Mycobacterium chelonae infection mimicking cutaneous vasculitis: case report

Small vessel vasculitis secondary to Mycobacterium chelonae

Mycobacterial infection can be seriously debilitating and challenging to diagnose. The infection can mimic vasculitis associated with positive anti-neutrophilic cytoplasmic autoantibodies (ANCA). This clinical scenario is exemplified with a well-studied case of a 63-year-old Caucasian man with uncontrolled diabetes and ulcerative colitis on immunosuppressive agents. The patient was hospitalized for 3 months with worsening painful hand ulcerations. Primary vasculitis was first suspected, but the patient was later diagnosed with vasculitis secondary to Mycobacterium chelonae infection. Report includes discussion on sequence of testing which led to the diagnosis. After proper diagnosis and change to proper antibiotics, the patient's vasculitis improved over time. It is our hope that this report further raises awareness of mycobacterial infection as a mimicker of vasculitis. We also provide a review of relevant literature on non-tuberculosis mycobacterial (NTM) infection including a review of 22 articles and 12 cases found in the literature. The salient features of the literature review include that 10 of the 12 cases were patients who had risk factors of immunosuppression due to medications, and all patients were infected by mycobacterium causing skin vasculitis. After given the proper directed antibiotic treatment, 11 of the 12 patients had a reported improved outcome.

Bilateral multiple choroidal granulomas and systemic vasculitis as presenting features of tuberculosis in an immunocompetent patient

Background

Multiple choroidal granulomas are a rare presentation of tuberculosis. Choroidal granulomas in immunocompetent patients can pose difficulty in diagnosis as in most cases systemic examination may not reveal any evidence of tuberculosis. We report a case of bilateral multiple choroidal granulomas with systemic vasculitis-like features and disseminated tuberculosis in an immunocompetent patient without pulmonary involvement.

Findings

A 26-year-old male Indian patient presented with bilateral blurred vision and systemic illness with vasculitis-like features. Examination revealed bilateral multiple choroidal granulomas and multisystem involvement without pulmonary involvement. Aqueous tap was positive for mycobacterium by polymerase chain reaction along with tissue biopsy leading to diagnosis. There was a good systemic and ocular response to anti-tubercular therapy with resolution of lesions.

Conclusions

Our case emphasizes that, although uncommon, tuberculosis can involve multiple organs without pulmonary involvement and may mimic systemic vasculitis, it is not mandatory to have pulmonary findings for a confirmation of tuberculosis. Timely diagnosis with appropriate treatment can improve systemic and ocular disease.

Facial ulcerations due to Acinetobacter baumannii: Vessel thrombosis with bacterial mycelia

A 14-year-old girl presented with a 2-week history of progressive facial ulcerations that did not respond to cephalexin and topical dexamethasone. Biopsy on the ulcer showed rod-shaped bacteria and actinomycetes-like mycelia in the vessel walls and within thrombi. Tissue culture yielded Acinetobacter baumannii, which was resistant to cephalexin. A favourite outcome was achieved with minocycline treatment. This is the first case report of A. baumannii-related vasculitis.

When typical is atypical: mycobacterial infection mimicking cutaneous vasculitis

Patients with systemic lupus erythematosus (SLE) who present with skin disease pose the clinician with diagnostic challenges. The skin disease can reflect an increase in systemic disease activity suggested by other features of active lupus and, as such, usually responds well to more aggressive immunosuppressive therapy. Other possibilities of skin disease include drug eruptions, skin disease unrelated to SLE and, more rarely, opportunistic skin infection. In patients who show a poor response to more aggressive immunosuppressive therapy, consideration must be given to the possibility of opportunistic infection. A high index of suspicion will allow prompt treatment. We describe two patients with SLE who developed cutaneous atypical mycobacterial infection during immunosuppressive therapy. The diagnosis of cutaneous vasculitis was considered in both cases, but subsequent skin biopsy revealed the correct diagnosis. This report illustrates the importance of skin biopsy in patients with suspected cutaneous lupus who are not responding to immunosuppressive therapy.

Recurrent catheter-related infection caused by a single clone of Mycobacterium chelonae with two colonial morphotypes

We describe herein a recurrent catheter-related (Port-A-Cath; Smiths Industries Medical Systems [SIMS] Deltec, Inc., St. Paul, Minn.) infection caused by multidrug-resistant Mycobacterium chelonae with two colonial morphotypes in a 53-year-old woman with gastric adenocarcinoma. Four isolates recovered from this patient within a 3-month period were found to belong to a single clone on the basis of the isolates' identical antibiotypes as determined by the E test and their identical random amplified polymorphic DNA patterns.