. Histopathology did not show classic granulomas and mycobacterial infection was not initially considered as a possibility. However repeat biopsies were sent for mycobacterial cultures which then grew M. kansasii.

Conclusion

Diagnosis of M. kansasii in such cases can be difficult and culture-positive results may not necessarily imply positive diagnosis as they can be environmental contaminants. Furthermore, M. kansasii can cause infections without the characteristic granuloma formation, which can further complicate tissue diagnosis. This underlines the importance of ensuring that tissue samples obtained are cultured for mycobacteria.

Atypical Hand Infections

Atypical infections of the hand are caused by organisms such as Mycobacterium, fungi, and viruses, and often do not respond to conventional management. They exist within a wide spectrum of presentations, ranging from cutaneous lesions to deep infections such as tenosynovitis and osteomyelitis. Having a high clinical suspicion for atypical hand infections is vital because diagnosis often requires special tests and/or cultures. Obtaining a detailed medical, work, and travel history is extremely important. An indolent clinical course, late diagnosis, and delayed treatment are common. In addition to medical therapies, surgical debridement is often required to effectively treat these infections.

Nontuberculous mycobacterial osteomyelitis

Osteomyelitis caused by nontuberculous mycobacteria (NTM) can have severe consequences and a poor prognosis. Physicians therefore need to be alert to this condition, especially in immunocompromised patients. Although the pathogenesis of NTM osteomyelitis is still unclear, studies in immunodeficient individuals have revealed close relationships between NTM osteomyelitis and defects associated with the interleukin-12-interferon-γ-tumor necrosis factor-α axis, as well as human immunodeficiency virus infection, various immunosuppressive conditions, and diabetes mellitus. Culture and species identification from tissue biopsies or surgical debridement tissue play crucial roles in diagnosing NTM osteomyelitis. Suitable imaging examinations are also important. Adequate surgical debridement and the choice of appropriate, combined antibiotics for long-term anti-mycobacterial chemotherapy, based on in vitro drug susceptibility tests, are the main therapies for these bone infections. Bacillus Calmette-Guerin vaccination might have limited prophylactic value. The use of multiple drugs and long duration of treatment mean that the therapeutic process needs to be monitored closely to detect potential side effects. Adequate duration of anti-mycobacterial chemotherapy together with regular monitoring with blood and imaging tests are key factors determining the recovery outcome in patients with NTM osteomyelitis.

Ostéite du trapèze à Ralstonia pickettii : à propos d'un cas et revue de la littérature

An immunocompromised 29-year-old man presented with a Ralstonia pickettii osteomyelitis affecting the trapezium bone. The patient underwent two surgical debridement stages, including trapezectomy and long-term drainage. The type of the contaminant organism and the trapezium localization make this observation atypical.

Septic monoarthritis of the first carpo-metacarpal joint caused by Mycobacterium Kansasii

A case of septic carpal monoarthritis due to Mycobacterium kansasii developing 16 months after accidental inoculation in a healthy laboratory technician is reported. No predisposing factor such as immunosuppression, preexisting degenerative, inflammatory arthritis or cortisone injection was present. Treatment with antituberculous oral medication alone resulted in resolution of the disease. Synovectomy was unnecessary. Ten years after the initial causative event, the patient remains free of symptoms.

Synthesis and antimycobacterial activity of new S-alkylisothiosemicarbazone derivatives

A new series of S-alkylisothiosemicarbazones of 3- and 4-pyridincarboxaldehyde and 4-fluoro- and 4-trifluoromethylbenzaldehyde was synthesized and evaluated for biological activity against various Mycobacterium strains. Inhibitory activity against Mycobacterium tuberculosis H37Rv ATCC 27294 and INH-R ATCC 35822 was compared with activity against clinical isolated Mycobacteria as well as against MOTT. Some of newly prepared compounds showed best inhibitory values against clinical isolated Mycobacteria, besides to low citotoxicity values.

Vertebral osteomyelitis due to infection with nontuberculous Mycobacterium species after blunt trauma to the back: 3 examples of the principle of locus minoris resistentiae

Osteomyelitis due to infection with nontuberculous mycobacterial organisms is unusual, especially in the absence of nonpenetrating trauma. We describe 3 patients with vertebral osteomyelitis due to infection with nontuberculous mycobacterial organisms that was precipitated by blunt trauma; these 3 unusual cases illustrate the principle of locus minoris resistentiae.

Scapholunate dissociation caused by gouty arthritis of the wrist. Case report

Gouty arthritis of the wrist is rare, and may be associated with scapholunate dissociation. To our knowledge, only two cases have been reported so far. In this report, we describe a 40-year-old patient with scapholunate dissociation caused by acute gouty arthritis of the wrist. His clinical findings and radiographs mimicked infectious arthritis or osteomyelitis of the carpal bones.

