Clinical and taxonomic status of pathogenic nonpigmented or late-pigmenting rapidly growing mycobacteria

A cord blood transplant recipient with Mycobacterium mucogenicum central venous catheter infection after infusion of tap water

Mycobacterium mucogenicum is an unusual cause of central venous catheter and wound infections in immunocompromised persons. The organism is often found in drinking water and is resistant to many disinfectants. We report a cord blood transplant recipient who developed a central venous catheter infection after the patient herself had flushed her catheter with tap water. The infection was successfully treated by removal of the central venous catheter and administration of antimicrobial therapy.

Lung Disease Due to the More Common Nontuberculous Mycobacteria

As the prevalence of tuberculosis (TB) declines in the developed world, the proportion of mycobacterial lung disease due to nontuberculous mycobacteria (NTM) is increasing. It is not clear whether there is a real increase in prevalence or whether NTM disease is being recognized more often because of the introduction of more sensitive laboratory techniques, and that more specimens are being submitted for mycobacterial staining and culture as the result of a greater understanding of the role of NTM in conditions such as cystic fibrosis, posttransplantation and other forms of iatrogenic immunosuppression, immune reconstitution inflammatory syndrome, fibronodular bronchiectasis, and hypersensitivity pneumonitis. The introduction of BACTEC liquid culture systems (BD; Franklin Lakes, NJ) and the development of nucleic acid amplification and DNA probes allow more rapid diagnosis of mycobacterial disease and the quicker differentiation of NTM from TB isolates. High-performance liquid chromatography, polymerase chain reaction, and restriction fragment length polymorphism analysis have helped to identify new NTM species. Although treatment regimens that include the newer macrolides are more effective than the earlier regimens, failure rates are still too high and relapse may occur after apparently successful therapy. Moreover, treatment regimens are difficult to adhere to because of their long duration, adverse effects, and interactions with the other medications that these patients require. The purpose of this article is to review the common presentations of NTM lung disease, the conditions associated with NTM lung disease, and the clinical features and treatment of the NTM that most commonly cause lung disease.

Diagnostic application of genotypic identification of mycobacteria

This study evaluated conventional methods, GLC and three molecular tests, including 16S rRNA sequencing, for the identification of mycobacteria, and the experiences of the authors with the integration of these methods into a diagnostic clinical laboratory were also recorded. Of 1067 clinical isolates of mycobacteria identified by conventional tests, 365 were tested by Accuprobe hybridization assays and PCRs specific for Mycobacterium tuberculosis (MTB) complex or Mycobacterium avium complex (MAC), 202 were tested by 16S rRNA sequencing, and 142 were tested by GLC. Three runs of all tests were performed on a weekly basis. The identifications for 209 MTB complex and 118 MAC isolates obtained by species-specific PCR were in complete agreement with AccuProbe hybridization and conventional test results. The 16S rRNA sequence-based identification, at a similarity of > or =99 %, for 132 of 142 isolates was concordant with the identifications made by the biochemical methods, and for 134 isolates was concordant with the identifications made by GLC at species, group or complex level. 16S rRNA sequencing resulted in fewer incorrectly identified or unidentified organisms than GLC or conventional tests. For the slowly growing non-tuberculous mycobacteria, the mean turnaround times for identification were 4-5 days for 16S rRNA sequencing, 14-29 days for GLC and 22-23 days for conventional methods. Considering the large proportion of some species among clinical isolates, a strategy of initial screening with species-specific PCR (or AccuProbe assays) for the MTB complex and MAC, followed by direct sequencing of the strains that yield negative results, should make 16S rRNA sequencing more affordable for routine application in diagnostic laboratories.

Mycobacterium abscessus: an emerging rapid-growing potential pathogen. Review article

Mycobacterium abscessus is the most pathogenic and chemotherapy-resistant rapid-growing mycobacterium. It is commonly associated with contaminated traumatic skin wounds and with post-surgical soft tissue infections. It is also one of the mycobacteria that are most often isolated from cystic fibrosis patients. It is essential to differentiate this species from the formerly indistinct "M. chelonae-complex", as chemotherapy is especially difficult in M. abscessussenso strictu. Clarithromycin or azithromycin are the only regular oral antimycobacterial agents with an effect on M. abscessus, and should preferably be supplemented with other drugs since long-term monotherapy may cause resistance. Amikacin is a major parenteral drug against M. abscessus that should also be given in combination with another drug. The recently introduced drug tigecycline may prove to be an important addition to chemotherapy, but has yet to be fully clinically evaluated as an antimycobacterial agent. Surgery can be curative, or at least helpful, in the healing of M. abscessus infection, and if conducted, it should include the removal of all foreign or necrotic material. There is increasing awareness of M. abscessus as an emerging pathogen.

Clinical significance and epidemiology of non-pigmented rapidly growing mycobacteria in a university hospital

OBJECTIVES

To study the clinical significance and epidemiology of Non-pigmented rapidly growing mycobacteria (NPRGM) during a 13-year period.

METHODS

We performed a retrospective study of patients with isolates of NPRGM to evaluate their clinical significance. We also analyzed the strains using Randomly Amplified Polymorphic DNA (RAPD) analysis to evaluate the relationship between strains.

RESULTS

Between 1990 and 2003, 65 patients had an isolate of NPRGM. Twenty of them were considered significant (19 cases) or doubtful (1 case). Many cases were skin and soft tissue infections. Six cases were foreign-body related. All the patients recovered with antibiotic therapy and removal of the foreign body. All the patients were apparently unrelated, despite 56.9% of the isolates were detected between 1995 and 1997. RAPD analysis was performed on 43 strains, and showed only a cluster of two Mycobacterium chelonae isolates. Both of them were related with contamination of a laboratory reactive, and were considered non-significant.

CONCLUSION

In our hospital, almost one-third of the isolates of NPRGM were significant, being this percentage higher for skin and soft tissue isolates. Patients were cured with antibiotic therapy, but the removal of foreign bodies appeared to be necessary for a good outcome. A minor pseudo-outbreak was detected. No predominant strain was detected.

