Correspondence
Sporotrichoid cutaneous infection by Mycobacterium abscessus
Sir, Mycobacterium abscessus is the most pathogenic and chemotherapy-resistant rapid-growing mycobacterium.1 It is an environmental mycobacterial species ubiquitous in soil and water causing a wide range of disease: most commonly localized infections of the skin and subcutaneous tissue, rarely pulmonary infections. A 48-year-old female patient presented to our department with reddish papular and nodular cherry-sized lesions following a linear distribution along the back of the left hand and arm. On admission, ill-defined erythematous nodules with purulent discharge were located on the left arm, which appeared swollen (Fig. 1). No other skin abnormalities or local lymphadenopathy were found, and the patient did not report signs or symptoms of arthritis, bursitis, or tenosynovitis. She was afebrile, with a heart rate of 75 beats/min and blood pressure of 120/ 80 mmHg, there were no systemic symptoms of infection, and all the systems were clinically normal. The patient had no background of immunosuppression or tuberculosis, and she denied having a history of previous cutaneous injury, injection, or surgical intervention. We asked the patient about her lifestyle and hobbies, and she mentioned having an aquarium with some fish in apparently good condition. Laboratory investigations revealed mild leukocytosis (11 240/ll, nv. 4000–10 000/ll), borderline antistreptolysin O titer (322 UI/ml, nv. < 200 UI/ml), elevated C-reactive protein (1.77 mg/dl, nv. < 1 mg/dl), and elevated erythrocyte sedimentation rate (42 mm/h, nv. M < 20 mm/h, F < 30 mm/h). Renal function tests were within normal limits. Tests for antibodies to human immunodeficiency virus, purified protein derivative skin
Figure 1 Caseous/purulent discharge from a nodular lesion on the medial upper left arm ª 2013 The International Society of Dermatology
test, and Widal test were negative. According to clinical and anamnestic data, an atypical mycobacteriosis infection was suspected; therefore, a needle aspiration biopsy of two of the most recent skin lesions was performed, and extracted material was subjected to both microbiological examination and molecular analysis. Acid-fast bacilli were detected by Ziehl–Neelsen staining (Fig. 2); caseous necrosis and eosinophil cells were also observed. Excisional biopsy was performed, and histological findings demonstrated pathology that ranged from nonspecific to suppurative or caseous granulomas. Standard drug therapy for non-tuberculous mycobacteria with doxycycline 100 mg twice daily and local rifamycin twice daily was started. In vitro culture on the Lowenstein Jensen medium, incubated at 30 °C, did not show any microbial growth after about 10 weeks’ incubation. Molecular diagnosis was based on the evaluation of the gene coding for the 65-kDa heat shock protein. The molecular test was carried out through a genus-specific polymerase chain reaction (PCR) targeting 65-kDa mycobacterial membrane protein gene followed by automated DNA-sequencing (ABI Prism 310 Sequencer; Applied Biosystems, Foster City, CA, USA). Standard microbiological techniques including culture and common mycobacterial PCRs did not reveal other mycobacterial pathogens. Routine laboratory tests did not show noteworthy alterations. According to both clinical pattern and laboratory and histological findings, a skin sporotrichoid atypical mycobacteriosis by M. abscessus was diagnosed. Because M. abscessus was isolated two months after induction of therapy, when a regression of the lesions had not yet been observed, the therapeutic regimen with doxycycline and rifamycin was carried on until the third month. At 4, 8, 12, 16, and 20 weeks, no concomitant skin lesion appeared and regression of the lesions was observed, leaving only a few scarred spots.
