Disseminated cutaneous Mycobacterium chelonae infection

Mycobacterium chelonae Cutaneous Infection: A Challenge for an Internist

Cutaneous infections caused by the Mycobacterium chelonae complex show a heterogeneous clinical presentation, which varies according to the patient’s immune status. Most standard antimycobacterials have no effect against these species. Clarithromycin alone was shown to provide adequate treatment, although resistance has been reported. Consequently, the literature supports multi-drug therapy to combat resistant strains. Here, we describe the case of a 59-year-old man under systemic immunosuppressive therapy who developed cutaneous lesions whose evolution was highly suggestive of atypical infection.

Disseminated Mycobacterium chelonae infection with Hughes-Stovin syndrome

Mycobacterium chelonae usually causes localized cutaneous infections and abscesses but has the potential to cause disseminated infections, especially in immunocompromised hosts. We report a 27-year-old man with Hughes-Stovin syndrome and catastrophic antiphospholipid syndrome who was on chronic immunosuppressant therapy and developed disseminated M. chelonae infection. To the best of our knowledge, this is the first case report of M. chelonae infection in a patient with Hughes-Stovin syndrome.

Mycobacterium abscessus Complex - a Particular Challenge in the Setting of Lung Transplantation

Mycobacterium abscessus complex is an emerging pathogen in lung transplant candidates and recipients. M. abscessus complex is widespread in the environment and can cause pulmonary, skin and soft tissue, and disseminated infection, particularly in lung transplant recipients. It is innately resistant to many antibiotics making it difficult to treat. Herein we describe the epidemiology, clinical manifestations, diagnosis and treatment of M. abscessus with an emphasis on lung transplant candidates and recipients. We also outline the areas where data are lacking and the areas where further research is urgently needed.

Mycobacterium chelonae Is an Ubiquitous Atypical Mycobacterium

The type of cutaneous infection varies mainly according to the patient's immune status, and the disseminated form is mostly found in the context of immunosuppression. We report the case of a 62-year-old male who was under long-term systemic corticosteroid therapy and presented with a 7-month history of multiple painless cutaneous lesions at various stages of development: papules, nodules, pustules and hemorrhagic crusts, as well as small erosions and ulcers distributed over the limbs and scalp. Cutaneous biopsy showed a suppurative granulomatous infiltrate with abscess formation. Fite stain revealed numerous extracellular bacilli, suggesting mycobacterial infection, particularly by atypical mycobacteria. Culture of a skin sample revealed Mycobacterium chelonae. The patient started multidrug therapy and showed clinical improvement despite of resistance to one of the antibiotics. This striking presentation underlines the role of immunosuppression with corticotherapy as a major risk factor for these infections. Multidrug therapy is advised and antibiogram is essential in directing treatment.

Disseminated Mycobacterium chelonae infection: Complicating a case of hidradenitis suppurativa

Mycobacteium chelonae is a rapidly growing atypical mycobacteria known to be pathogenic in humans. We report a case of Hidradenitis Suppurativa (HS) with diabetes complicated by infection of the lesions with Staphylococcus aureus and M. chelonae leading to non-healing and discharging lesions. HS is a rare, insidious and debilitating disease characterized by swollen, painful, inflamed lesions in the axillae, groin, and other parts of the body that contain apocrine glands. Discharge from HS lesions are often found to be sterile, however, polymicrobial bacterial colonization commonly occurs within sinus tracts which can lead to offensive smelling discharge, infection, cellulitis, and superinfection. The incidence of HS is very low and the association with M. chelonae makes it a rare and interesting case.

Identification and Treatment of Nontuberculous Mycobacterium Sinusitis

Background

The purpose of this study was to identify the incidence of atypical Mycobacterium identified by routine sinus cultures and review the recent literature on management.

Methods

A retrospective case series was performed in a tertiary academic hospital. A retrospective case series of all patients treated with atypical Mycobacterium rhinosinusitis from 2005 to 2010 was performed. Cases were identified from a prospective database of 676 endoscopically guided sinus cultures.

Results

Eight patients with atypical Mycobacterium sinusitis were identified. There were five women and three men. Median age was 63 years (range, 55–71 years). All patients had prior endoscopic sinus surgery a median of 14 months (range, 0.8–162 months) before a positive culture result. Species identified included Mycobacterium chelonae, Mycobacterium fortuitum, Mycobacterium abscessus, and Mycobacterium avium complex. Chief presenting symptoms were postnasal discharge (88%), followed by decreased smell and taste (63%), and facial pain/pressure (38%). Patients were treated based on sensitivity results with long-term oral antibiotics for at least 2 months based on improvements on endoscopy. Median follow-up for patients in this study after treatment was 1.3 years (range, 0.6–4.6 years).

