Cutaneous infection with Mycobacterium fortuitum after localized microinjections (mesotherapy) treated successfully with a triple drug regimen.

Mesotherapy is a treatment method devised for controlling pain syndromes or diseases by subcutaneous microinjections given at or around the involved areas at short intervals of time. Different adverse effects have been described due to this modality of treatment. This report describes 3 patients with cutaneous infection caused by Mycobacterium fortuitum after mesotherapy. Three women, aged 24, 27 and 44 years, presented with similar clinical features, consisting of painful nodules located at the points where mesotherapy had been applied. A smear from a skin biopsy revealed the presence of acid-fast bacilli in all 3 cases. The specimen was cultured and eventually identified as M. fortuitum. A multidrug long-term regimen (combinations of 3 drugs from the following: ciprofloxacin, cotrimoxazole, clarithromycin and amoxicillin-clavulanic acid) was needed to achieve resolution of the lesions. After 15, 25 and 26 months of follow-up, no patient relapsed. Mycobacterium fortuitum is a rapidly growing mycobacterium that can lead to cutaneous infection after minor surgical procedures when aseptic measures are not adequate. Multiple drugs for several months are usually needed to treat this disease successfully.     

High discordance between punch biopsy and excision in establishing basal cell carcinoma subtype: analysis of 500 cases

Background Basal cell carcinoma (BCC) is the most frequently occurring cancer in humans. Worldwide incidences rise about 10% each year, increasing the burden on dermatologists, general practitioners and pathologists as well as increasing costs for the health care system. Increasingly non‐surgical treatment options are used in the treatment of BCC, without histological confirmation of BCC subtype, potentially resulting in under‐treatment. Objective We evaluated the diagnostic accuracy of a punch biopsy for the BCC histological subytpe in a primary BCC and the prevalence of biopsy‐based under‐diagnosis of aggressive subtypes. Accuracy of a punch biopsy was defined as concordance of the diagnosis of subtype of BCC at punch biopsy and excision. Methods A retrospective chart‐review was performed of primary BCC, which were proven by punch biopsy and subsequently treated by excision. The first 100 consecutive BCCs per year during the years 2004–2009 were included, yielding a total of 500 evaluated BCCs. Results The overall accuracy of punch biopsy for BCC subtype at excision was 69%, in single‐type BCC 83% (n = 343) and in mixed‐type BCC 37% (n = 157). Accuracy varied substantially according to BCC subtype, being highest in the superficial subtype (84%) and subsequently in infiltrative (69%), nodular (63%) and micronodular subtype (38%). In 11% of all cases, an unsuspected more aggressive subtype was present. Conclusion Punch biopsy has a high accuracy in single‐type BCCs and a considerably lower accuracy in mixed‐type BCCs for establishing BCC subtype compared to excision. The presence of an unsuspected aggressive subtype could explain therapy failure of non‐surgical treatments like imiquimod or photodynamic therapy.     

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.     

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.     

Agreement between histological subtype on punch biopsy and surgical excision in primary basal cell carcinoma

Background Diagnosis of clinically suspected basal cell carcinoma (BCC) by histological confirmation with punch biopsy has been recommended before treatment. Even shave biopsy has been proposed as useful to predict the correct subtype in primary BCC in 76–81%, whereas the agreement between histological BCC subtype on punch biopsy and subsequent excision specimens in recurrent BCC is 67.1%. However, no large studies on the agreement between histological BCC subtype seen on punch biopsy and the following surgical excision are performed in primary BCC. Objective The aims of this study were (i) to establish the agreement between histological BCC subtype on punch biopsy and the subsequent surgical excision of primary BCC and; (ii) to investigate the proportion of primary BCCs in which punch biopsy enables identification of the most aggressive growth pattern. Methods Retrospective analyses of 243 primary BCCs with both punch biopsy and subsequent surgical excision. Analyses were based on the most aggressive histological subtype of the tumour. Results The agreement between BCC subtype on punch biopsy and the subsequent surgical excision of primary BCCs was 60.9%. A punch biopsy can predict the most aggressive growth pattern of primary BCCs in 84.4%. Seventy‐four percentage of all primary BCCs consisted of more than one histological subtype. Conclusion Dermatologists and other physicians have to be aware of the limited diagnostic value of a punch biopsy to determine the histological BCC subtype of the whole lesion. Misdiagnosis of the subtype will lead to undertreatment in one of six primary BCCs.     

Cryotherapy for lentigo maligna — is clinical acumen combined with a single punch biopsy good enough for staging?

