MYCOBACTERIUM
FORTUITUM
INFECTIONS
OF THE
HAND
Report of five cases F. K. IP and S. P. CHOW From the Department of Orthopaedic Surgery, Queen Mary Hospital, Hong Kong
Five cases are reported of infection due to Mycobucteriumfovtuitum involving the hand following contaminated injection or traumatic wounds. Synovectomy, debridement, or amputation together with prolonged chemotherapy using kanamycin or amikacin were required. Doxycycline and sulphamethoxasole also seemed to be the effective antibiotics for this organism. A high index of suspicion is important in order to obtain the correct diagnosis. Journal of Hand Surgery
(British Volume, 1992)
17B: 675-677
Mycobacterium
fortuitum has been regarded as a saprophytic organism, and when isolated from wounds, as a contaminant. Despite isolation of the organism by Cruz in 1938, attention was only given to these atypical mycobacterial infections in the 1960s. Beck (1965) reported three patients who developed abscesses at injection sites after BCG and iron-dextran injections. Hand et al (1970) reported six cases of M. fort&urn infection. He suggested that they should be regarded as a human pathogen, and there have been other reports of M. firtuitum infections leading to cutaneous abscesses (Shocket et al, 1964; Canilang and Armstrong, 1968). However, reports of such infections in the hand are rare (Booth et al, 1979; Ariel et al, 1983; Crick and Vandevelde, 1986).
Cases 3,4 and 5 received local steroid infections from the same practitioner. The practitioner’s clinic was searched by the police for investigation of this epidemic of infection. Multiple swabs were taken from various areas in the clinic. The bacterium, M. fortuitum, was obtained from the flower pot in his office, the sterilizer and the antiseptic solution. In his clinic, disposable needles and syringes were resterilized for repeated usage. Such contaminated inoculation accounted for this outbreak of atypical mycobacterial infection. DISCUSSION Mycobacterium
fortuitum belongs to Runyon’s group IV mycobacterium (Runyon, 1959). The isolated bacteria are strongly acid-fast, non-virulent to guinea pigs and grow rapidly in McConkie and ordinary blood agar (within one week) at 37°C. They are widespread in nature and can be found in fish, water and soil. They are usually considered to be non-pathogenic unless introduced deep into the body.
MATERIAL The details of five cases of M. fort&urn infection in the hand are shown in Table 1. Figure 1 shows the appearance of the infected right index finger in case 1. Table l-Summary Case
Sex/
?lO.
age
of the five cases Site of involvement
Presentation
Surgery
1.
M/adult
(R) index finger
Pierced by metal piece leading to tenosynovitis
Synovectomy
2.
M/adult
(R) thumb
Dirt on floor leading to ulceration of thumb tip
Repeated debridement and finally amputation MP level
Result
at
Antibiotic used
Length of medication
Healed in weeks Satisfactory function
Kanamycin doxycycline and sulphamethoxazole
9 months
Healed soon after amputation
Kanamycin, amikacin, doxycycline and sulphamethoxazole
9 months
Healed soon after amputation
Kanamycin, amikacin, doxycycline and sulphamethoxazole
1 year
3.
F/l3
(R) middle finger
4 local steriod injections leading to sinus and tenosynovitis
Debridement and finally amputation at MP level
4.
F/56
(R) wrist (R) knee
> 30 local steriod injections leading to subacute pyogenic arthritis of right knee and right wrist
Biopsy of wrist swelling, Healed in 5 synovectomy of knee and months excision of granuloma (R) wrist
Kanamycin, rifampicin, isoniazid, pyrazinamide, doxycycline and sulphamethoxazole
1 year
5.
F/62
(L) middle finger
6 local steriod injections leading to tenosynovitis
Synovectomy
Amikacin, kanamycin, doxycycline and sulphamethoxazole
1 year
675
Healed in 2 months
616
THE
JOURNAL
OF HAND
SURGERY
VOL.
17B No. 6 DECEMBER
1992
Chow et al, 1983, 1987). Infections from Mycobacterium kansasii, Mycobacterium avium and Mycobacterium intracelldare have been reported (Kelly et al, 1967). They
Fig.