Conclusion

In this study, atypical mycobacteria were identified in < 1% of sinus cultures. Prolonged, culture-directed antibiotic therapy remains the mainstay of treatment when there is clinical evidence of infection. Previous endoscopic sinus surgery may represent a risk factor for colonization and subsequent infection. Further research is necessary to determine the optimal treatment duration and management to prevent disease relapse

Disseminated cutaneous Mycobacterium chelonae infection in an immunocompetent host

Mycobacterium chelonae is a rare, rapidly growing, atypical acid-fast bacillus. Disseminated cutaneous infection has been reported in immunocompromised patients. We report an immunocompetent 86-year-old white woman, who presented with an 8-month history of extensive ulcerated abscess-like nodules. Mycobacterial culture confirmed M. chelonae infection and the patient was treated with a combination of clarithromycin and tobramycin. To our knowledge, this is the first reported case of spontaneous, disseminated cutaneous disease occurring in an immunocompetent patient.

[Cutaneous infection due to Mycobacterium chelonae in a hemodialysed patient]

We report a case of a hemodialysed patient who developed a cutaneous Mycobacterium chelonae infection. This infection was only localised on the left upper limb, downstream from the arteriovenous fistula. M. chelonae is an unusual human pathogen, which is present in soil, dust, and stagnant water. Various factors, especially immunosuppression can favour this sort of infection in humans. Because of the ubiquity of the mycobacterium, the source of the inoculation sometimes remains unknown. However, a great number of cases are related to nosocomial infections. The preferential localizations are cutaneous, ocular, and pulmonary. Some cases of cutaneous infections due to M. chelonae, or caused by other atypical mycobacterium, are described in renal transplantation, peritoneal dialysis and hemodialysis. In the case we describe here, the source of contamination was not identified. The outcome was favourable with clarithromycin. This treatment is still continued because of a reappearance of the lesions when treatment was discontinued.

Mycobacterial lipomannan induces matrix metalloproteinase-9 expression in human macrophagic cells through a Toll-like receptor 1 (TLR1)/TLR2- and CD14-dependent mechanism

Lipomannans (LM) from various mycobacterial species were found to induce expression and secretion of the matrix metalloproteinase 9 (MMP-9) both in human macrophage-like differentiated THP-1 cells and in primary human macrophages. Inhibition studies using antireceptor-neutralizing antibodies are indicative of a Toll-like receptor 1 (TLR1)/TLR2- and CD14-dependent signaling mechanism. Moreover, LM was shown to down-regulate transcription of the metalloproteinase inhibitor TIMP-1, a major endogenous MMP-9 regulator.

Mycobacterium chelonae Keratitis

PURPOSE

To describe the microbiologic diagnosis of putative Mycobacterium chelonae keratitis in a soft contact lens wearer by initial evaluation of Gram- and Kinyoun (acid fast)-stained smears of fluid from patient's contact lens care system.

METHODS

Corneal ulcer of suspected Acanthamoeba etiology developed in a 28-year-old soft contact lens wearer. After corneal scrapings were negative, microbiologic consultation led to evaluation of stained smears and culture of fluid from patient's contact lens care system.

RESULTS

Gram stain of smears showed a polymicrobic flora distinguished by numerous gram-positive, beaded, tightly banded, "diphtheroid-like" bacilli strongly suggestive of a rapidly growing mycobacterial species. Kinyoun-stained smears revealed innumerable acid-fast bacilli singly and in tightly woven bundles (cords), which culturally proved to be M. chelonae. Treatment with ciprofloxacin and amikacin resolved the ulcer.

CONCLUSION

Diagnosis of M. chelonae keratitis in contact lens wearers is often delayed or even overlooked. Additionally, in the absence of overt corneal injury, eg, trauma or surgery, a source for the infecting mycobacterial species in the setting of contact lens wear has not been identified. If searched for, however, as in the present case, the patient's contact lens care system may serve as the reservoir for the microorganism. Staining for acid-fast bacilli is further recommended when smears of contact lens care solution of a patient with a corneal ulcer shows the presence of gram-positive "diphtheroid-like" organisms.

Clinical patterns of cutaneous nontuberculous mycobacterial infections

BACKGROUND

Cutaneous nontuberculous mycobacterial infections result from external inoculation, spread of a deeper infection, or haematogenous spread of a disseminated infection. There are two species-specific infections (fish-tank or swimming-pool granuloma, due to Mycobacterium marinum, and Buruli ulcer, caused by M. ulcerans). Most infections, however, produce a nonspecific clinical picture.

OBJECTIVES

To define clinical patterns of cutaneous disease in nontuberculous mycobacterial infections.

METHODS

Fifty-one patients with cutaneous nontuberculous mycobacterial infections were reviewed. Clinical and histopathological features of normal hosts and immunosuppressed patients were compared. Two subgroups of immunosuppressed patients were distinguished: patients with cutaneous infection and patients with a disseminated infection and cutaneous involvement.

RESULTS

In immunosuppressed patients the number of lesions was significantly higher. Abscesses and ulceration were also more frequently observed. Different species were found in normal hosts and immunosuppressed patients. Several clinical patterns of cutaneous infection were defined: lymphocutaneous or sporotrichoid lesions; nonlymphocutaneous lesions at the site of trauma; folliculitis and furunculosis involving the lower extremities; disseminated lesions on the extremities in immunosuppressed patients. Two patterns were observed in patients with a disseminated infection: localized cutaneous lesions and disseminated cutaneous and mucosal lesions.

CONCLUSIONS

Cutaneous manifestations of nontuberculous mycobacterial infections may be classified according to criteria such as cutaneous lesions and immune status.