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.     

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。     

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.     

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.     

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.     

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.     

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.     

Skin and wound infection by rapidly growing mycobacteria: an unexpected complication of liposuction and liposculpture. The Venezuelan Collaborative Infectious and Tropical Diseases Study Group

OBJECTIVE: To describe 10 patients with skin and soft tissue infection caused by rapidly growing mycobacteria after cosmetic liposuction and liposculpture. DESIGN: Case series. SETTINGS: Eight private geographically separate surgical facilities from a single metropolitan area. PATIENTS: Eight patients with definite and 2 with presumptive cases of skin and soft tissue infection caused by rapidly growing mycobacteria after cosmetic surgery procedures during a 24-month period. Microorganisms were isolated from the purulent drainage obtained from wounds or fistulas in 8 cases and were identified as Mycobacterium fortuitum (3 cases) and Mycobacterium abscessus (5 cases) by routine microbiologic techniques. Acid-fast bacilli were observed on Ziehl-Neelsen-stained smears in the 2 remaining cases, but these ultimately failed to grow. In 2 of the surgical units, no apparent environmental predisposing factors were identified after thorough microbiologic environmental investigation. Clinically, all patients exhibited signs of inflammation, microabscesses, and purulent wound drainage within 24 months of abdominal and/or thigh liposuction or homologous fat tissue injection. INTERVENTION: A combined therapeutic approach including surgical drainage, debridment, and prolonged (>3 months) treatment with combined antimicrobial agents including clarithromycin was used in all cases. RESULTS: Nine of 10 patients responded to the combined therapeutic approach, and no evidence of infection was present during at least 12 months of follow-up. CONCLUSION: To our knowledge, this is the first series of patients with rapidly growing mycobacterial infections to be described after liposuction and liposculpture. Rapidly growing mycobacteria should be included in the differential diagnosis of skin and soft tissue infection after cosmetic surgery.     

Rapid identification of cutaneous infections by nontubercular mycobacteria by polymerase chain reaction-restriction analysis length polymorphism of the hsp65 gene

BACKGROUND: Nontubercular mycobacteria (NTM) may cause cutaneous infections which are difficult to interpret due to the variability of the clinical manifestations. This study involved eight patients (four men and four women) with primary cutaneous infections caused by NTM; the skin lesions included dermo-hypodermal abscesses, suppurative granulomas, and papulonodules localized on the legs, arms, hands, and face. The general condition of the patients was relatively good and they were not immunosuppressed. METHODS: All samples were processed with standard methods and the isolates were identified by pattern restriction analysis after polymerase chain reaction (PCR-PCA) amplification of the heat shock protein of 65 kDa. RESULTS: In this way, we were able to identify three Mycobacterium chelonae strains, two Mycobacterium marinum, two Mycobacterium fortuitum, and one Mycobacterium avium. The lesions disappeared in 3 or 4 weeks after treatment with two or more antimicrobials. CONCLUSIONS: For a correct diagnosis of cutaneous infection by NTM, demonstrating the presence of mycobacteria is essential; routinely available techniques lack sensitivity and are extremely tedious; often mycobacteria are not seen after acid-fast stain. We used PCR-PCA to identify mycobacteria grown in liquid media; the time of identification of mycobacteria was shortened relative to conventional methods.     

WIDESPREAD PRIMARY CUTANEOUS INFECTION WITH MYCOBACTERIUM FORTUITUM

Background. Cutaneous infection with Mycobacterium fortuitum, a ubiquitous rapid growing atypical mycobacterium, most often occurs as a postsurgical wound complication or at the site of a penetrating injury to the skin. Rarely, disseminated infection with cutaneous involvement can occur in immunocompromised patients. Case Report. A 47-year-old black woman presented with a 10-year history of numerous draining abscesses and tender nodules on the back and buttocks unresponsive to oral and intravenous antibiotics. Biopsy showed a granulomatous and suppurative dermatitis and panniculitis and special stains did not reveal organisms. M. fortuitum was cultured from involved skin on two separate occasions. The patient improved with a 2-week course of intravenous amikacin and cefoxitin combined with oral probenecid followed by a course of doxycycline and ciprofloxacin. Conclusions. Widespread primary cutaneous infection with M. fortuitum may occur in an immunocompetent patient. Chronic draining skin abscesses unresponsive to routine antibiotics may represent infection with an atypical mycobacterium; tissue cultures of affected skin should be performed to rule out this possibility. Therapy should be directed by culture sensitivity results.     

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.     

Disseminated skin infection due to Mycobacterium fortuitum in an immunocompetent patient

Skin infections caused by atypical rapid-growing mycobacteria, which used considered to be unusual, have become more frequent, especially in immunodepressed patients. Clinical cutaneous disease with these pathogens seems to follow two patterns: in the immunocompetent host, a traumatic injury is followed by the development of localized abscess formation; but in the immunocompromised individual there is no history of trauma and the patient presents with multiple subcutaneous nodular lesions. We describe a rare case of an immunocompetent young woman with disseminated skin infection due to Mycobacterium fortuitum. We emphasize the diagnostic and therapeutic problems associated with such infections.     