Description of Mycobacterium conceptionense sp. nov., a Mycobacterium fortuitum group organism isolated from a posttraumatic osteitis inflammation

A nonpigmented rapidly growing mycobacterium was isolated from wound liquid outflow, bone tissue biopsy, and excised skin tissue from a 31-year-old woman who suffered an accidental open right tibia fracture and prolonged stay in a river. The three isolates grew in 3 days at 24 to 37 degrees C. 16S rRNA sequence analyses over 1,483 bp showed that they were identical and shared 99.7% (4-bp difference) sequence similarity with that of Mycobacterium porcinum, the most closely related species. Partial rpoB (723 bp) sequence analyses showed that the isolates shared 97.0% sequence similarity with that of M. porcinum. Further polyphasic approaches, including biochemical tests, antimicrobial susceptibility analyses, and hsp65, sodA, and recA gene sequence analysis, as well as % G+C determination and cell wall fatty acid composition analysis supported the evidence that these isolates were representative of a new species. Phylogenetic analyses showed the close relationship with M. porcinum in the Mycobacterium fortuitum group. The isolates were susceptible to most antibiotics and exhibited evidence for penicillinase activity, in contrast to M. porcinum. We propose the name Mycobacterium conceptionense sp. nov. for this new species associated with posttraumatic osteitis. The type strain is D16(T) (equivalent to CIP 108544(T) and CCUG 50187(T)).

Effectiveness of fluoroquinolones against Mycobacterium abscessus in vivo

PURPOSE

To determine the effectiveness of fluoroquinolones against Mycobacterium abscessus in vivo.

METHODS

M. abscessus growth was determined quantitatively in rabbit corneas after intrastromal bacterial injection (10(4) CFU/cornea; n >or= 4 corneas per group). Eyes were treated topically with 0.3% ciprofloxacin, 0.5% levofloxacin, or 0.5% moxifloxacin by three protocols: (1) 1 drop of antibiotic applied hourly for 10 hr on day 3 postinfection (PI); (2) 1 drop applied every 2 hr for 10 hr on days 2 and 3 PI; or (3) 1 drop applied every 2 hr for 10 hr on days 1, 2, and 3 PI. Corneas were cultured 1 hr after the last topical drop. Results are expressed as the log CFU.

RESULTS

Bacteria in control group reached maximal numbers in vivo by day 3 PI (approximately 6 logs CFU/cornea). Treatment of infected eyes on day 3 with moxifloxacin or levofloxacin resulted in approximately 2.0 log decrease in CFU/cornea relative to the untreated control. Treatment on days 2 and 3 with moxifloxacin or levofloxacin resulted in approximately 3.0 and 2.5 log CFU/cornea decrease, respectively. Ciprofloxacin had no effect on bacterial load. Treatment on days 1, 2, and 3 with moxifloxacin resulted in a 5.5 log CFU decrease, whereas treatment with levofloxacin or ciprofloxacin resulted in a approximately 4.0 log CFU decrease.

CONCLUSIONS

Moxifloxacin, and to a lesser extent levofloxacin and ciprofloxacin, demonstrated significant effectiveness for reducing the number of M. abscessus in vivo, suggesting the potential usage of these agents in prevention of M. abscessus keratitis.

Atypical infections in tsunami survivors

After a tsunami hit Asia in December 2004, 2 survivors had severe infections due to multidrug-resistant and atypical bacteria and rare fungi weeks afterwards. Treating these infections is challenging from a clinical and microbiologic point of view.

Successfully treated spondylodiscitis due to a previously unreported mycobacterium

A non-tuberculous mycobacterium was isolated, following a vertebral needle aspiration, from the blood of a patient with severe spondylodiscitis. The strain turned out to be different from any known mycobacterial species and was quite drug-susceptible in vitro. The patient improved markedly following treatment with meropenem, clarithromycin and amikacin.

Characterization of tetracycline resistance mediated by the efflux pump Tap from Mycobacterium fortuitum

OBJECTIVES

The aim of this study was to characterize the efflux pump Tap from Mycobacterium fortuitum, to test its sensitivity to well known efflux inhibitors, to study the interaction between tetracycline and these compounds and to test the ability of these compounds to overcome efflux pump-mediated tetracycline resistance. For all these studies, we produced Tap protein in Mycobacterium smegmatis.

METHODS

Antibiotic susceptibility tests, tetracycline uptake/efflux experiments and checkerboard synergy tests.

RESULTS

Tetracycline uptake/efflux experiments showed that Tap protein from M. fortuitum uses the electrochemical gradient across the cytoplasmic membrane to extrude tetracycline from the cell. This efflux activity is inhibited by carbonyl cyanide m-chlorophenylhydrazone (CCCP) and reserpine, consistent with the decrease in MIC observed in antibiotic susceptibility testing in the presence of these inhibitors. Accumulation was not inhibited in experiments in which o-vanadate and chlorpromazine (CPZ) were tested. Inhibitor-treated cells used glycerol as a carbon source to re-establish the electrochemical gradient across the membrane and to restore efflux activity. CCCP, reserpine and CPZ reduced the MIC of tetracycline in the M. smegmatis strain expressing the Tap protein, whereas o-vanadate increased the MIC. We also observed synergy between tetracycline and CPZ or reserpine, and antagonism with o-vanadate.

CONCLUSIONS

The Tapfor efflux pump uses the electrochemical gradient to extrude tetracycline from the cell. This efflux activity can be inhibited by several compounds. This suggests that similar compounds could be used to overcome antibiotic resistance mediated by efflux pumps.