Figure 2 Acid-fast bacilli detected by Ziehl–Neelsen staining International Journal of Dermatology 2014, 53, e240–e316
e291
e292
Correspondence
Mycobacterium abscessus infection in humans is comparatively rare. Although it is an opportunistic pathogen in immunosuppressed patients, causing disseminated infections, M. abscessus may occasionally affect immunocompetent patients as well. Infections in immunocompetent patients usually occur following cutaneous injury, injections, and surgical intervention.2 Mycobacterium abscessus infection in the hand, in particular, is rare and usually occurs in immunocompromised patients, even if two cases of M. abscessus infection of the hand have been reported in otherwise healthy fish handlers.3 Chronic tenosynovitis, osteomyelitis, and myositis can accompany the symptoms even in immunocompetent patients.2,3 Outbreaks of M. abscessus infection have been reported following acupuncture, laparoscopic surgery, mesotherapy, and rhytidectomy.4–6 Because our patient did not report any predisposing exposure factors – except for her aquarium activity – and no other similar cases have been reported, we ruled out the possibility of an outbreak in favor of a sporadic occurrence. The sporotrichoid pattern of our case is also rare as in the literature only two cases of sporotrichoid dermatosis caused by M. abscessus have been reported.7,8 Drug treatment is a challenge because this mycobacterium is usually resistant to most antimycobacterial drugs. Chemotherapeutic options for infections caused by M. abscessus are amikacin, tigecycline, linezolid, clarithromycin, and cefoxitin; instead, drug resistance is attributed to doxycycline, imipenem, and sulfamethoxazole.9 The diagnosis of M. abscessus infection requires a detailed history as well as complex microbiological cultures and mycobacterial antigen detection by PCR-based procedures that often require a long time. No large systemic studies have been performed for determining the optimal treatment regimen. In most cases, a combination of antimycobacterials should be administered depending on infection severity. Doxycycline resistance is well documented in the literature. In the present case, the therapeutic success of doxycycline, administered before the typization of mycobacterium species, could be attributed to a spontaneous recovery, which has been reported in 10–20% of immunocompetent patients with localized skin disease,10 or to a susceptibility to doxycycline that we have not investigated. Ada Lo Schiavo, MD Stefano Caccavale, MD Michele Del Vecchio, MD Michele Schiavone, MD Rossella Alfano, MD Department of Dermatology Second University of Naples Naples
International Journal of Dermatology 2014, 53, e240–e316
Italy E-mail: [email protected] Francesca Bombace, MD Maria Rosaria Iovene, MD Department of Microbiology Second University of Naples Naples Italy Conflict of interest: We declare that there isnt any kind of conflict of interest. We certify that there are no financial or personal relationships between our institutions and others that could bias the work set out in the manuscript. Our original work has not been published before and is not being considered for publication elsewhere in its final form either in printed or electronic form. References 1 Petrini B. Mycobacterium abscessus: an emerging rapidgrowing potential pathogen. APMIS 2006; 114: 319–328. 2 Lee WJ, Kang SM, Sung H, et al. Non-tuberculous mycobacterial infections of the skin: a retrospective study of 29 cases. J Dermatol 2010; 37: 965–972. 3 Kang GC, Gan AW, Yam A, et al. Mycobacterium abscessus hand infections in immunocompetent fish handlers: case report. J Hand Surg Am 2010; 35: 1142–1145. 4 Koh SJ, Song T, Kang YA, et al. An outbreak of skin and soft tissue infection caused by Mycobacterium abscessus following acupuncture. Clin Microbiol Infect 2010; 16: 895–901. 5 Galmes-Truyols A, Gimenez-Duran J, Bosch-Isabel C, et al. An outbreak of cutaneous infection due to Mycobacterium abscessus associated to mesotherapy. Enferm Infecc Microbiol Clin 2011; 29: 510–514. 6 Agarwal A, Maloney RW. Mycobacterium abscessus outbreak after rhytidectomies performed in an outpatient surgery center. Plast Reconstr Surg 2011; 128: 85e–86e. 7 Teo RY, Tay YK, Poh WT. Sporotrichoid nodules caused by Mycobacterium abscessus. Acta Derm Venereol 2008; 88: 625–627. 8 Lee WJ, Kim TW, Shur KB, et al. Sporotrichoid dermatosis caused by Mycobacterium abscessus from a public bath. J Dermatol 2000; 27: 264–268. 9 Cavusoglu C, Gurpinar T, Ecemis T. Evaluation of antimicrobial susceptibilities of rapidly growing mycobacteria by Sensititre RAPMYCO panel. New Microbiol 2012; 35: 73–76. 10 Weitzul S, Eichhorn PJ, Pandya AG. Nontuberculous mycobacterial infections of the skin. Dermatol Clin 2000; 18: 359–377.