Atypical cutaneous mycobacteriosis diagnosed by polymerase chain reaction

Atypical mycobacteria are important human pathogens. Although they often cause systemic disease, mycobacterial infection may present solely as cutaneous lesions. It is not easy to detect nontuberculous mycobacteria by the traditional histochemical Ziehl-Neelsen stain, or by culture on specific media. Polymerase chain reaction (PCR) may be used to identify nontuberculous mycobacteria in skin lesions. We report a 40-year-old man and a 36-year-old woman, both of whom were immunocompetent and kept fish, who had skin lesions on the backs of their right hands. Ziehl-Neelsen staining and culture on Lowenstein-Jensen media were negative. Mycobacterial DNA was detected by amplification of 16S ribosomal DNA. In both cases, PCR-enzyme-linked immunosorbent assay showed a positive signal when probes for Mycobacterium (universal probe) and M. chelonae were used, and in one patient M. fortuitum was also discovered. Antibiotic therapy with clarithromycin 500 mg twice daily was begun. After 6 months of treatment, the skin lesions were cured.     

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.     

A Case of Skin and Soft Tissue Infection Caused by Mycobacterium abscessus

Mycobacterium abscessus (M. abscessus) is an acid-fast bacillus that''s classified as a pathogenic "rapid growing" nontuberculous mycobacteria. It is an uncommon cause of human disease, but it can cause skin and soft tissue infection after skin injury following inoculation, minor trauma and surgery. The single most important factor for determining the course and prognosis of a M. abscessus infection is the underlying immune status of the host. We report here on a 71-year-old female who presented with multiple painful erythematous cutaneous nodules on her left forearm. She had diabetes mellitus and had taken oral steroid by herself for two years because of her osteoarthritis. Histologically, granulomas and inflammatory cell infiltration were observed and M. abscessus was identified via the mycobacterial culture. We performed curettage and drainage, followed by 6 months of oral clarithromycin and the patient''s disease completely healed.     

Sweet's syndrome associated with non-tuberculous mycobacterial infection: a report of five cases

We report the rare association of Sweet's syndrome with non-tuberculous mycobacteria in five patients (three women, two men, aged 25–41 years). Clinical and histological evidence supported the diagnosis of Sweet's syndrome in all patients. The skin lesions responded well to systemic corticosteroid but recurred in two cases. All of our patients had chronic disseminated non-tuberculous mycobacterial infection. They initially presented with lymphadenopathy and developed involvement in other organs later. All of them were treated as having tuberculous lymphadenitis based on pathological findings before definite diagnosis was made by culture. The organisms isolated were Mycobacterium chelonae in three cases, M. scrofulaceum in one case and M. avium intracellulare complex in one case. All the patients gradually improved with treatment but one had multiple recurrences. The search for an infectious agent, especially non-tuberculous mycobacteria, should be performed in cases of Sweet's syndrome that appear in association with chronic granulomatous lymphadenitis which is recalcitrant to antituberculous drugs.     

Cutaneous infection by Mycobacterium fortuitum biovariant "third group"--a case report and bacteriological examination of the isolate

A 22-year-old woman with ten-year history of atopic dermatitis first noticed an erythematous ++, indurated, and fluctuant lesion on her back six month prior to visiting our hospital in February 1989. The dusky red skin lesion gradually spread to the right side of her trunk and drained small amount of purulent or serosanguineous fluid. A skin biopsy specimen showed mixed pattern of nonspecific inflammatory infiltrate and granulomatous infiltrate in the dermis. A culture of the biopsy specimen showed a rapidly growing atypical acid-fast bacteria, which was identified as Mycobacterium fortuitum and classified as biovariant "third group" by positive growth on mannitol and inositol. Minimum inhibitory concentrations (MICs) of different antimicrobial agent using broth medium showed that the isolate was susceptible to the new quinolones such as ofloxacin and ciprofloxacin. The patient responded to treatment with doxycycline followed by with ofloxacin. Subspecies classification and antibiotic susceptibilities were discussed with special reference to treatment of rapidly growing mycobacteria.     

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.     

Chest infection due to M. fortuitum in a case of lepromatous leprosy--a case report

Lepromatous leprosy cases may be immunocompromised due to the extensive disease and also because of steroid therapy for repeated reactions. Such patients are likely to be at higher risk for getting opportunistic infection due to various environmental microbes. This paper reports a case of lepromatous leprosy with repeated lepra reaction who was found to have chest infection due to M. fortuitum. It is suggested that mycobacterial culture and sensitivity should be recommended in cases who are immunocompromised and whose pathological specimens contain acid fast bacilli. Species identification and sensitivity can be very helpful in proper management of such cases who will otherwise pass off as tuberculosis.