1
Case
1. Infection
in the right index finger following a
penetrating injury.
Becki (1965). first drew attention to subcutaneous abscesses of M. fortuitum in patients receiving various injections. Since then, M. fortuitum has been found in pulmonary disease (Dross et al, 1964; Phillips and Larkin, 1964) and cornea1 ulcerations (Turner and Stinson, 1965; Lauring et al, 1969). They have also been isolated as agents causing infection after prosthetic arthroplasty (Booth et al, 1979; Herold et al, 1987). Among the atypical mycobacterial infection of the hand, Mycobacterium marinum is the most frequent agent (Cortez and Pankey, 1973 ; Williams and Riordan, 1973 ;
usually present as tenosynovitis. Arielet al (1983) reported one case of extensor tenosynovitis of the hand due to M. fortuitum after a dog bite. Crick and Vandevelde (1986) reported a mid-palmar space infection by the same organism following a penetrating injury. A case of M. fortuitum infection after silastic trapezium prosthesis insertion was reported by Booth et al (1979). Our series adds five more cases to the literature. It seems that these infections are caused by penetrating injuries or injections. In Hand and Sandford’s (1970) series of six patients, the extremities were involved in five and they were associated with external trauma such as laceration, gunshot injury or injection. All our patients had some form of trauma prior to the development of infection. In his three cases of abscesses secondary to injection, Beck (1965) postulated that infection was due either to contamination of syringe or the injected material. The organism might also be present on skin. Foz et al (1978) reported an outbreak of cutaneous infection by M. fortuitum after stripping of varicose veins. The source was found to be a contaminated aqueous solution of merbromium used in presurgical care. In our series, cases 3,4 and 5 had similar contact with contaminants. The diagnosis of these infections is not easy (Dalovisio and Pankey, 1978). Pus can sometimes be found on exploration, as in case 4. If mycobacterial culture is not specifically requested, the organism may never be isolated. Colonies of M. fortuitum resemble diphtheroid organisms when examined under Gram stain and they may be missed unless Ziehl-Neelson staining is also performed. Skin tests are of doubtful value. Treatment is often difficult because of drug resistance. Kanamycin is the drug of choice. There are also reports of sensitivity to amikacin, doxycycline and sulphamethoxazole (Dalovisio et al, 1981). Local surgical treatment also has a role in treatment. Herndon et al (1972) reported successful debridement of infected below-knee amputation stumps in three patients. Sometimes, both surgery and chemotherapy are needed. In summary, atypical mycobacterial infection of the hand should be suspected when infection follows trauma and responds poorly to standard antibiotics. Once the diagnosis is confirmed by tissue examination, a combined approachof early radical debridement and chemotherapy using kanamycin and amikacin, or doxycycline and sulphamethoxazole give the best chance of controlling the infection.
References ARIEL, I., HAAS, H., WEINBERG, H., ROUSSO, M. and ROSSENMANN, E. (1983). Mycobacteriumfortuitum granulomatous synovitis caused by a dog bite. Journal of Hand Surgery, 8 : 3 : 342-343. BECK, A. (1965). Mycobacterium firtuitum in abscesses of man. Journal of Clinical Pathology, 18: 307-313.