ª 2013 The International Society of Dermatology
Sporotrichoid cutaneous infection by Mycobacterium abscessus
Sir, Mycobacterium abscessus is the most pathogenic and chemotherapy-resistant rapid-growing mycobacterium.1 It is an environmental mycobacterial species ubiquitous in soil and water causing a wide range of disease: most commonly localized infections of the skin and subcutaneous tissue, rarely pulmonary infections. A 48-year-old female patient presented to our department with reddish papular and nodular cherry-sized lesions following a linear distribution along the back of the left hand and arm. On admission, ill-defined erythematous nodules with purulent discharge were located on the left arm, which appeared swollen (Fig. 1). No other skin abnormalities or local lymphadenopathy were found, and the patient did not report signs or symptoms of arthritis, bursitis, or tenosynovitis. She was afebrile, with a heart rate of 75 beats/min and blood pressure of 120/ 80 mmHg, there were no systemic symptoms of infection, and all the systems were clinically normal. The patient had no background of immunosuppression or tuberculosis, and she denied having a history of previous cutaneous injury, injection, or surgical intervention. We asked the patient about her lifestyle and hobbies, and she mentioned having an aquarium with some fish in apparently good condition. Laboratory investigations revealed mild leukocytosis (11 240/ll, nv. 4000–10 000/ll), borderline antistreptolysin O titer (322 UI/ml, nv. < 200 UI/ml), elevated C-reactive protein (1.77 mg/dl, nv. < 1 mg/dl), and elevated erythrocyte sedimentation rate (42 mm/h, nv. M < 20 mm/h, F < 30 mm/h). Renal function tests were within normal limits. Tests for antibodies to human immunodeficiency virus, purified protein derivative skin
Figure 1 Caseous/purulent discharge from a nodular lesion on the medial upper left arm ª 2013 The International Society of Dermatology
test, and Widal test were negative. According to clinical and anamnestic data, an atypical mycobacteriosis infection was suspected; therefore, a needle aspiration biopsy of two of the most recent skin lesions was performed, and extracted material was subjected to both microbiological examination and molecular analysis. Acid-fast bacilli were detected by Ziehl–Neelsen staining (Fig. 2); caseous necrosis and eosinophil cells were also observed. Excisional biopsy was performed, and histological findings demonstrated pathology that ranged from nonspecific to suppurative or caseous granulomas. Standard drug therapy for non-tuberculous mycobacteria with doxycycline 100 mg twice daily and local rifamycin twice daily was started. In vitro culture on the Lowenstein Jensen medium, incubated at 30 °C, did not show any microbial growth after about 10 weeks’ incubation. Molecular diagnosis was based on the evaluation of the gene coding for the 65-kDa heat shock protein. The molecular test was carried out through a genus-specific polymerase chain reaction (PCR) targeting 65-kDa mycobacterial membrane protein gene followed by automated DNA-sequencing (ABI Prism 310 Sequencer; Applied Biosystems, Foster City, CA, USA). Standard microbiological techniques including culture and common mycobacterial PCRs did not reveal other mycobacterial pathogens. Routine laboratory tests did not show noteworthy alterations. According to both clinical pattern and laboratory and histological findings, a skin sporotrichoid atypical mycobacteriosis by M. abscessus was diagnosed. Because M. abscessus was isolated two months after induction of therapy, when a regression of the lesions had not yet been observed, the therapeutic regimen with doxycycline and rifamycin was carried on until the third month. At 4, 8, 12, 16, and 20 weeks, no concomitant skin lesion appeared and regression of the lesions was observed, leaving only a few scarred spots.