Mycobacterial ecology of the Rio Grande

This is the first study to characterize the environmental conditions which contribute to the presence and proliferation of environmental mycobacteria in a major freshwater river. Over 20 different species of environmental mycobacteria were isolated, including the pathogenic M. avium and M. kansasii. Species of the rapidly growing M. fortuitum complex were the most commonly isolated mycobacteria, and one-third of all isolates were not identified at the species level, even by 16S sequencing. PCR restriction analysis of the hsp65 gene was more accurate and rapid than biochemical tests and as accurate as yet less expensive than 16S sequencing, showing great promise as a new tool for species identification of environmentally isolated mycobacteria. Total environmental mycobacteria counts positively correlated with coliform and Escherichia coli counts and negatively correlated with chemical toxicity and water temperature. Environmental mycobacteria can survive in the alkaline conditions of the river despite previous reports that especially acidic conditions favor their presence. A representative river isolate (M. fortuitum) survived better than E. coli O157:H7 at pHs below 7 and above 8 in nutrient broth. The river strain also retained viability at 8 ppm of free chlorine, while E. coli was eliminated at 2 ppm and above. Thus, in vitro studies support environmental observations that a variety of extreme conditions favor the hardy environmental mycobacteria.

Das langsame Wachstum von Mykobakterien

A characteristic feature of mycobacteria is their slow growth rate, which in addition strongly varies in different species of the genus. All highly pathogenic species such as M. tuberculosis and M. leprae causing tuberculosis and leprosy, respectively, belong to the slow growing mycobacteria, while the apathogenic and opportunistic species are members of the fast growing mycobacteria. This suggests that the question be posed whether there is causality between mycobacterial growth rate and virulence. We discuss possible reasons for the slow and variable growth rates of mycobacteria and the current state of knowledge concerning the significance of slow growth for mycobacterial pathogenicity.

Catheter-associated bacteremia by Mycobacterium senegalense in Korea

Background

Rapidly growing mycobacteria is recognized as one of the causative agents of catheter-related infections, especially in immunocompromised hosts. To date, however, Mycobacterium senegalense, which was known as the principal pathogen of bovine farcy, has not been reported in human infection.

Case presentation

We describe the first case of human infection by M. senegalense, which has caused catheter-related bloodstream infection in a cancer patient in Korea. The microorganism was identified by the 16S rRNA gene, rpoB, and 16S-23S rRNA gene internal transcribed spacer (ITS) sequence analyses.

Conclusion

Our first report of catheter-associated bacteremia caused by M. senegalense suggests the zoonotic nature of this species and indicates the expansion of mycobacterial species relating to human infection. M. senegalense should be considered as one of the causes of human infections in the clinical practice.

Mycobacterium smegmatis Erm(38) is a reluctant dimethyltransferase

The waxy cell walls of mycobacteria provide intrinsic tolerance to a broad range of antibiotics, and this effect is augmented by specific resistance determinants. The inducible determinant erm(38) in the nontuberculous species Mycobacterium smegmatis confers high resistance to lincosamides and some macrolides, without increasing resistance to streptogramin B antibiotics. This is an uncharacteristic resistance pattern falling between the type I and type II macrolide, lincosamide, and streptogramin B (MLS(B)) phenotypes that are conferred, respectively, by Erm monomethyltransferases and dimethyltransferases. Erm dimethyltransferases are typically found in pathogenic bacteria and confer resistance to all MLS(B) drugs by addition of two methyl groups to nucleotide A2058 in 23S rRNA. We show here by mass spectrometry analysis of the mycobacterial rRNA that Erm(38) is indeed an A2058-specific dimethyltransferase. The activity of Erm(38) is lethargic, however, and only a meager proportion of the rRNA molecules become dimethylated in M. smegmatis, while most of the rRNAs are either monomethylated or remain unmethylated. The methylation pattern produced by Erm(38) clarifies the phenotype of M. smegmatis, as it is adequate to confer resistance to lincosamides and 14-member ring macrolides such as erythromycin, but it is insufficient to raise the level of resistance to streptogramin B drugs above the already high intrinsic tolerance displayed by this species.

Porins limit the intracellular persistence of Mycobacterium smegmatis

The genus Mycobacterium comprises highly pathogenic as well as opportunistic or apathogenic species exhibiting a great variability with respect to their ability to persist or multiply within monocytic host cells. The impact of the permeability of the mycobacterial outer membrane on intracellular persistence was studied. For this purpose, a Mycobacterium smegmatis mutant with a deletion of the major porin gene mspA and a second mutant lacking mspA and the homologous porin gene mspC were used. Deletion of mspA together with mspC significantly enhanced intracellular persistence in murine bone marrow macrophages, the mouse macrophage cell line J774A.1 and Acanthamoeba castellanii. Complementation of mspA in the porin mutant strains resulted in restoration of the wild-type phenotype with respect to intracellular persistence. This is the first report to show that the deletion of porins of mycobacteria results in improved persistence in eukaryotic cells, demonstrating that the intracellular persistence of M. smegmatis depends upon the permeability of the outer membrane.

Isolation of Mycobacterium septicum from the sputum of a patient suffering from hemoptoic pneumonia

A rapidly growing mycobacterium was isolated in pure culture from the sputum of a 78-year-old woman suffering from hemoptoic pneumonia. The isolate exhibited an antimicrobial susceptibility pattern and a biochemical profile similar to that of Mycobacterium septicum ATCC 700731(T) and shared 100% 16S rRNA gene sequence similarity with this type strain over 1480 bp. Its partial rpoB sequence shared 98.2% similarity with the latter species, suggesting the isolate was representative of a sequevar of M. septicum. Contrary to the type strain, this isolate was resistant to azithromycin, erythromycin, vancomycin and tobramycin. This case illustrates the first isolation from sputum of M. septicum, a member of the Mycobacterium fortuitum group previously isolated once from bacteremia. Strain D13 has been deposited in the Collection de l'Institut Pasteur as CIP 108512.

Pneumonia due to Mycobacterium abscessus in two domestic ferrets (Mustelo putorius furo)

Two ferrets were diagnosed with pneumonia due to Mycobacterium abscessus. Both cases were treated successfully using clarithromycin after positive cultures were obtained via unguided bronchoalveolar lavage. This is the first time M abscessus has been isolated in our laboratory and the first report of this organism causing disease in companion animals in Australia. Underlying respiratory tract disease was thought to be an important factor in the development of the infections. Thorough investigation of chronic lower respiratory tract disease in ferrets is recommended as this species appears predisposed to atypical infections.