Aim We aimed to clarity the effectivenes of our staging of LM over a I-year period. Background Cryosurgery has become accepted as a simple and effective treatment for lentigo maligna (LM) but not necessarily lentigo maligna melanoma (LMM). Pigmented epithelial cells are extremely sensitive to cold injury. If adequate freezing is delivered to the proper depth into the dermal appendages, LM should be eradicated. However, if the initial staging does not detect invasion the lesion may be inadequately treated. Methods Over 1 year prospectively. all patients presenting with LM(n= 12) wore stayed clinically by experienced dermatologists and by a single punch biopsy. This was then checked by complete excision of the lesion. Results In 9 patients the clinical and punch biopsy diagnosis was confirmed after excision. Two melanomas were missed clinically but detected on punch biopsy. In one patient the punch biopsy described a “LM with probable invasion elsewhere in the lesion”. Surgical excision yielded a melanoma, 0.8 mm thick. Clark's level 4. In a second patient, punch biopsy diagnosed superficial spreading melanoma (-SSM) in situ, confirmed on excision. Conclusions We therefore feel that clinical diagnosis combined with a single punch biopsy will diagnose invasion when present. We emphasise that cryotherapy should not be performed without punch biopsy confirmation of the clinical diagnosis.     

Utilidad de la ecografía cutánea en el diagnóstico de invasividad del carcinoma basocelular recurrente tras tratamiento no quirúrgico

Introduction and objectivesAccurate subtyping of basal cell carcinoma (BCC) is crucial for the effective management of this disease and it is particularly important to distinguish between aggressive and nonaggressive histologic variants. Histologic subtype is not always accurately identified by biopsy and this can have serious implications. High-resolution ultrasound (HRUS) is a recent technique that has proven to be of value in differentiating between variants of BCC. The aim of this study was to investigate the potential usefulness of HRUS for detecting invasive disease in recurrent BCC treated nonsurgically following an initial diagnosis of noninvasive BCC by biopsy.Material and methodsThis was a prospective observational study of consecutive cases of BCC with clinical suspicion of recurrence following nonsurgical treatment and a pretreatment diagnosis of superficial BCC by punch biopsy. Before surgical excision, the recurrent lesions were evaluated by HRUS followed by a punch biopsy of the site of suspected recurrence. The diagnostic agreement between HRUS, punch biopsy, and excisional biopsy was then evaluated.ResultsEight lesions were studied. HRUS identified invasive disease in 3 of the 4 cases that were incorrectly classified as superficial subtypes by punch biopsy.ConclusionHRUS could be useful for detecting persistent tumor after nonsurgical treatment and for choosing the site most likely to harbor invasive disease for punch biopsy.     

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.     

Concurrent chronic lymphocytic leukemia cutis and acute myelogenous leukemia cutis in a patient with untreated CLL

Patients who have chronic lymphocytic leukemia (CLL) are known to have a high frequency of second malignant neoplasms. However, acute myelogenous leukemia (AML) occurring concurrent with or after a diagnosis of CLL is extremely rare. In this article we report a case of AML developing in a 55-year-old male with a 6-year history of untreated CLL. The diagnosis was facilitated by touch preparation of a skin punch biopsy specimen. The patient presented with a two-week history of fever, weakness, anasarca, and a skin rash. Physical examination revealed pink to skin-colored firm papules, which coalesced into indurated plaques on his trunk, upper extremities, and face. The lesions, in combination with generalized edema, produced a leonine facies. Touch prep of the biopsy showed medium to large blasts, large monocytoid cells, and numerous small mature lymphocytes, providing the preliminary diagnosis of a second, previously undiagnosed myelomonocytic malignancy in this patient. The initial diagnosis was subsequently confirmed by histologic, cytochemical, immunohistochemical and flow cytometry studies. This is the first reported case of CLL with concurrent AML in which rapid touch prep of a skin punch biopsy facilitated diagnosis.     

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.     

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.     

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.     

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.     

Versatile punch surgery

BACKGROUND: Punch instrument is a circular blade that can be used for many diagnostic and therapeutic purposes in different medical and surgical specialties. Punch surgery (or biopsy) is achieved by using this versatile punch blade under local anesthesia. Basic punch surgery is quick and easy to learn. Complications such as bleeding and infection are minimal. Diagnostic punch surgery can obtain a part of or whole skin lesion for histologic examination. In addition to the skin, nail and mucous membrane tissue can be obtained by punch biopsy. Interestingly, punch biopsy can be used as an adjunctive to fine-needle aspiration to establish the diagnosis of tumors of solid organ such as the breast. Diagnostic punch surgery can be modified to overcome certain problems. The split-punch technique helps avoid crushing the tissue punch when trying to divide it for different examinations. The double-trephine punch facilitates obtaining subcutaneous tissue without the need for full elliptical excision. The string-of-beads technique obviates the need for dissection of tissue into pieces. In other nondermatology and dermatology conditions, such as nerve pathology, arteriosclerosis, melanoma mapping, and eyelid tumors, the diagnosis can be enhanced with the use of punch surgery.Therapeutic punch surgery can be used for excision of unwanted lesions such as nevi, as well as pathologic bone and cartilage tissues. Punch grafting is used in vitiligo surgery and hair transplantion. Punch evacuative surgery can help in the evacuation of unwanted tissue or materials such as lipoma, subungual hematoma, scrotal calcinosis, pseudocyst of the auricle, pilar cyst, and others.Reconstructive punch surgery includes correction of ear lobe defects and acne scars. Enhancement of wound healing can be achieved by use of the punch; therefore, it can help nonhealing ulcers.     