MYCOBACTERIUM
FORTUITUM
INFECTIONS
OF THE
HAND
BOOTH, J. E., JACOBSON, J. A., KURRUS, T. A. and EDWARDS, T. W. (1979). Infection of prosthetic arthroplasty by Mycobacteriumfortuitum: Two case reports. Journal of Bone and Joint Surgery, 61A: 2: 300-302. CANILANG, B. and ARMSTRONG, D. (1968). Subcutaneous abscesses due to Mycobacteriumfortuitum: Report of a case. American Review of Respiratory Diseases, 97: 451454. CHOW, S. P., STROEBEL, A. B., LAU, J. H. K. and COLLINS, R. J. (1983). Mycobacterium marinum infection of the hand involving deep structures. Journal of Hand Surgery, 8: 5(l): 568-573. CHOW, S. P., IP, F. K., LAU, J. H. K., COLLINS, R. J., LUK, K. D. K., SO, Y. C. and PUN, W. K. (1987). Mycobacteriummarinum infectionofthe hand and wrist. Journal of Bone and Joint Surgery, 69A: 8: 1161-l 168. CORTEZ, L. M. and PANKEY, G. A. (1973). Mycobncteriummnrinum infections of the hand. Report of three cases and review of the literature. Journal of Bone and Joint Surgery, 55A : 2: 363-370. CRICK, J. C. and VANDEVELDE, A. G. (1986). Mycobacterium fortuitum midpalmar space abscess: a case report. Journal of Hand Surgery, 11A: 3: 438-440. CRUZ, J. D. A. C. (1938). “Mycobacterium fortuitum,” urn Nova Bacilo Acidoresistente Patogenico para o Homen. Acta Medical Rio de Janeiro, 1: 297301. DALOVISIO, J. R. and PANKEY, G. A. (1978). Problems in diagnosis and therapy on Mycobacterium ,firtuitum infections. American Review of Respiratory Diseases, 117 : 625-630. DALOVISIO, J. R., PANKEY, G. A., WALLACE, R. J. and JONES, D. B. (1981). Clinical usefulness of amikacin and doxycycline in the treatment of chelonei. infection due to Mycobacterium fortuitum and Mycobacterium Reviews of Infectious Diseases, 3: 5: 1068-1074. DROSS, I. C., ABBATIELLO, A. A., JENNEY, F. S. and COHEN, A. C. (1964). Pulmonary infection due to Mycobacterium firtuitum. American Review of Respiratory Diseases, 89: 923-925. FOZ, A., ROY, C., JURADO, J.,ARTEAGA, E., RUIZ, J. M. and MORAGAS, A. (1978). Mycobacterium chelonei iatrogenic infections. Journal of Clinical Microbiology, 7: 3: 319-321.
611 HAND, W. L. and SANFORD, J. P. (1970). Mycobacteriumfirtuitum-a human pathogen. Annals of Internal Medicine, 73 : 971-977. HERNDON, J. H., DANTZKER, D. R. and LANOUE, A. M. (1972). Mycobacteriumfortuitum infections involving the extremities: report of three cases. Journal of Bone and Joint Surgery, 54A: 6: 1279-1282. HEROLD, R. C., LOTKE, P. A. and MACGREGOR, R. R. (1987). Prosthetic joint infections secondary to rapidly growing Mycobacterium fortuitum. Clinical Orthopaedics and Related Research, 216: 183-186. KELLY, P. J., KARLSON, A. G., WEED, L. A. and LIPSCOMB, P. R. (1967). Infection of synovial tissues by mycobacteria other than Mycobacterium tuberculosis. Journal of Bone and Joint Surgery, 49A: 8: 1521&1530. LAURING, L. M., WERGELAND, F. L. and SACK, G. E. (1969). Anonymous Mycobacterium keratitis. American Journal of Ophthalmology, 67: 130-133. PHILLIPS, S. and LARKIN, J. C. (1964). Atypical pulmonary tuberculosis caused by unclassified mycobacteria. Annals of Internal Medicine, 60: 401408. RUNYON, E. H. (1959). Anonymous mycobacteria in pulmonary disease. Medical Clinics of North America, 43: 1: 273-290. SHOCKET, E., DROSD, R. E. and TATE, C. F. (1964). Granuloma of the skin due to Mycobacteriumfbrtuitum. Southern Medical Journal, 57: 1352-1356. as a cause of TURNER, L. and STINSON, I. (1965). Mycobacteriumfortuitum cornea1 ulcer. American Journal of Ophthalmology, 60 : 329-33 1. WILLIAMS, C. S. and RIORDAN, D. C. (1973). Mycobacterium marinum (atypical acid-fast bacillus) infections of the hand: A report of six cases. Journal of Bone and Joint Surgery, 55A: 5: 1042-1050.