Chronic leg ulcer caused by Mycobacterium immunogenum

Rare tropical skin diseases are seen more frequently in Western countries because of the increased popularity of visiting tropical regions. A 55-year-old white man developed a painless leg ulcer after traveling in Guatemala and Belize. A mycobacterium was cultured from a biopsy specimen and was identified as Mycobacterium immunogenum by 16S recombinant deoxyribonucleic acid sequence analysis. The leg ulcer healed after 6 months of compression therapy and hydrocolloids; a hypopigmented depressed scar remained.

Thin-section CT findings of nontuberculous mycobacterial pulmonary diseases: comparison between Mycobacterium avium-intracellulare complex and Mycobacterium abscessus infection

We aimed to compare the CT findings of nontuberculous mycobacterial pulmonary diseases caused by Mycobacterium avium-intracellulare complex (MAC) and Mycobacterium abscessus. Two chest radiologists analyzed retrospectively the thin-section CT findings of 51 patients with MAC and 36 with M. abscessus infection in terms of patterns and forms of lung lesions. No significant difference was found between MAC and M. abscessus infection in the presence of small nodules, tree-in-bud pattern, and bronchiectasis. However, lobar volume decrease (p=0.001), nodule (p=0.018), airspace consolidation (p=0.047) and thin-walled cavity (p=0.009) were more frequently observed in MAC infection. The upper lobe cavitary form was more frequent in the MAC (19 of 51 patients, 37%) group than M. abscessus (5 of 36, 14%) (p=0.029), whereas the nodular bronchiectatic form was more frequent in the M. abscessus group ([29 of 36, 81%] vs. [27 of 51, 53%] in MAC) (p=0.012). In conclusion, there is considerable overlap in common CT findings of MAC and M. abscessus pulmonary infection; however, lobar volume loss, nodule, airspace consolidation, and thin-walled cavity are more frequently seen in MAC than M. abscessus infection.

In Vitro Activity of Fluoroquinolones Against Mycobacterium abscessus and Mycobacterium chelonae Causing Infectious Keratitis After LASIK in Brazil

PURPOSE

To evaluate the in vitro activity of fluoroquinolones against Mycobacterium abscessus and Mycobacterium chelonae isolated from outbreaks of infectious keratitis in Brazil.

MATERIAL AND METHODS

Micobacterial isolates were recovered from infectious keratitis cases related outbreaks that occurred in Brazil after LASIK for myopia. Two outbreaks occurred in Rio de Janeiro in 1998 and 1999, and 3 in São Paulo between 2000 and 2003. All laboratorial analysis, including molecular identification and antibiotic susceptibility testing with determination of the minimum inhibitory concentration (MIC) levels for ciprofloxacin, ofloxacin, gatifloxacin, and moxifloxacin, were performed at Universidade Federal de São Paulo in Brazil.

RESULTS

Fifteen samples were identified as M. chelonae, and 3 were identified as M. abscessus. The outbreaks studied were designated SP-1 in 2000; SP-2 in 2000-2001; and SP-3 in 2003, R1 in 1988 and R2 in 1999. All but 1 of the M. chelonae were resistant to all fluoroquinolones with an MIC90 greater than 32 microg/mL. The only susceptible isolate had MIC levels for ciprofloxacin, ofloxacin, gatifloxacin, and moxifloxacin of 0.38 microg/mL, 0.032 microg/mL, 0.047 microg/mL, and 0.19 microg/mL, respectively. MIC levels for all 3 M. abscessus isolates tested were greater then 32 microg/mL for all fluoroquinolones tested.

CONCLUSIONS

Fluoroquinolone MICs for 17 M. abscessus and M. chelonae isolates recovered from infectious keratitis cases in Brazil indicate that they are not susceptible to these drugs in vitro. Further studies to investigate the in vivo effectiveness of fluoroquinolones against mycobacteria are required because in vitro tests do not support their use in the treatment of micobacterial keratitis in this particular geographic area.

Mycobactéries atypiques et mucoviscidose

Patients with cystic fibrosis are particularly at risk of infection with non-tuberculous mycobacteria (NTM). Prevalence of these infections increases with age to around 15 %. The main species involved are M. abscessus and M. avium, the latter not found in children under 15. Diagnosis relies on clinical, radiological and above all bacteriological criteria defined by the ATS. Identification of the causal species of NTM is essential and requires genetic techniques, some of which are currently evaluated. Treatment depends on the mycobacterial species. For M. avium, combined therapy with rifampicin, clarithromycin and ethambutol must be extended 12 months after negativation. M. abscessus infection is particularly resistant to therapy. Usual treatment is a one month course of intravenous imipenem or cefoxitin plus amikacin followed by oral clarithromycin plus ethambutol for at least 12 months after negativation. In case of local lesions, surgery is an option.

Mycobacterium farcinogenes infection after total hip arthroplasty

Atypical mycobacterium infection after total hip arthroplasty is a very rare but a potential cause of implant failure. We present the first report of Mycobacterium farcinogenes infection in human beings. Although the treatment of atypical mycobacterium infection after total hip arthroplasty is controversial, we successfully treated the infection in this case, after consultation with a microbiologist regarding infection management, with both surgery and chemotherapy. It is important to maintain a high index of suspicion for atypical mycobacterium infection, particularly when standard culture findings are negative despite strong clinical evidence of prosthesis infection.

