Cutaneous infections due to nontuberculous mycobacteria: histopathological review of 28 cases. Comparative study between lesions observed in immunosuppressed patients and normal hosts

To evaluate the histopathological features observed in patients with cutaneous infections due to nontuberculous mycobacteria (NTM) and to compare the histopathological patterns observed in immunosuppressed patients and normal hosts. Twenty-eight biopsy specimens corresponding to 27 patients with cutaneous infections due to NTM were reviewed. Eighteen biopsies corresponded to normal hosts (14 Mycobacterium marinum, 2 Mycobacterium chelonae, 1 Mycobacterium terrae and 1 Mycobacterium gordonae) and 10 biopsy specimens were obtained from 9 immunosuppressed patients (3 Mycobacterium chelonae, one of which had two biopsies, 1 Mycobacterium abscessus, 2 Mycobacterium kansasii, 1 Mycobacterium marinum, 1 Mycobacterium avium complex and 1 Mycobacterium simiae). A panel of histopathological features was evaluated by two independent observers in each biopsy specimen. Epidermal changes (acanthosis, pseudoepitheliomatous hyperplasia, exocytosis) were mainly observed in M. marinum infections. In immunosuppressed patients the infiltrate tended to be deeper, involving the subcutaneous tissue (100%) with a more diffuse distribution and constant abscess formation. A marked granulomatous inflammatory reaction was observed in 83% of immunocompetent and in 60% of immunosuppressed patients. In immunosuppressed patients a relationship between the chronic evolution of the disease and granuloma formation was demonstrated. A diffuse infiltrate of histiocytes with occasionally foamy appearance was noted in three biopsy specimens from three patients with AIDS. Acute and chronic panniculitis was detected in 8 biopsy specimens. In one biopsy (M. chelonae) an acute suppurative folliculitis was observed. Different histopathological patterns can be noted in biopsy specimens from cutaneous nontuberculous mycobacterial infections. The evolution of the disease and the immunologic status of the host may explain this spectrum of morphological changes. Tuberculoid, palisading and sarcoid-like granulomas, a diffuse infiltrate of histiocytic foamy cells, acute and chronic panniculitis, non-specific chronic inflammation, cutaneous abscesses, suppurative granulomas and necrotizing folliculitis can be detected. Suppurative granulomas are the most characteristic feature in skin biopsy specimens from cutaneous NTM infections. Some histopathological patterns seem more prevalent in immunosuppressed patients.     

A Case of Cutaneous Mycobacterium Chelonae Abscessus Infection in a Renal Transplant Patient

Abstract Background: Mycobacterium chelonae is an atypical "fast-growing Mycobacteria" that is a rare cause of human infection. There have been several reports of cutaneous infection among immunosuppressed patients, as well as in immunocompetent individuals following trauma. Most cases to date seem to have occurred among renal transplant recipients, raising the possibility that there is something inherent to the renal transplant patient that increases their susceptibility more than other immunocompromised patients. Objective: The differential diagnosis of subcutaneous nodules distributed in a sporotrichoid pattern is extensive, particularly in an immunocompromised host. Although several cases of cutaneous M. chelonae abscessus infection have been reported among both immunosuppressed and immunocompetent patients, the clinical presentation has varied, and few cases have reported the appearance of lesions in a sporotrichoid pattern. We present a case of a renal transplant patient with a reported history of trauma to the lower extremities, who presents with subcutaneous nodules distributed in a sporotrichoid pattern. The patient is found to have M. chelonae abscessus infection, fails several treatment regimens, and presents with a recurrence. The literature of M. chelonae infection is reviewed, and the various treatment options are discussed. Methods: An initial skin biopsy was stained with Hematoxylin and Eosin and revealed deep dermal abscesses with acid-fast bacilli in clusters. The culture became positive for Mycobacterium chelonae abscesses in four days and was found to be sensitive to multiple antibiotics. The patient underwent surgical excision of 14 nodules, which revealed findings consistent with the skin biopsy, and was subsequently treated with the appropriate antibiotics. Results: Despite treatment with a full course of an organism-sensitive antibiotic regimen, the patient returned with persistent and recurrent nodules six weeks later. The patient was then treated as an inpatient with a seven-week course of intravenous antibiotics and was discharged home on a combined intravenous and oral regimen. Conclusion: Although M. chelonae abscessus is an extremely rare cause of infection among humans, there seems to be a predominance of cases reported among renal transplant patients. The explanation for this is not entirely clear; however, the organism must be considered as a cause of infection in any renal transplant recipient who presents with subcutaneous nodules. Eradication of the organism presents a tremendous challenge to the clinician, and, as presented here, even with appropriate antibiotics, there is a high rate of recurrence.     

