Rapidly growing mycobacterial infections after pedicures

BACKGROUND: Rapidly growing mycobacteria (RGM) can cause a variety of cutaneous and systemic diseases. The causative organisms are typically Mycobacterium fortuitum or Mycobacterium chelonae (also known as Mycobacterium abscessus). Primary cutaneous lesions may develop after a variable latent period, from weeks to several months, and usually result from direct inoculation after trauma, from injections, or during surgery via contaminated medical instruments. Recently, investigators from the Centers for Disease Control and Prevention, Atlanta, Ga, and the California Department of Health Services, Berkeley, documented a large, unprecedented outbreak of community-acquired RGM infection, during which more than 100 patrons of a northern California nail salon contracted furunculosis in their legs as a result of exposure to whirlpool footbaths that were contaminated with M fortuitum. OBSERVATIONS: We report the clinical and epidemiological findings in 3 cases of lower extremity RGM infections that occurred after similar whirlpool footbath exposure at several different nail salons in southern California. These infections typically presented as recurrent furunculosis, causing considerable morbidity as a result of scarring, delayed diagnosis, and the need for long-term polymicrobial therapy. CONCLUSIONS: Rapidly growing mycobacterial infections related to pedicures may continue to occur in a sporadic fashion. Clinicians should consider the possibility of RGM infection and inquire about recent pedicures in a patient with recurrent lower extremity furunculosis and abscesses that are unresponsive to conventional antibiotic therapy.     

Levofloxacin alone efficiently treated a cutaneous mycobacterium fortuitum infection

Cutaneous infections with Mycobacterium (M.) fortuitum are rare, and some cases resist treatment. We report two cases of cutaneous M. fortuitum infection successfully treated with levofloxacin alone.     

Skin and soft tissue infections due to rapidly growing mycobacteria: comparison of clinical features, treatment, and susceptibility

OBJECTIVE: To compare the demographics, clinical features, susceptibility patterns, and treatment for skin and soft tissue infections due to Mycobacterium fortuitum and Mycobacterium chelonae or Mycobacterium abscessus. DESIGN: Retrospective medical record review. SETTING: Mayo Clinic, Rochester, Minn. PATIENTS: All patients seen at our institution with a positive culture for M chelonae, M abscessus, or M fortuitum from skin or soft tissue sources between January 1, 1987, and October 31, 2004. MAIN OUTCOME MEASURES: Patient demographics, clinical characteristics, therapeutic data, microbiological data, and outcomes. RESULTS: The medical records of 63 patients with skin or soft tissue infections due to rapidly growing mycobacteria were reviewed. Patients with M chelonae or M abscessus were older (61.5 vs 45.9 years, P<.001) and more likely to be taking immunosuppressive medications (60% vs 17%, P = .002) than patients with M fortuitum. Mycobacterium fortuitum tended to manifest as a single lesion (89% vs 38%, P<.001), while most M chelonae or M abscessus manifested as multiple lesions (62% vs 11%, P<.001). More patients with M fortuitum had a prior invasive surgical procedure at the infected site (56% vs 27%, P = .04). Patients with multiple lesions were more likely to be taking immunosuppressive medications than those with single lesions (67% vs 30%, P = .006). Seven patients failed treatment, several of whom were immunocompromised and had multiple comorbidities. CONCLUSIONS: Skin and soft tissue infections due to rapidly growing mycobacteria are associated with systemic comorbidities, including the use of immunosuppressive medications. There are significant differences in the demographic and clinical features of patients who acquire specific organisms, including association with immunosuppression and surgical procedures.     

Non-tuberculous mycobacterial infections of the skin: a retrospective study of 29 cases

The incidence of infections caused by non-tuberculous mycobacteria has increased in recent years, due to a rise in dermatological procedures and a greater prevalence of immunosuppression in the general population. This study investigated the clinical and microbiological findings of non-tuberculous mycobacterial skin infections. The study population included 29 patients from whom non-tuberculous mycobacteria were cultured after isolation from skin biopsy materials, cutaneous abscesses or exudates. Clinical, microbiological and epidemiological data were collected from each patient. Eight patients were immunocompromised while 21 were not. Precipitating factors such as acupuncture, filler injection, surgical procedures and other traumatic events preceded infection in 13 (including 11 normal hosts and two immunocompromised hosts) of the 29 patients. Multiple skin lesions were present in eight patients (including three normal hosts and five immunocompromised hosts). In eight patients (including four immunocompromised hosts), symptoms were accompanied by tenosynovitis, osteomyelitis and myositis. Mycobacterium abscessus was isolated from nine patients, Mycobacterium fortuitum was isolated from nine patients, Mycobacterium chelonae was isolated from six patients, Mycobacterium marinum was isolated from two patients, a Mycobacterium avium complex member was isolated from two patients, and Mycobacterium haemophilum was isolated from one patient. Ten of the 24 cases caused by rapidly growing organisms (i.e. M. chelonae, M. abscessus and M. fortuitum groups) were precipitated by skin injuries such as acupuncture, filler infection and other medical procedures. Increases in skin medical procedures, including both acupuncture and esthetic interventions, explain the increasing incidence of these organisms. Immunocompromised patients tended to develop multiple skin lesions and deep tissue infections.     