Pyrosequencing as a tool for the identification of common isolates of Mycobacterium sp

Pyrosequencing technology, sequencing by addition, was evaluated for categorization of mycobacterial isolates. One hundred and eighty-nine isolates, including 18 ATCC and Trudeau Mycobacterial Culture Collection (TMC) strains, were studied. There were 38 Mycobacterium tuberculosis complex, 27 M. kansasii, 27 MAI complex, 21 M. marinum, 14 M. gordonae, 20 M. chelonae-abscessus group, 10 M. fortuitum, 5 M. xenopi, 3 M. celatum, 2 M. terrae complex, 20 M. mucogenicum, and 2 M. scrofulaceum. Nucleic acid extracts were prepared from solid media or MGIT broth. Traditional PCR was performed with one of the primers biotinylated; the assay targeted a portion of the 16S rRNA gene that contains a hypervariable region, which has been previously shown to be useful for the identification of mycobacteria. The PSQ Sample Preparation Kit was used, and the biotinylated PCR product was processed to a single-stranded DNA template. The sequencing primer was hybridized to the DNA template in a PSQ96 plate. Incorporation of the complementary nucleotides resulted in light generation peaks, forming a pyrogram, which was evaluated by the instrument software. Thirty basepairs were used for isolate categorization. Manual interpretation of the sequences was performed if the quality of the 30-bp sequence was in doubt or if more than 4 bp homopolymers were recognized. Sequences with more than 5 bp of bad quality were deemed unacceptable. When blasted against GenBank, 179 of 189 sequences (94.7%) assigned isolates to the correct molecular genus or group. Ten M. gordonae isolates had more than 5 bp of bad quality sequence and were not accepted. Pyrosequencing of this hypervariable region afforded rapid and acceptable characterization of common, routinely isolated clinical Mycobacterium sp. Algorithms are recommended for further differentiation with an additional sequencing primer or additional biochemicals.

Misidentification of Mycobacterium peregrinum, the causal organism of a case of bacteremia and automatic implantable cardioverter defibrillator-associated infection, due to its unusual acid-fast staining characteristics

We report an unusual case of Mycobacterium peregrinum bacteremia and infection of an automatic implantable cardioverter defibrillator that was originally misidentified as a Nocardia sp. due, in part, to its partially acid-fast staining characteristic, morphology, and odor. The misdiagnosis had a direct effect on patient care, though the patient was subsequently successfully treated.

Hypersensitivity pneumonitis associated with environmental mycobacteria

A previously healthy man working as a machine operator in an automotive factory developed respiratory symptoms. Medical evaluation showed abnormal pulmonary function tests, a lung biopsy showed hypersensitivity pneumonitis, and his illness was traced to his work environment. His physician asked the employer to remove him from exposure to metalworking fluids. Symptoms reoccurred when he was later reexposed to metalworking fluids, and further permanent decrement in his lung function occurred. Investigation of his workplace showed that five of six large reservoirs of metalworking fluids (cutting oils) grew Mycobacterium chelonae (or Mycobacterium immunogenum), an organism previously associated with outbreaks of hypersensitivity pneumonitis in automaking factories. His lung function remained stable after complete removal from exposure. The employer, metalworking fluid supplier, union, and the National Institute for Occupational Safety and Health were notified of this sentinel health event. No further cases have been documented in this workplace.

Dissection of phylogenetic relationships among 19 rapidly growing Mycobacterium species by 16S rRNA, hsp65, sodA, recA and rpoB gene sequencing

The current classification of non-pigmented and late-pigmenting rapidly growing mycobacteria (RGM) capable of producing disease in humans and animals consists primarily of three groups, the Mycobacterium fortuitum group, the Mycobacterium chelonae-abscessus group and the Mycobacterium smegmatis group. Since 1995, eight emerging species have been tentatively assigned to these groups on the basis of their phenotypic characters and 16S rRNA gene sequence, resulting in confusing taxonomy. In order to assess further taxonomic relationships among RGM, complete sequences of the 16S rRNA gene (1483-1489 bp), rpoB (3486-3495 bp) and recA (1041-1056 bp) and partial sequences of hsp65 (420 bp) and sodA (441 bp) were determined in 19 species of RGM. Phylogenetic trees based upon each gene sequence, those based on the combined dataset of the five gene sequences and one based on the combined dataset of the rpoB and recA gene sequences were then compared using the neighbour-joining, maximum-parsimony and maximum-likelihood methods after using the incongruence length difference test. Combined datasets of the five gene sequences comprising nearly 7000 bp and of the rpoB+recA gene sequences comprising nearly 4600 bp distinguished six phylogenetic groups, the M. chelonae-abscessus group, the Mycobacterium mucogenicum group, the M. fortuitum group, the Mycobacterium mageritense group, the Mycobacterium wolinskyi group and the M. smegmatis group, respectively comprising four, three, eight, one, one and two species. The two protein-encoding genes rpoB and recA improved meaningfully the bootstrap values at the nodes of the different groups. The species M. mucogenicum, M. mageritense and M. wolinskyi formed new groups separated from the M. chelonae-abscessus, M. fortuitum and M. smegmatis groups, respectively. The M. mucogenicum group was well delineated, in contrast to the M. mageritense and M. wolinskyi groups. For phylogenetic organizations derived from the hsp65 and sodA gene sequences, the bootstrap values at the nodes of a few clusters were <70 %. In contrast, phylogenetic organizations obtained from the 16S rRNA, rpoB and recA genes were globally similar to that inferred from combined datasets, indicating that the rpoB and recA genes appeared to be useful tools in addition to the 16S rRNA gene for the investigation of evolutionary relationships among RGM species. Moreover, rpoB gene sequence analysis yielded bootstrap values higher than those observed with recA and 16S rRNA genes. Also, molecular signatures in the rpoB and 16S rRNA genes of the M. mucogenicum group showed that it was a sister group of the M. chelonae-abscessus group. In this group, M. mucogenicum ATCC 49650(T) was clearly distinguished from M. mucogenicum ATCC 49649 with regard to analysis of the five gene sequences. This was in agreement with phenotypic and biochemical characteristics and suggested that these strains are representatives of two closely related, albeit distinct species.

Mycobacteria in drinking water distribution systems: ecology and significance for human health

In contrast to the notorious pathogens Mycobacterium tuberculosis and M. leprae, the majority of the mycobacterial species described to date are generally not considered as obligate human pathogens. The natural reservoirs of these non-primary pathogenic mycobacteria include aquatic and terrestrial environments. Under certain circumstances, e.g., skin lesions, pulmonary or immune dysfunctions and chronic diseases, these environmental mycobacteria (EM) may cause disease. EM such as M. avium, M. kansasii, and M. xenopi have frequently been isolated from drinking water and hospital water distribution systems. Biofilm formation, amoeba-associated lifestyle, and resistance to chlorine have been recognized as important factors that contribute to the survival, colonization and persistence of EM in water distribution systems. Although the presence of EM in tap water has been linked to nosocomial infections and pseudo-infections, it remains unclear if these EM provide a health risk for immunocompromised people, in particular AIDS patients. In this regard, control strategies based on maintenance of an effective disinfectant residual and low concentration of nutrients have been proposed to keep EM numbers to a minimum in water distribution systems.