Figure 2 Acid-fast bacilli detected by Ziehl–Neelsen staining International Journal of Dermatology 2014, 53, e240–e316
e291
e292
Correspondence
Mycobacterium abscessus infection in humans is comparatively rare. Although it is an opportunistic pathogen in immunosuppressed patients, causing disseminated infections, M. abscessus may occasionally affect immunocompetent patients as well. Infections in immunocompetent patients usually occur following cutaneous injury, injections, and surgical intervention.2 Mycobacterium abscessus infection in the hand, in particular, is rare and usually occurs in immunocompromised patients, even if two cases of M. abscessus infection of the hand have been reported in otherwise healthy fish handlers.3 Chronic tenosynovitis, osteomyelitis, and myositis can accompany the symptoms even in immunocompetent patients.2,3 Outbreaks of M. abscessus infection have been reported following acupuncture, laparoscopic surgery, mesotherapy, and rhytidectomy.4–6 Because our patient did not report any predisposing exposure factors – except for her aquarium activity – and no other similar cases have been reported, we ruled out the possibility of an outbreak in favor of a sporadic occurrence. The sporotrichoid pattern of our case is also rare as in the literature only two cases of sporotrichoid dermatosis caused by M. abscessus have been reported.7,8 Drug treatment is a challenge because this mycobacterium is usually resistant to most antimycobacterial drugs. Chemotherapeutic options for infections caused by M. abscessus are amikacin, tigecycline, linezolid, clarithromycin, and cefoxitin; instead, drug resistance is attributed to doxycycline, imipenem, and sulfamethoxazole.9 The diagnosis of M. abscessus infection requires a detailed history as well as complex microbiological cultures and mycobacterial antigen detection by PCR-based procedures that often require a long time. No large systemic studies have been performed for determining the optimal treatment regimen. In most cases, a combination of antimycobacterials should be administered depending on infection severity. Doxycycline resistance is well documented in the literature. In the present case, the therapeutic success of doxycycline, administered before the typization of mycobacterium species, could be attributed to a spontaneous recovery, which has been reported in 10–20% of immunocompetent patients with localized skin disease,10 or to a susceptibility to doxycycline that we have not investigated. Ada Lo Schiavo, MD Stefano Caccavale, MD Michele Del Vecchio, MD Michele Schiavone, MD Rossella Alfano, MD Department of Dermatology Second University of Naples Naples
International Journal of Dermatology 2014, 53, e240–e316
Italy E-mail: [email protected] Francesca Bombace, MD Maria Rosaria Iovene, MD Department of Microbiology Second University of Naples Naples Italy Conflict of interest: We declare that there isnt any kind of conflict of interest. We certify that there are no financial or personal relationships between our institutions and others that could bias the work set out in the manuscript. Our original work has not been published before and is not being considered for publication elsewhere in its final form either in printed or electronic form. References 1 Petrini B. Mycobacterium abscessus: an emerging rapidgrowing potential pathogen. APMIS 2006; 114: 319–328. 2 Lee WJ, Kang SM, Sung H, et al. Non-tuberculous mycobacterial infections of the skin: a retrospective study of 29 cases. J Dermatol 2010; 37: 965–972. 3 Kang GC, Gan AW, Yam A, et al. Mycobacterium abscessus hand infections in immunocompetent fish handlers: case report. J Hand Surg Am 2010; 35: 1142–1145. 4 Koh SJ, Song T, Kang YA, et al. An outbreak of skin and soft tissue infection caused by Mycobacterium abscessus following acupuncture. Clin Microbiol Infect 2010; 16: 895–901. 5 Galmes-Truyols A, Gimenez-Duran J, Bosch-Isabel C, et al. An outbreak of cutaneous infection due to Mycobacterium abscessus associated to mesotherapy. Enferm Infecc Microbiol Clin 2011; 29: 510–514. 6 Agarwal A, Maloney RW. Mycobacterium abscessus outbreak after rhytidectomies performed in an outpatient surgery center. Plast Reconstr Surg 2011; 128: 85e–86e. 7 Teo RY, Tay YK, Poh WT. Sporotrichoid nodules caused by Mycobacterium abscessus. Acta Derm Venereol 2008; 88: 625–627. 8 Lee WJ, Kim TW, Shur KB, et al. Sporotrichoid dermatosis caused by Mycobacterium abscessus from a public bath. J Dermatol 2000; 27: 264–268. 9 Cavusoglu C, Gurpinar T, Ecemis T. Evaluation of antimicrobial susceptibilities of rapidly growing mycobacteria by Sensititre RAPMYCO panel. New Microbiol 2012; 35: 73–76. 10 Weitzul S, Eichhorn PJ, Pandya AG. Nontuberculous mycobacterial infections of the skin. Dermatol Clin 2000; 18: 359–377.
ª 2013 The International Society of Dermatology