Atypical mycobacterial cutaneous infections

Atypical mycobacterial infections have been a cause of steadily growing infections over the past decades, especially in immunocompromised patients. They are classified by their ability to produce pigment, growth rate, and optimal temperature. Mycobacterium marinum, M. kansasii, and M. avium-intracellulare are examples of slow-growing mycobacteria. M. fortuitum, M. chelonei, and M. abscessus are examples of rapidly growing mycobacteria. Atypical mycobacteria are ubiquitous in the environment. No specific treatment guidelines exist but a multidrug regimen combined with surgical modalities is often used for therapy.     

Successive development of cutaneous polyarteritis nodosa, leucocytoclastic vasculitis and Sweet's syndrome in a patient with cervical lymphadenitis caused by Mycobacterium fortuitum

Mycobacterium fortuitum is a rapidly growing mycobacterium found in soil and water throughout the world. It can cause diseases in immunocompetent patients, usually resulting in localized skin and soft tissue infections. Cervical lymphadenitis caused by M. fortuitum is rare. We report a 46-year-old woman in whom skin lesions of cutaneous polyarteritis nodosa, leucocytoclastic vasculitis and Sweet's syndrome had successively developed before the diagnosis of cervical lymphadenitis caused by M. fortuitum was made. The skin lesions responded to colchicine and systemic corticosteroids but recurred intermittently. After establishment of the diagnosis, she received treatment with clarithromycin and ciprofloxacin. The cervical lymph nodes decreased in size 6 months later and no more new skin lesions were found.     

Treatment of cutaneous infections due to Mycobacterium fortuitum: two cases

INTRODUCTION: Cutaneous infections due to Mycobacterium fortuitum, a rapidly growing environmental mycobacteria, are often iatrogenic, resulting from surgery or injection. We report two cases following plastic surgery and describe the outcome after surgery and antibiotics. CASE REPORTS: Two immunocompetent women underwent abdominal plastic surgery and liposuction, which were complicated with recurrent abscesses one and 13 months later respectively. Cultures of bacteriologic samples isolated M. fortuitum in the two patients. The two strains exhibited different antibiotic sensibility profiles. The initial antibiotic therapy consisted of combined amikacin and moxifloxacin in both patients plus imipenem in one, followed by oral doxycycline and clarithromycin in one and moxifloxacin in the other for a total duration of nine and five months, respectively. In both cases, surgical treatment was also given before, during and after antibiotic therapy. No new lesions had appeared six months after the end of antibiotic therapy. DISCUSSION: Cutaneous infections due to M. fortuitum are rare and secondary to iatrogenic skin wounds. The clinical appearance is not specific, accounting for delayed diagnosis. Treatment is difficult and there is no consensus. According to our experience, surgical treatment is essential whereas the efficacy of antibiotics, even involving multiple agents, seems more doubtful.     

Mycobacterium fortuitum skin infection occurring after a facelift

INTRODUCTION: Mycobacterium fortuitum skin infections are rare and usually iatrogenic. We report a case with cervical involvement following a facelift. OBSERVATION: A 65 year-old woman, without past history, underwent bilateral surgical facelift, complicated by cutaneous necrosis and treated with directed healing at home. Six weeks later, an abscessed nodule appeared under the left maxillary and was drained surgically. Then other pre-auricular and left cervical inflammatory nodules appeared without adenopathy or fever. M. fortuitum was isolated in bacteriological samples. The initially probabilistic antibiotherapy with carithromycin, subsequently adapted with amikacine and cirprofloxacine and then imipeneme for a total duration of 3 months, led to the clinical cure. DISCUSSION: Mycobacterium fortuitum is a rapidly growing, ubiquitous, mycobacteria responsible for nosocomial infections in immunocompetent patients, notably following plastic surgery. Contamination occurs where there has been a rupture in the skin barrier through contact with a vector (water, surgical material, antiseptic.). Treatment, which is not codified, consists in the association of surgery and antibiotics for several months.     