Analysis of the precursor rRNA fractions of rapidly growing mycobacteria: quantification by methods that include the use of a promoter (rrnA P1) as a novel standard

Mycobacterial species are able to control rRNA production through variations in the number and strength of promoters controlling their rrn operons. Mycobacterium chelonae and M. fortuitum are members of the rapidly growing mycobacterial group. They carry a total of five promoters each, encoded, respectively, by one and two rrn operons per genome. Quantification of precursor rrn transcriptional products (pre-rrn) has allowed detection of different promoter usage during cell growth. Bacteria growing in several culture media with different nutrient contents were compared. Balanced to stationary phases were analyzed. Most promoters were found to be used at different levels depending on the stage of bacterial growth and the nutrient content of the culture medium. Some biological implications are discussed. Sequences of the several promoters showed motifs that could be correlated to their particular level of usage. A product corresponding to the first rrnA promoter in both species, namely, rrnA P1, was found to contribute at a low and near-constant level to pre-rRNA synthesis, regardless of the culture medium used and the stage of growth analyzed. This product was used as a standard to quantitate rRNA gene expression by real-time PCR when M. fortuitum infected macrophages. It was shown that this bacterium actively synthesizes rRNA during the course of infection and that one of its rrn operons is preferentially used under such conditions.

Measurement of Immunoglobulin G against Mycobacterial Antigen A60 in Patients with Cystic Fibrosis and Lung Infection Due to Mycobacterium abscessus

BACKGROUND

The diagnosis and prognosis of lung infections due to the emerging nontuberculous mycobacterium (NTM) Mycobacterium abscessus are difficult to establish in children with cystic fibrosis.

METHODS

We evaluated the usefulness of an enzyme-linked immunosorbent assay for detecting serum IgG antibodies against the ubiquitous mycobacterial antigen A60.

RESULTS

A total of 186 patients with cystic fibrosis (mean age+/-SD, 12.0+/-5.0 years) were studied, including 15 M. abscessus-positive patients who fulfilled American Thoracic Society (ATS) criteria for NTM infection (M. abscessus-infected patients), 7 M. abscessus-positive patients who did not fulfill ATS criteria, 20 patients positive for various other NTM who did not fulfill ATS criteria, and 144 NTM-negative control patients; mean IgG titers (+/-SD) for these 4 groups were 718+/-342 U, 193+/-113 U, 129+/-49 U, and 121+/-53 U, respectively (M. abscessus-infected patients vs. each of the other groups, P<.005). The A60 IgG test was both sensitive (approximately 87%) and specific (approximately 95%) if adapted cutoff values were used (150 U and 250 U for patients aged <or=10 years and patients aged >10 years, respectively) and correlated well with results of acid-fast bacilli smears.

CONCLUSION

Measurement of anti-A60 IgG may be useful for both the diagnosis and assessment of activity of M. abscessus lung infection in persons with cystic fibrosis.

Rapid species identification within the Mycobacterium chelonae-abscessus group by high-resolution melting analysis of hsp65 PCR products

Polymerase chain reaction (PCR) amplification of the heat shock protein 65 (hsp65) gene followed by high-resolution melting analysis with LCGreen I (Idaho Technology, Salt Lake City, UT) was used to differentiate the mycobacteria species Mycobacterium chelonae, Mycobacterium abscessus, and Mycobacterium immunogenum in less than 20 minutes. A 105-base-pair amplicon that clustered the different species by predicted melting temperature was found from available GenBank hsp65 sequences. We identified 24 clinical isolates within the M chelonae-abscessus group by proximal 16S ribosomal RNA and hsp65 gene sequencing. Rapid-cycle PCR followed by high-resolution melting analysis clustered these samples into the following groups: M abscessus, 12; M abscessus sequence variant, 2; M chelonae, 7; unexpected M chelonae sequence variant, 1; and M immunogenum, 2. The M chelonae variant had a single base change not found in reported GenBank sequences. Advantages of the method include speed, low risk of amplicon contamination (closed-tube), and no need for separation steps (sequencing, electrophoresis, high-performance liquid chromatography) or real-time monitoring.

Multidrug resistance of a porin deletion mutant of Mycobacterium smegmatis

Mycobacteria contain an outer membrane of unusually low permeability which contributes to their intrinsic resistance to many agents. It is assumed that small and hydrophilic antibiotics cross the outer membrane via porins, whereas hydrophobic antibiotics may diffuse through the membrane directly. A mutant of Mycobacterium smegmatis lacking the major porin MspA was used to examine the role of the porin pathway in antibiotic sensitivity. Deletion of the mspA gene caused high-level resistance of M. smegmatis to 256 microg of ampicillin/ml by increasing the MIC 16-fold. The permeation of cephaloridine in the mspA mutant was reduced ninefold, and the resistance increased eightfold. This established a clear relationship between the activity and the outer membrane permeation of cephaloridine. Surprisingly, the MICs of the large and/or hydrophobic antibiotics vancomycin, erythromycin, and rifampin for the mspA mutant were increased 2- to 10-fold. This is in contrast to those for Escherichia coli, whose sensitivity to these agents was not affected by deletion of porin genes. Uptake of the very hydrophobic steroid chenodeoxycholate by the mspA mutant was retarded threefold, which supports the hypothesis that loss of MspA indirectly reduces the permeability by the lipid pathway. The multidrug resistance of the mspA mutant highlights the prominent role of outer membrane permeability for the sensitivity of M. smegmatis to antibiotics. An understanding of the pathways across the outer membrane is essential to the successful design of chemotherapeutic agents with activities against mycobacteria.