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.     

Iatrogenic Mycobacterium abscessus infection associated with acupuncture: clinical manifestations and its treatment

BACKGROUND: Mycobacterial infections transmitted by acupuncture are an emerging problem. There have been two reports of mycobacterial infections complicating acupuncture in the English literature. AIM: To describe the clinical manifestations and treatment of patients who acquired localized Mycobacterium abscessus infection in the process of acupuncture. METHODS: Clinical manifestations and responses to different methods of treatment were reviewed in 40 patients who developed various skin lesions after acupuncture at a Korean oriental medicine clinic. Results The morphology of the lesions which developed at the acupuncture sites varied. Although the lesions disappeared with the combined administration of clarithromycin and amikacin for 3 months in most cases, five out of 25 patients (20%) showed residual lesions at the end of treatment, and had to be treated with a higher dosage of clarithromycin or alternative antibiotics based on sensitivity tests. CONCLUSIONS: We recommend at least 3 months of treatment with clarithromycin for treating skin infections caused by M. abscessus, with supplementary antibiotics selected based on patients' drug sensitivity tests.     

Atypische Mykobakteriose der Haut durch Mycobacterium abscessus bei einer immunkompetenten Frau

Mycobacterium abscessus is the most pathogenic of the fast-growing mycobacteria, and it is resistant to most of the antimicrobial and tuberculostatic drugs available. This non-tuberculous mycobacterium is significant in medicine because it can contaminate post-traumatic wounds and be a causative agent in chronic skin and soft tissue infection after surgical procedures.A 60-year-old immunocompetent woman was suffering from chronic ulcers and abscesses on the heels and malleoli of both feet. Histological examination revealed a granulomatous inflammation with detection of acid-fast rods, albeit without fibrinoid necrosis. The repeated detection of atypical mycobacteria, which were ultimately identified as Mycobacterium abscessus, allowed the diagnosis of an atypical mycobacteriosis of the skin. This was successfully treated first with clarithromycin and rifabutin and later with a combination of ethambutol, minocycline, clofazimine and azithromycin.     

Cutaneous Infection with Mycobacterium abscessus in a child

Nontuberculous mycobacteria can cause cutaneous infections in both children and adults. Localized nontuberculous mycobacterial infections of the skin have been reported in children following injections or surgical procedures. We report a child who developed a cutaneous nontuberculous mycobacterial infection after exposure of a skin wound to pond water. Cutaneous infection with the rapidly growing mycobacteria Mycobacterium abscessus was demonstrated by clinical and histologic evaluation on the lower leg of an otherwise healthy 12-year-old Caucasian boy. We describe this as an instance of an unusual acquisition of cutaneous M. abscessus infection in a child.     

Foreign-body reaction with Mycobacterium abseccus superinfection

Mycobacterium abscessus is a rare cause of skin and soft tissue infections that often results from inoculation with contaminated foreign material. A 41-year-old woman is described regarding an outbreak of M. abscessus following soft tissue augmentation. Clinical features and treatment options are reviewed.     

Mycobacterium marinum infection. Case report and review of the literature

Atypical mycobacterial infections are increasingly important in immunosuppressed patients as well as in healthy hosts. The atypical mycobacterium that most commonly affects the skin is Mycobacterium marinum. The infection should be suspected upon the presence of ulcers, nodules or chronic plaques and a history of contact with fresh or salt water. Optimal therapy is yet to be established. We report a case of Mycobacterium marinum infection in a patient receiving immunosuppressive therapy that responded favourably to treatment with doxicycline. We review the different antibiotic regimens prescribed in the past years for the treatment of Mycobacterium marinum infection.     

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.     

Stenotrophomonas maltophila cellulitis in an immunocompromised patient presenting with purpura,diagnosed on skin biopsy

Stenotrophomas maltophilia is an opportunistic Gram‐negative bacillus and an important cause of nosocomial infections, particularly in immunosuppressed individuals. Although infections with this organism are most often in the form of pneumonia, bacteremia and endocarditis, awareness of the impact of S. maltophilia skin infections has been increasing. Here we describe a case of S. maltophilia cellulitis in a 65‐year‐old man with severe neutropenia and purpuric skin lesions to highlight the critical histopathological findings and correlate them with the clinical manifestations of the skin infection with this organism. Because identification of S. maltophilia can be challenging and infections are difficult to manage, this case illustrates essential considerations regarding the multifaceted histopathological, dermatological, clinical and microbiological aspects of the diagnosis and treatment of S. maltophilia cellulitis in a severely immunocompromised patient. Cognizance of the increasing incidence of nosocomial infections with uncommon microorganisms such as S. maltophilia is necessary when presented with atypical cutaneous manifestations, particularly in immunocompromised patients.     