龟分枝杆菌和偶发分枝杆菌皮肤感染

报告1例皮肤龟分枝杆菌和偶发分枝杆菌感染。患者男,42岁。左膝关节结节、斑块2年,逐渐增大。1个月前局部皮肤出现肿胀、破溃。皮肤科检查可见左膝关节有一7cm×5cm暗红色斑块,中心有脓性分泌物。分枝杆菌培养阳性,经鉴定为龟分枝杆菌和偶发分枝杆菌。经抗分枝杆菌治疗,皮损明显改善。     

Mycobacterium fortuitum Infection Occurring After a Punch Biopsy Procedure

Abstract: Mycobacterium fortuitum is a rapidly growing atypical mycobacterium frequently reported as a postsurgical wound complication from a major surgical procedure. We present a unique case of M. fortuitum infection occurring in a 4-year-old boy after a minor punch biopsy surgical procedure. As far as we know there has been no published case of M. fortuitum occurring after a punch biopsy procedure.     

Nail involvement in leprosy

Leprosy, a disease caused by Mycobacterium leprae, primarily affects the skin and nerves, but the nails are also involved in as many as 3 out of 4 patients .The factors that trigger nail changes in leprosy are numerous and include repeated trauma, neuropathy, vascular impairment, infections, lepra reactions, and the drugs used to manage the disease. The changes most often reported include subungual hematomas, onycholysis, onychauxis, onychogryphosis, pterygium unguis, and onychoheterotopia, most of which can be attributed to nerve damage and trauma. Furthermore, the acro-osteolysis that occurs in the advanced stages of the disease may present with brachyonychia, racquet nails, or even anonychia. Infections of the nail bed leading to paronychia and onychomycosis should also be taken into account in leprosy. Other typical changes include longitudinal striae, pitting, macrolunula, Terry nails, leukonychia, hapalonychia, and Beau lines. In this review, we describe the principal nail changes associated with leprosy. These changes, which are highly varied and diverse in origin, are in fact a reflection of the significant morbidity caused by M. leprae infection.     

M. fortuitum and M. chelonei—fast growing mycobacteria

Infection due to opportunist mycobacteria is considered in general and that due to the fast growing mycobacteria in particular. The group is now seen to contain two facultative pathogens, M. fortuitum and M. chelonei (abscessus), all other synonyms for these two species having been shown to be invalid. Both organisms are ubiquitous and normally harmless; however, following injury or injection, they may cause chronic sub-cutaneous abscesses. Pulmonary lesions have also been described. More recently M. fortuitum has been found to cause osteomyelitis and corneal ulceration and both organisms have been identified in cases of septicaemia associated with renal dialysis. In the past M. chelonei my have been identified as M. fortuitum but although it is more difficult to isolate, it may in fact be the more common cause of disease. A case is reported of an English girl who received a small injury to her shin in Spain. The initial lesion failed to heal and for 18 months there was repeated formation small sinuses in the area. Healing then occurred spontaneously. Histology showed a chronic granuloma and on two occasions a rapid growing mycobacteria resistant to all antibiotics was isolated. This was initially identified as M. fortuitum but finally as M. chelonei and the latter diagnosis was confirmed by differential skin tests. Difficulties in interpretation of these tests are discussed.     

Mycobacterium fortuitum in cutaneous infections

Three cases of culture proven primary cutaneous infections caused by Mycobacterium fortuitum, a rapidly growing non tuberculous mycobacterium, are reported. The first case was treated with ciprofloxacin and the other two, with trimethoprim / sulphamethoxazole with an excellent outcome.     

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 Mycobacterium abscessus

Cutaneous infection with rapidly growing mycobacteria is uncommon and diagnosis may be difficult. However, the histopathological features are distinctive and may aid diagnosis. The three pathogenic species, Mycobacterium fortuitum, M. chelonae and M. abscessus, show major differences in their antimicrobial sensitivities, and species identification is therefore important. We describe a case of infection with M. abscessus, and discuss the clinical and pathological features of such infections, and approaches to their treatment.     