Mycobacterium goodii infections associated with surgical implants at Colorado hospital

From February to October 2003, Mycobacterium goodii wound infections were identified among three patients who received surgical implants at a Colorado hospital. This report summarizes the investigation of the first reported nosocomial outbreak of M. goodii. Increased awareness is needed about the potential for nontuberculous mycobacteria to cause postoperative wound infections.

Molecular basis of intrinsic macrolide resistance in clinical isolates of Mycobacterium fortuitum

OBJECTIVES

Some clinical isolates of Mycobacterium fortuitum are naturally resistant to macrolides, e.g. clarithromycin. Thus, the aim of this study was to identify the gene(s) conferring this resistance.

METHODS

M. fortuitum ATCC 6841T DNA libraries were screened for plasmids that complemented the macrolide-susceptible phenotype of Mycobacterium smegmatis variant ermKO4 [erm(38)-negative]. Macrolide-resistant M. smegmatis transformants were selected on agar containing 128 mg/L erythromycin.

RESULTS

Genetic complementation identified an M. fortuitum rRNA methylase gene, termed erm(39), 69% identical to erm(38) of M. smegmatis. In addition, erm(39) was found to be in the same chromosomal location as erm(38) in their respective hosts. Like erm(38), erm(39) conferred resistance (MIC >128 mg/L) to macrolide-lincosamide (ML) agents, but not to streptogramin B. Analysis of erm gene expression in M. fortuitum showed that ML agents increased erm(39) RNA levels, reaching a steady state level approximately 20-fold higher than baseline. Screening of 32 M. fortuitum clinical isolates by PCR showed that all were positive for erm(39), irrespective of clarithromycin susceptibility. A majority of clarithromycin-susceptible (MIC < or = 2 mg/L) isolates were postulated to carry a disabled erm(39) gene as they had a GTG-->CTG mutation in the putative initiation codon of the erm(39) gene.

CONCLUSIONS

The similarity of the erm genes of M. smegmatis and M. fortuitum suggests that they were inherited from a common ancestor. Although the clinical impact of erm(39) on the therapeutic utility of clarithromycin is unclear, induction of this gene is consistent with the trailing end-points commonly seen during susceptibility testing of M. fortuitum isolates against macrolides.

Amoebal coculture of "Mycobacterium massiliense" sp. nov. from the sputum of a patient with hemoptoic pneumonia

A nonphotochromogenic, rapidly growing Mycobacterium strain was isolated in pure culture from the sputum and the bronchoalveolar fluid of a patient with hemoptoic pneumonia by using axenic media and an amoebal coculture system. Both isolates grew in less than 7 days at 24 to 37 degrees C with an optimal growth temperature of 30 degrees C. The isolates exhibited biochemical and antimicrobial susceptibility profiles overlapping those of Mycobacterium abscessus, Mycobacterium chelonae, and Mycobacterium immunogenum, indicating that they belonged to M. chelonae-M. abscessus group. They differed from M. abscessus in beta-galactosidase, beta-N-acetyl-beta-glucosaminidase, and beta-glucuronidase activities and by the lack of nitrate reductase and indole production activities, as well as in their in vitro susceptibilities to minocycline and doxycycline. These isolates and M. abscessus differed from M. chelonae and M. immunogenum by exhibiting gelatinase and tryptophane desaminase activities. Their 16S rRNA genes had complete sequence identity with that of M. abscessus and >99.6% similarity with those of M. chelonae and M. immunogenum. Further molecular investigations showed that partial hsp65 and sodA gene sequences differed from that of M. abscessus by five and three positions over 441 bp, respectively. Partial rpoB and recA gene sequence analyses showed 96 and 98% similarities with M. abscessus, respectively. Similarly, 16S-23S rRNA internal transcribed spacer sequence of the isolates differed from that of M. abscessus by a A-->G substitution at position 60 and a C insertion at position 102. Phenotypic and genotypic features of these two isolates indicated that they were representative of a new mycobacterial species within the M. chelonae-M. abscessus group. Phylogenetic analysis suggested that these isolates were perhaps recently derived from M. abscessus. We propose the name of "Mycobacterium massiliense" for this new species. The type strain has been deposited in the Collection Institut Pasteur as CIP 108297(T) and in Culture Collection of the University of Goteborg, Goteborg, Sweden, as CCUG 48898(T).

Mycobacterium goodii infection in a dog with concurrent hyperadrenocorticism

Abstract A 9-year-old Boston terrier was diagnosed with multifocal, nodular panniculitis caused by an organism belonging to the Mycobacterium smegmatis group by histological evaluation and bacteriological identification. The mycobacterial species was identified by direct gene sequence analysis and confirmed to be Mycobacterium goodii. Treatment using doxycycline and ciprofloxacin was successfully implemented for the mycobacterial panniculitis over a period of 9 months. Concurrent pituitary-dependent hyperadrenocorticism (Cushing's disease) was also identified using routine diagnostic methods and mitotane therapy was implemented. There was follow-up for 14 months after cessation of antimicrobial therapy with no recurrence of mycobacterial infection. Although cutaneous infections are frequently recognized as complications of canine pituitary-dependent hyperadrenocorticism, concurrent mycobacterial panniculitis due to any rapidly growing mycobacterium has not previously been reported. This is the first confirmed case of mycobacterial panniculitis due to M. goodii infection in a dog and also the first of any rapidly growing mycobacterial infection in a dog with concurrent endogenous Cushing's disease.

Infections of the subcutis and skin of dogs caused by rapidly growing mycobacteria

Nine dogs with panniculitis due to rapidly growing mycobacteria (RGM) were examined over 17 years. Dogs were two to 15 years; five were male, four were female. All were obese or in good condition. Antecedent injury, typically a dog bite or vehicular trauma, could be identified in some patients, while one bitch had hyperadrenocorticism. Infections involved different locations, although the cervicothoracic region, dorsum or flank were most often affected. Patients were systemically well, apart from one dog with pyrexia and two with pain or lameness. Cytology demonstrated pyogranulomatous inflammation, but in only one case was it possible to see acid-fast bacilli (AFB) in smears. Histology demonstrated chronic active pyogranulomatous panniculitis and dermatitis; AFB could be detected in only four specimens. Culture of aspirates or resected tissues demonstrated RGM in all cases, comprising six Mycobacterium smegmatis group and three Mycobacterium fortuitum group isolates. Resection of infected tissues, perioperative injectable antimicrobials and long courses of oral antimicrobials chosen according to susceptibility data generally effected a cure, although some cases recurred.