Outbreak of acupuncture-associated cutaneous Mycobacterium abscessus infections

BACKGROUND: Cutaneous atypical mycobacterial infections have been increasingly described in association with cosmetic and alternative procedures. OBJECTIVE: We report an outbreak of acupuncture-associated mycobacteriosis. Between April and December 2002, 32 patients developed cutaneous mycobacteriosis after visiting an acupuncture practice in Toronto, Canada. RESULTS: Of 23 patients whose lesions were biopsied, 6 (26.1%) had culture-confirmed infection with Mycobacterium abscessus. These isolates were genetically indistinguishable by amplified fragment length polymorphism. The median incubation period was 1 month. Of 24 patients for whom clinical information was available, 23 (95.8%) had resolution of their infection. All patients developed residual scarring or hyperpigmentation. CONCLUSION: Nontuberculous mycobacteria should be recognized as an emerging, but preventable, cause of acupuncture-associated infections.     

Practical evaluation of skin lesions in immunosuppressed patients

Physicians today are seeing many more immunosuppressed patients because of the prevalence of infection with the human immunodeficiency virus, use of chemotherapy for malignancies, and immunosuppressive therapy for patients undergoing organ transplantation. This paper gives many practical tips for the evaluation of skin lesions in these patients. Banal-appearing skin lesions in immunosuppressed patients may represent an unusual infection, a malignancy, or a reactive process. Even common disorders may produce unusual manifestations in such patients. The astute clinician will constantly be alert to the possibilities of combined infections or drug-related eruptions, and will investigate the possibility of an infectious process in patients who appear to have vasculitis or panniculitis.     

Micobacteriosis cutáneas y ganglionares: estudio descriptivo retrospectivo

Introduction

Atypical mycobacteria are microorganisms that act as opportunistic pathogens in patients with a predisposing factor for infection, such as immunosuppression, local lesions or the presence of foreign bodies. The incidence of disease caused by atypical mycobacteria has increased in recent years.

Objective

To determine the clinical, epidemiological and microbiological features of atypical cutaneous and nodal mycobacteriosis in the Health Area of Albacete (Spain) from 1997 to 2010.

Material and methods

We performed a retrospective observational study using the databases of the Dermatology and Microbiology Services of the Complejo Hospitalario Universitario de Albacete (C.H.U.A) to select cases with a positive culture for atypical mycobacteria in skin or lymph node biopsies, abscess exudates, and cutaneous ulcers.

Results

We diagnosed six cases of atypical cutaneous mycobacteriosis from 1997 to 2010 in the C.H.U.A. The mean age of the patients was 52 years, with no differences between the sexes. A total of 33.3% of the patients were immunosuppressed and 33.3% reported a history of trauma. The mean duration of symptoms until specialist consultation was 41 days. The most frequently isolated microorganisms were Mycobacterium chelonae followed by M. marinum. In addition, ten cases atypical mycobacterial adenitis were diagnosed, all of them in children. The mean age was 4 years, with no differences between the sexes. The mean duration of symptoms before specialist consultation was 33 days. The most frequent locations were submandibular followed by cervical. Clinically, the disease presented as lymph node enlargement with or without inflammatory signs, and up to 40% of the patients had cutaneous fistulization. None of the patients had predisposing factors for opportunistic infection, and the most frequently isolated microorganism was M. lentiflavum. In all patients, definitive treatment was surgical.

Conclusions

Atypical mycobacterial infections of the skin or lymph nodes are rare. In our cohort, skin involvement was present only in adults and nodal presentation exclusively in children. There were no sex differences in either clinical presentation. Only 12.5% (2/16) of the patients were immunosuppressed.     

Cryptococcosis presenting as upper limb cellulitis and ulceration: a case series

We report four cases of cryptococcosis presenting as upper limb cellulitis or ulceration, or both. Three of the four patients were on long-term prednisolone therapy at the time of presentation. In each case, the diagnosis of cryptococcosis was established by a biopsy of the skin. Only one of the four patients had conclusive evidence of disseminated disease. Our cases highlight the importance of skin biopsy in immunosuppressed individuals presenting with cellulitis, particularly when the cellulitis occurs in an atypical location and when the clinical condition fails to respond to standard antibacterial therapy.     