Recommendations for treatment of nail psoriasis during the COVID‐19 pandemic

The novel coronavirus disease 2019 (COVID‐19) pandemic has resulted in a paradigm shift in disease management. Since immunosuppression may cause increased susceptibility to COVID‐19, there is uncertainty as to whether systemically treated nail psoriasis patients are at increased infection risk. While specific data on nail psoriasis treatments and COVID‐19 is lacking, we present clinical trial data on rates of upper respiratory infections, nasopharyngitis, viral infection, pneumonia and overall infections. Some systemic medications and biologics are associated with increased in infections risk compared to placebo in clinical trials. However, this data should be regarded cautiously since clinical trials on nail psoriasis, particularly controlled studies, are lacking. Our recommendations may be helpful in guiding physicians managing nail psoriasis patients during the COVID‐19 pandemic.     

Onycomycosis due to artificial nails

Background  The use of artificial nails (ANs) as part of nail-care cosmetics is very popular. Several side effects and complications, such as contact dermatitis and bacterial and fungal infections, have been reported in patients using ANs.
Objective  The purpose of this study was to identify the fungal pathogens in nail abnormalities appearing in patients with ANs.
Methods  We evaluated 68 patients suffering from nail changes and paronychia, which appear after removal of ANs. Mycological samples were obtained from two sites: distal parts of the involved nail and the proximal nail fold. KOH examination and fungal culture were used for detection and identification of fungal infection.
Results  Mycological results from the distal part of the nail showed positive KOH test in 57 cases (83.8%), and culture was positive in 67 patients (98.5%). Mycological results obtained from the proximal nail fold showed positive KOH test in 36 patients (52.9%); in 36 of the cases, culture was positive. Candida spp. were the most common pathogen. Both KOH and culture results were significantly better while sampling from the distal part of the nail compared with sampling from the proximal nail fold ( P =  0.0001).
Conclusion  Onychomycosis was found to be very common in nail changes due to ANs, leading to an increased risk of transmitting microbial infections. Therefore, health care personnel and workers in the food industry should avoid using ANs.     

Bilateral Sporotrichoid Lymphocutaneous Dermatosis in a Drug Abuser

Bilateral sporotrichoid mycobacterial cutaneous infection is unusual and has been reported in only three cases involving different species and with an unknown route of infection in the literature.We report a case of bilateral sporotrichoid dermatosis in an immunocompetent patient with a history of intravenous heroin injection before development of the skin lesions. Both special stain and culture of biopsy specimen were negative. Finally, Mycobacterium fortuitum was identified by a polymerase chain reaction-based method. The patient responded well to clarithromycin and ciprofloxacin therapy. This case represents an unusual primary cutaneous M. fortuitum infection manifested as bilateral sporotrichoid lesions of the limbs. Review of previous reported cases of bilateral sporotrichoid mycobacterial infection shows different isolated organisms and routes of infection to that found in our case.     

Nail abrasion

Certain diseases of the nail complex cause hyperkeratosis or alterations of the shape of the nail plate. These conditions may be painful, may decrease the penetration of topical medicaments and may be ugly. The nail plate abrasion, performed with dermabrader device or sandpaper, has application in patients suffering from onychomycosis, psoriasis, subnail infections and haematomas. The technique facilitates the collection of scales for mycological examination, decreases treatment time (of topical monotherapy) for onychomycosis and provides greater comfort for the patient by reducing nail plate thickness. It can also be useful for the partial removal of the nail plate in cases of haematomas and subnail infections. Nail abrasion is an effective and inexpensive method, easily applied in either nail pathologies with hyperkeratosis of the nail plate or in those requiring partial removal of the plate.     

Cutaneous manifestations of infection by nontuberculous mycobacteria

Cutaneous infections by nontuberculous mycobacteria (NTM) are not usual but their relative importance has changed during the last few years and still further changes are expected. This study comprised 13 patients from whom NTM were recovered from skin biopsy specimens, sinus exudates or cutaneous abscesses. All samples were processed according to standard methods, and the isolates were identified by biochemical testing. Skin biopsy specimens, when available, were processed for histopathological study. The clinical records of the patients were reviewed, and the relevant clinical, microbiological and epidemiological data collected. The clinical manifestations were noted to be relatively nonspecific and consisted of draining sinuses, abscesses, ulcers and nodules with multicentric or sporotrichoid patterns. Tissue culture isolated Mycobacterium fortuitum complex in nine patients, M. avium in three, and M. marinum in one. In the nine patients studied by histopathology, various patterns were observed. These included dermo-hypodermal abscesses, suppurative granulomas, tuberculoid granulomas and granulomas with a perifollicular distribution. Cutaneous lesions can thus be the first and the only sign of NTM disease, and culture still remains the definitive diagnostic procedure.