Accepted: 30 December 1991 Prof. S. P. Chow, Department oforthopaedic &gay, Kong. 0 1992 The British Society for Surgery of the Hand
Queen Mary Hospital, Pokfulam, Hong
FORTUITUM
INFECTIONS
OF THE
HAND
Report of five cases F. K. IP and S. P. CHOW From the Department of Orthopaedic Surgery, Queen Mary Hospital, Hong Kong
Five cases are reported of infection due to Mycobucteriumfovtuitum involving the hand following contaminated injection or traumatic wounds. Synovectomy, debridement, or amputation together with prolonged chemotherapy using kanamycin or amikacin were required. Doxycycline and sulphamethoxasole also seemed to be the effective antibiotics for this organism. A high index of suspicion is important in order to obtain the correct diagnosis. Journal of Hand Surgery
(British Volume, 1992)
17B: 675-677
Mycobacterium
fortuitum has been regarded as a saprophytic organism, and when isolated from wounds, as a contaminant. Despite isolation of the organism by Cruz in 1938, attention was only given to these atypical mycobacterial infections in the 1960s. Beck (1965) reported three patients who developed abscesses at injection sites after BCG and iron-dextran injections. Hand et al (1970) reported six cases of M. fort&urn infection. He suggested that they should be regarded as a human pathogen, and there have been other reports of M. firtuitum infections leading to cutaneous abscesses (Shocket et al, 1964; Canilang and Armstrong, 1968). However, reports of such infections in the hand are rare (Booth et al, 1979; Ariel et al, 1983; Crick and Vandevelde, 1986).
Cases 3,4 and 5 received local steroid infections from the same practitioner. The practitioner’s clinic was searched by the police for investigation of this epidemic of infection. Multiple swabs were taken from various areas in the clinic. The bacterium, M. fortuitum, was obtained from the flower pot in his office, the sterilizer and the antiseptic solution. In his clinic, disposable needles and syringes were resterilized for repeated usage. Such contaminated inoculation accounted for this outbreak of atypical mycobacterial infection. DISCUSSION Mycobacterium
fortuitum belongs to Runyon’s group IV mycobacterium (Runyon, 1959). The isolated bacteria are strongly acid-fast, non-virulent to guinea pigs and grow rapidly in McConkie and ordinary blood agar (within one week) at 37°C. They are widespread in nature and can be found in fish, water and soil. They are usually considered to be non-pathogenic unless introduced deep into the body.
MATERIAL The details of five cases of M. fort&urn infection in the hand are shown in Table 1. Figure 1 shows the appearance of the infected right index finger in case 1. Table l-Summary Case
Sex/
?lO.
age
of the five cases Site of involvement
Presentation
Surgery
1.
M/adult
(R) index finger
Pierced by metal piece leading to tenosynovitis
Synovectomy
2.
M/adult
(R) thumb
Dirt on floor leading to ulceration of thumb tip
Repeated debridement and finally amputation MP level
Result
at
Antibiotic used
Length of medication
Healed in weeks Satisfactory function
Kanamycin doxycycline and sulphamethoxazole
9 months
Healed soon after amputation
Kanamycin, amikacin, doxycycline and sulphamethoxazole
9 months
Healed soon after amputation
Kanamycin, amikacin, doxycycline and sulphamethoxazole
1 year
3.
F/l3
(R) middle finger
4 local steriod injections leading to sinus and tenosynovitis
Debridement and finally amputation at MP level
4.
F/56
(R) wrist (R) knee
> 30 local steriod injections leading to subacute pyogenic arthritis of right knee and right wrist
Biopsy of wrist swelling, Healed in 5 synovectomy of knee and months excision of granuloma (R) wrist
Kanamycin, rifampicin, isoniazid, pyrazinamide, doxycycline and sulphamethoxazole
1 year
5.
F/62
(L) middle finger
6 local steriod injections leading to tenosynovitis
Synovectomy
Amikacin, kanamycin, doxycycline and sulphamethoxazole
1 year
675
Healed in 2 months
616
THE
JOURNAL
OF HAND
SURGERY
VOL.
17B No. 6 DECEMBER
1992
Chow et al, 1983, 1987). Infections from Mycobacterium kansasii, Mycobacterium avium and Mycobacterium intracelldare have been reported (Kelly et al, 1967). They
Fig.