自体脂肪填充术后脓肿分枝杆菌感染

报告2例皮肤脓肿分枝杆菌感染.2例患者均为面部自体脂肪填充术后相继发生脓肿,脓液涂片抗酸染色阳性,培养鉴定均为脓肿分枝杆菌.根据药敏结果给予阿奇霉素、环丙沙星及阿米卡星治疗.提醒临床医师应提高对该病的认识,尤其在局部外伤、手术或局部穿刺后出现脓肿者,对可疑病例行分枝杆菌培养及鉴定.     

美容注射术后皮肤脓肿分枝杆菌感染临床分析

对2018年12月至2019年12月我院确诊的7例皮肤脓肿分枝杆菌感染患者的临床资料进行回顾性分析。本文患者均在非正规医院行美容注射术,术后注射部位都发生脓肿分枝杆菌感染。7例患者均为多发皮损,且为美容注射后发病,表现为红斑、结节、脓肿、溃疡。病理呈感染性肉芽肿改变。6例皮损组织脓液培养结果为脓肿分枝杆菌,1例行组织PCR扩增提示脓肿分枝杆菌感染。诊断为皮肤脓肿分枝杆菌感染。给予克拉霉素、利福平、左氧氟沙星治疗,皮损均消退,随访半年无复发。     

Disseminated ecthymatous herpes varicella-zoster virus infection in patients with acquired immunodeficiency syndrome

Herpesvirus infections are among the most common and debilitating opportunistic infections in patients with acquired immunodeficiency syndrome (AIDS), and they may have atypical clinical features. We describe the cases of three patients with AIDS in whom atypical persistent ulcerative skin lesions developed as a result of varicella-zoster virus infection. Two patients had disseminated infection without a vesicular stage; one patient had underlying asteatotic eczema. All responded well to acyclovir. One patient was treated with azidothymidine, and typical dermatomal herpes zoster subsequently developed. The profound loss of helper T cell function in AIDS may lead to multiple abnormalities in local immune response to cutaneous herpesvirus infections and may be responsible for the atypical morphology and a prolonged course.     

Mycobacterium mucogenicum: report of a skin infection associated with etanercept

Mycobacterium mucogenicum is a recently characterized organism that rarely may cause human infections. This rapidly growing mycobacterium is commonly identified in tap water. Both immunosuppressed and immunocompetent patients may develop infections from Mycobacterium mucogenicum. Some patients have experienced lethal disease, including sepsis. Infections occurring in the skin and soft tissues have been described only after a preceding injury. We present the first case of infection with Mycobacterium mucogenicum occurring in a patient on the TNF-alpha antagonist etanercept and without any prior soft tissue injury.     

脓肿分枝杆菌性皮肤溃疡

报告1例院外散发的皮肤脓肿分枝杆菌病，患者女，52岁，左颞部慢性皮肤溃疡3年，常规细菌学和真菌学检查阴性，多种抗生素（包括异烟肼和利福平）治疗无效，皮损分枝杆菌培养及菌株鉴定为脓肿分枝杆菌，该分离株对异烟肼，利福平，乙胺丁醇耐药，对链霉素临界耐药。给予阿米卡星，克拉霉素及左旋氧氟沙星治疗后明显好转，提示在我国有院外散发脓肿分枝杆菌感染的病例，临床医生应提高对本病的认识，对可疑病例做非结核分枝杆菌培养和鉴定。     

Disseminated dermatophytic pseudomycetoma caused by Microsporum species

Background  Dermatophyte infection is almost exclusively a superficial cutaneous mycosis usually confined to the stratum corneum of nails and hairs of normal hosts. Deep cutaneous and subcutaneous infections due to dermatophytes are exceedingly rare and usually limited to immunosuppressed individuals. These infections remain chronic and persist in spite of treatment. Materials and methods  We report two clinical cases of disseminated dermatophytic pseudomycetoma caused by Microsporum gypseum and Microsporum canis in immunosuppressed patients. Results  Patient 1, in 2008, showed improvement with fluconazole, cephalothin, and terbinafine treatment for Microsporum gypseum. After suspension of the treatment, new lesions appeared and culture from material was positive. In 2009, she presented confluent papules and nodules forming plaques on her face and neck with the isolation of Microsporum canis. Clinical response to this treatment was poor. Patient 2 was affected by both tinea corporis due to Trichophyton rubrum and dermatophytic pseudomycetoma caused by Microsporum canis. The response to treatment was successful with oral itraconazole and local surgical excision. Conclusions  It is important to recognize these atypical presentations of dermatophytic infections in immunosuppressed patients, which may warrant a more aggressive treatment in order to achieve resolution.