Novel Uses of Skin Biopsy Punches in Dermatosurgery

The skin punch or surgical punch is an instrument which is used almost exclusively by dermatologists. It is a circular hollow blade attached to a pencil-like handle ranging in size from 0.5 to 10 mm. It is available as a disposable, reusable, and automated instrument. The punch can be used as a diagnostic, therapeutic, and cosmetic tool in dermatology. We have used punch as a diagnostic, therapeutic, and cosmetic tool in our dermatosurgery practice in our hospital. Various original research articles, text book publications, and review articles were studied and compiled. Techniques used by various authors and our own experiences with punch have been described. This article aims at providing the novel usefulness of skin biopsy punch in dermatology as the basic punch surgery is quick and easy to learn. Complications such as bleeding and infection are minimal.     

Faster healing and less pain in skin biopsy sites treated with an occlusive dressing

We prospectively studied 174 patients on whom 226 unsutured parallel incisional (shave) and 3-mm punch skin biopsies were performed. Two wound-care programs, occlusive dressing therapy and conventional therapy, were compared. The biopsy sites were evaluated after 1 or 2 weeks for healing, pain, and infection. We found that healing was unrelated to the indication for biopsy or the patients' age, gender, or race. Occlusive dressing therapy-treated shave biopsy sites were 3.83 times more likely to be healed than those treated with conventional therapy. Regardless of the treatment method, a facial shave biopsy site was 3.6 times more likely to be healed than a biopsy site in other locations. No punch biopsy site had healed after 1 week. At 2 weeks, only 7% and 36% of conventional therapy- and occlusive dressing therapy-treated punch biopsy sites, respectively, had healed. Pain at the biopsy site was six times more common in both shave and punch biopsy sites treated with conventional therapy. The absence of pain with occlusive dressing therapy was significant for both types of biopsy. One punch biopsy site treated with conventional therapy became infected, and one treated with occlusive dressing therapy was suspected of being infected. Forty patients, who had biopsy sites treated with both therapies, preferred occlusive dressing therapy over conventional therapy by a ratio of 3:1 because of ease of wound care and lack of pain. We conclude that occlusive dressing therapy may be the wound management of choice for shave biopsy sites. Since punch biopsy sites do not heal readily, it may be more appropriate to suture them, at least until therapies are developed that more effectively speed their healing.     

Basal cell carcinoma: a comparison of shave biopsy versus punch biopsy techniques in subtype diagnosis.

BACKGROUND: There are two standard ways to obtain tissue for histologic classification of a clinically suspected basal cell carcinoma: shave and punch biopsy. However, information on the value of each method is limited. OBJECTIVE: The purpose of this study was to identify accuracy rates of two standard biopsy techniques in diagnosing subtypes of basal cell carcinoma. METHODS: A total of 86 cases were identified that had received either a punch or a shave biopsy with subsequent total excision of tumor. The biopsy specimens and excisions were compared for histologic correlation. RESULTS: Analysis of specimens from punch and shave biopsies produced equivalent diagnostic accuracy rates: 80.7% and 75.9%, respectively. There was no statistically significant tendency to overcall or undercall any particular tumor subtype on the basis of the type of biopsy procedure used. CONCLUSION: For histologic classification of basal cell carcinoma, there is an approximately 80% accuracy rate with both the shave and the punch biopsy. Therefore either biopsy technique is appropriate.     

Atypical Mycobacterium furunculosis occurring after pedicures

Mycobacterium fortuitum complex are rapidly-growing nontuberculous mycobacteria found ubiquitously in the environment including, water, soil, dust, and biofilms. M fortuitum has been reported to cause skin and soft-tissue infections in association with nail salon footbath use during pedicures. Four cases of M fortuitum complex furunculosis are reported that occurred after pedicures in the Cincinnati, Ohio/Northern Kentucky area. Dermatologists and clinicians should consider mycobacterial infections from the M fortuitum complex when patients present with nonhealing furuncles on the lower legs and should inquire about recent pedicures. Early recognition and institution of appropriate therapy are critical. Public health measures should be explored to protect against such infections, given the recent popularity of the nail care industry.     

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。     

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.