1
Case
1. Infection
in the right index finger following a
penetrating injury.
Becki (1965). first drew attention to subcutaneous abscesses of M. fortuitum in patients receiving various injections. Since then, M. fortuitum has been found in pulmonary disease (Dross et al, 1964; Phillips and Larkin, 1964) and cornea1 ulcerations (Turner and Stinson, 1965; Lauring et al, 1969). They have also been isolated as agents causing infection after prosthetic arthroplasty (Booth et al, 1979; Herold et al, 1987). Among the atypical mycobacterial infection of the hand, Mycobacterium marinum is the most frequent agent (Cortez and Pankey, 1973 ; Williams and Riordan, 1973 ;
usually present as tenosynovitis. Arielet al (1983) reported one case of extensor tenosynovitis of the hand due to M. fortuitum after a dog bite. Crick and Vandevelde (1986) reported a mid-palmar space infection by the same organism following a penetrating injury. A case of M. fortuitum infection after silastic trapezium prosthesis insertion was reported by Booth et al (1979). Our series adds five more cases to the literature. It seems that these infections are caused by penetrating injuries or injections. In Hand and Sandford’s (1970) series of six patients, the extremities were involved in five and they were associated with external trauma such as laceration, gunshot injury or injection. All our patients had some form of trauma prior to the development of infection. In his three cases of abscesses secondary to injection, Beck (1965) postulated that infection was due either to contamination of syringe or the injected material. The organism might also be present on skin. Foz et al (1978) reported an outbreak of cutaneous infection by M. fortuitum after stripping of varicose veins. The source was found to be a contaminated aqueous solution of merbromium used in presurgical care. In our series, cases 3,4 and 5 had similar contact with contaminants. The diagnosis of these infections is not easy (Dalovisio and Pankey, 1978). Pus can sometimes be found on exploration, as in case 4. If mycobacterial culture is not specifically requested, the organism may never be isolated. Colonies of M. fortuitum resemble diphtheroid organisms when examined under Gram stain and they may be missed unless Ziehl-Neelson staining is also performed. Skin tests are of doubtful value. Treatment is often difficult because of drug resistance. Kanamycin is the drug of choice. There are also reports of sensitivity to amikacin, doxycycline and sulphamethoxazole (Dalovisio et al, 1981). Local surgical treatment also has a role in treatment. Herndon et al (1972) reported successful debridement of infected below-knee amputation stumps in three patients. Sometimes, both surgery and chemotherapy are needed. In summary, atypical mycobacterial infection of the hand should be suspected when infection follows trauma and responds poorly to standard antibiotics. Once the diagnosis is confirmed by tissue examination, a combined approachof early radical debridement and chemotherapy using kanamycin and amikacin, or doxycycline and sulphamethoxazole give the best chance of controlling the infection.
References ARIEL, I., HAAS, H., WEINBERG, H., ROUSSO, M. and ROSSENMANN, E. (1983). Mycobacteriumfortuitum granulomatous synovitis caused by a dog bite. Journal of Hand Surgery, 8 : 3 : 342-343. BECK, A. (1965). Mycobacterium firtuitum in abscesses of man. Journal of Clinical Pathology, 18: 307-313.