Mycobacterium canariasense sp. nov

A novel rapidly growing, non-pigmented mycobacterium was isolated from blood samples obtained from 17 patients with febrile syndrome. Bacterial growth occurred at 30 and 37 °C on Löwenstein–Jensen medium and also on MacConkey agar without crystal violet. Strains contained α- and α′-mycolates in their cell wall. Sequence analysis of the hsp65 and 16S rRNA genes identified the isolates as rapidly growing mycobacteria. Sequences of both genes were unique within the mycobacteria. DNA–DNA hybridization showed that the isolates had less than 15 % reassociation with 13 other recognized rapidly growing mycobacteria. The name Mycobacterium canariasense sp. nov. is proposed for this novel opportunistic pathogen, which is most closely related to Mycobacterium diernhoferi. The type strain is 502329T (=CIP 107998T=CCUG 47953T).

LightCycler-based differentiation of Mycobacterium abscessus and Mycobacterium chelonae

In this study we introduce a rapid procedure to identify Mycobacterium abscessus (types I and II) and M. chelonae using LightCycler-based analysis of the hsp65 gene. Results from 36 clinical strains were compared with hsp65 gene restriction analysis and biochemical profiles of bacilli. As all three methods yielded identical results for each isolate, this procedure offers an excellent alternative to previously established nucleic acid amplification-based techniques for the diagnosis of mycobacterial diseases.

An experimental model of mycobacterial infection under corneal flaps

In order to develop a new experimental animal model of infection with Mycobacterium chelonae in keratomileusis, we conducted a double-blind prospective study on 24 adult male New Zealand rabbits. One eye of each rabbit was submitted to automatic lamellar keratotomy with the automatic corneal shaper under general anesthesia. Eyes were immunosuppressed by a single local injection of methyl prednisolone. Twelve animals were inoculated into the keratomileusis interface with 1 microl of 10(6) heat-inactivated bacteria (heat-inactivated inoculum controls) and 12 with 1 microl of 10(6) live bacteria. Trimethoprim drops (0.1%, w/v) were used as prophylaxis for the surgical procedure every 4 h (50 microl, qid). Animals were examined by 2 observers under a slit lamp on the 1st, 3rd, 5th, 7th, 11th, 16th, and 23rd postoperative days. Slit lamp photographs were taken to document clinical signs. Animals were sacrificed when corneal disease was detected and corneal samples were taken for microbiological analysis. Eleven of 12 experimental rabbits developed corneal disease, and M. chelonae could be isolated from nine rabbits. Eleven of the 12 controls receiving a heat-inactivated inoculum did not develop corneal disease. M. chelonae was not isolated from any of the control rabbits receiving a heat-inactivated inoculum, or from the healthy cornea of control rabbits. Corneal infection by M. chelonae was successfully induced in rabbits submitted to keratomileusis. To our knowledge, this is the first animal model of M. chelonae infection following corneal flaps for refractive surgery to be described in the literature and can be used for the analysis of therapeutic responses.

Mycobacteriosis in zebrafish (Danio rerio) research facilities

The Zebrafish International Resource Center was established to support the zebrafish research community, and includes a diagnostic service. One of the most common diseases that we have diagnosed is mycobacteriosis, which represented 18% of the diagnostic cases submitted from November 1999 to June 2003. We describe here the severity of the disease and associated pathological changes of 24 diagnostic cases from 14 laboratories. Identifications of the bacteria are provided for seven of these cases. For two cases in which culture of the organism was not successful, these identifications were based on ribosomal DNA (rDNA) sequence analysis obtained directly from infected tissues. Biochemical characteristics and rDNA sequence analysis from cultures are reported for the other isolates. Two severe outbreaks from different facilities on different continents were associated with an organism identified as Mycobacterium haemophilum based on rDNA sequence from tissues. Another severe outbreak was associated with an organism most closely related to Mycobacterium peregrinum. These species are recognized pathogens of humans, but this is the first report of them from fish. Bacteria identified as Mycobacterium chelonae or M. abscessus were recovered from fish in cases categorized as moderate disease or as an incidental finding. These findings indicate that species of Mycobacterium previously undescribed from fish (i.e., M. haemophilum and M. peregrinum) may pose significant health problems in zebrafish research facilities, whereas species and strains that are already recognized as common in fish usually cause limited disease on a population basis in zebrafish.

Intrinsic macrolide resistance in Mycobacterium smegmatis is conferred by a novel erm gene, erm(38)

High-level, acquired macrolide resistance in mycobacteria is conferred by mutation within the 23S rRNA gene. However, several mycobacteria are naturally resistant to macrolides, including the Mycobacterium smegmatis group and Mycobacterium tuberculosis complex. Thus, the aim of this study was to characterize this resistance. Intrinsic macrolide resistance in M. smegmatis was inducible and showed cross-resistance to lincosamides but not to streptogramin B (i.e., ML resistance). A similar phenotype was found with Mycobacterium microti and macrolide-resistant Mycobacterium fortuitum. A search of the DNA sequence data for M. smegmatis strain mc(2)155 identified a novel erm gene, erm(38), and expression analysis showed that erm(38) RNA levels increased >10-fold after a 2-h incubation with macrolide. Inducible ML resistance was not expressed by an erm(38) knockout mutant, and complementation of this mutant with intact erm(38) in trans resulted in high-level ML resistance (e.g., clarithromycin MIC of >512 micro g/ml). Thus, the results indicate that erm(38) confers the intrinsic ML resistance of M. smegmatis. Southern blot analysis with an erm(38)-specific probe indicated that a similar gene may be present in macrolide-resistant M. fortuitum. This finding, with the presence of the erm(37) gene (Rv1988) in the M. tuberculosis complex, suggests that such genes are widespread in mycobacteria with intrinsic macrolide resistance.