Non-tuberculous mycobacterial tenosynovitis: a review

The clinical characteristics, outcome and treatment of non-tuberculous mycobacterial tenosynovitis are reviewed. From lesions localized in the hand, 10 different species of non-tuberculous mycobacteria have been reported. The most common are Mycobacterium marinum and Mycobacterium kansasii. Other less frequent organisms are Mycobacterium avium complex, Mycobacterium szulgai, Mycobacterium terrae, Mycobacterium fortuitum, Mycobacterium chelonae, Mycobacterium abscessus, Mycobacterium malmoense and Mycobacterium xenopi. The infections appear to be the result of previous trauma, surgical procedure, corticosteroid injection or non-apparent inoculation (water contamination). Immunosuppression is sometimes associated with the infections and can be considered as a risk factor. Surgical debridement and appropriate mycobacterial cultures are critical to enable diagnosis and appropriate management. Specimens should be inoculated on a range of media and incubated at a range of temperatures in order to isolate mycobacteria with different growth characteristics (with prolonged incubation). The optimal treatment of these infections is discussed.

Mycobacterium kansasii osteomyelitis presenting as a solitary lytic lesion of the ulna: fine-needle aspiration findings and morphologic comparison with other mycobacteria

A 35-yr-old woman, with acquired immunodeficiency syndrome, presented with right arm pain, erythema, and swelling. A lytic lesion of the ulna was found by radiograph. Ultrasonic and fluoroscopic guided fine-needle aspiration (FNA) yielded a neutrophilic and histiocytic exudate admixed with abundant long, bacillary forms that appeared as negative images on Papanicolaou stain and as very coarsely beaded acid-fast bacilli, resembling candy canes, on Kinyoun stain. These morphologic features permitted a preliminary diagnosis of mycobacteriosis, possibly of M. kansasii (MK) etiology. Appropriate therapy was initiated and resulted in not only marked symptomatic improvement of osteomyelitis and cellulitis, but resolution of chronic pulmonary infiltrates, presumed to be caused by fibrosis. Culture confirmed MK infection 3 wk after FNA. MK is one of the few mycobacteria that has a sufficiently characteristic morphology to permit presumptive diagnosis by smear. Culture, however, still remains the definitive method of speciation.

Osteomyelitis of the scaphoid with sequestration of the primary ossification centre

An 8-year-old boy presented with Staphylococcus aureus osteomyelitis affecting the left (non-dominant) scaphoid. Surgical drainage resulted in the expulsion of the primary ossification centre as a sequestrum. Seven years later the wrist function was minimally impaired and X-rays showed complete ossification of the cartilage remnant with a relatively normal scaphoid.

Release of TNF alpha and IL6 from human monocytes infected with Mycobacterium kansasii: a comparison to Mycobacterium avium

Tumor necrosis factor alpha (TNF alpha) and interleukin 6 (IL6) are cytokines with a varied spectrum of inflammatory and immunological activities, for example modulation of acute phase proteins, fever and stimulation of B-lymphocytes. Mycobacterium avium has been shown to stimulate the release of TNF alpha and IL6 from cultured human monocytes and macrophages into the cell supernatant. Cultured human monocytes were infected with Mycobacterium kansasii and M. avium. The concentrations of TNF alpha and IL6 were measured in the supernatant. Monocytes infected with M. kansasii produced significantly lower amounts of TNF alpha (34.8 +/- 20.3 pg/ml) and IL6 (12.0 +/- 8.9 pg/ml) compared to monocytes infected with M. avium (198.3 +/- 171.7 pg/ml and 63.2 +/- 37.6 pg/ml respectively). The extent of cytokine production might be relevant for the clinical manifestation of mycobacterial disease.

Atypical mycobacterium osteomyelitis of the fibula

Atypical mycobacterium osteomyelitis is rare. An 81 year old woman has been found to have an osteomyelitis of the upper end of the fibula due to mycobacterium avium complex. The occurrence may be related to advanced age and chronic respiratory disease. Treatment by surgery and drugs has been successful over two years of follow-up.

[Mycobacterium terrae tenosynovitis of the hand]

This article presents the seventh case of human infection due to Mycobacterium terrae. This report of typical tenosynovitis clearly illustrates well all of the standard problems raised by this kind of atypical acid-fast mycobacterial infection: delayed and difficult diagnosis, danger of steroid infiltrations, frequency of recurrence. Nevertheless, M. terrae has certain specific features: it is probably less pathogenic than other atypical acid-fast such as marinum. Some authors propose surgical treatment alone, but this case suggests the need for surgery combined with antituberculous therapy.

Osteomyelitis of the wrist in a patient with Hodgkin's disease

Osteomyelitis of the carpal bones is extremely uncommon. We here report a case of Staphylococcus aureus osteomyelitis involving the wrist in a patient with Hodgkin's disease, and review the existing literature on this subject. The case illustrates the importance of considering pertinent clinical evidence in a patient with disseminated malignancy.