MYCOBACTERIUM
FORTUITUM
INFECTIONS
OF THE
HAND
BOOTH, J. E., JACOBSON, J. A., KURRUS, T. A. and EDWARDS, T. W. (1979). Infection of prosthetic arthroplasty by Mycobacteriumfortuitum: Two case reports. Journal of Bone and Joint Surgery, 61A: 2: 300-302. CANILANG, B. and ARMSTRONG, D. (1968). Subcutaneous abscesses due to Mycobacteriumfortuitum: Report of a case. American Review of Respiratory Diseases, 97: 451454. CHOW, S. P., STROEBEL, A. B., LAU, J. H. K. and COLLINS, R. J. (1983). Mycobacterium marinum infection of the hand involving deep structures. Journal of Hand Surgery, 8: 5(l): 568-573. CHOW, S. P., IP, F. K., LAU, J. H. K., COLLINS, R. J., LUK, K. D. K., SO, Y. C. and PUN, W. K. (1987). Mycobacteriummarinum infectionofthe hand and wrist. Journal of Bone and Joint Surgery, 69A: 8: 1161-l 168. CORTEZ, L. M. and PANKEY, G. A. (1973). Mycobncteriummnrinum infections of the hand. Report of three cases and review of the literature. Journal of Bone and Joint Surgery, 55A : 2: 363-370. CRICK, J. C. and VANDEVELDE, A. G. (1986). Mycobacterium fortuitum midpalmar space abscess: a case report. Journal of Hand Surgery, 11A: 3: 438-440. CRUZ, J. D. A. C. (1938). “Mycobacterium fortuitum,” urn Nova Bacilo Acidoresistente Patogenico para o Homen. Acta Medical Rio de Janeiro, 1: 297301. DALOVISIO, J. R. and PANKEY, G. A. (1978). Problems in diagnosis and therapy on Mycobacterium ,firtuitum infections. American Review of Respiratory Diseases, 117 : 625-630. DALOVISIO, J. R., PANKEY, G. A., WALLACE, R. J. and JONES, D. B. (1981). Clinical usefulness of amikacin and doxycycline in the treatment of chelonei. infection due to Mycobacterium fortuitum and Mycobacterium Reviews of Infectious Diseases, 3: 5: 1068-1074. DROSS, I. C., ABBATIELLO, A. A., JENNEY, F. S. and COHEN, A. C. (1964). Pulmonary infection due to Mycobacterium firtuitum. American Review of Respiratory Diseases, 89: 923-925. FOZ, A., ROY, C., JURADO, J.,ARTEAGA, E., RUIZ, J. M. and MORAGAS, A. (1978). Mycobacterium chelonei iatrogenic infections. Journal of Clinical Microbiology, 7: 3: 319-321.
611 HAND, W. L. and SANFORD, J. P. (1970). Mycobacteriumfirtuitum-a human pathogen. Annals of Internal Medicine, 73 : 971-977. HERNDON, J. H., DANTZKER, D. R. and LANOUE, A. M. (1972). Mycobacteriumfortuitum infections involving the extremities: report of three cases. Journal of Bone and Joint Surgery, 54A: 6: 1279-1282. HEROLD, R. C., LOTKE, P. A. and MACGREGOR, R. R. (1987). Prosthetic joint infections secondary to rapidly growing Mycobacterium fortuitum. Clinical Orthopaedics and Related Research, 216: 183-186. KELLY, P. J., KARLSON, A. G., WEED, L. A. and LIPSCOMB, P. R. (1967). Infection of synovial tissues by mycobacteria other than Mycobacterium tuberculosis. Journal of Bone and Joint Surgery, 49A: 8: 1521&1530. LAURING, L. M., WERGELAND, F. L. and SACK, G. E. (1969). Anonymous Mycobacterium keratitis. American Journal of Ophthalmology, 67: 130-133. PHILLIPS, S. and LARKIN, J. C. (1964). Atypical pulmonary tuberculosis caused by unclassified mycobacteria. Annals of Internal Medicine, 60: 401408. RUNYON, E. H. (1959). Anonymous mycobacteria in pulmonary disease. Medical Clinics of North America, 43: 1: 273-290. SHOCKET, E., DROSD, R. E. and TATE, C. F. (1964). Granuloma of the skin due to Mycobacteriumfbrtuitum. Southern Medical Journal, 57: 1352-1356. as a cause of TURNER, L. and STINSON, I. (1965). Mycobacteriumfortuitum cornea1 ulcer. American Journal of Ophthalmology, 60 : 329-33 1. WILLIAMS, C. S. and RIORDAN, D. C. (1973). Mycobacterium marinum (atypical acid-fast bacillus) infections of the hand: A report of six cases. Journal of Bone and Joint Surgery, 55A: 5: 1042-1050.
Accepted: 30 December 1991 Prof. S. P. Chow, Department oforthopaedic &gay, Kong. 0 1992 The British Society for Surgery of the Hand
Queen Mary Hospital, Pokfulam, Hong
