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Cinicola BL, Ottaviano G, Hashim IF, Zainudeen ZT, Hamid IJA, Elfeky R. Prevalence and Characteristics of Non-tuberculous Mycobacteria (NTM) Infection in Recipients of Allogeneic Hematopoietic Stem Cell Transplantation: a Systematic Review and Meta-analysis. J Clin Immunol 2023; 44:23. [PMID: 38129624 PMCID: PMC10739425 DOI: 10.1007/s10875-023-01615-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/22/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE Non-tuberculous mycobacteria (NTM) infections in hematopoietic stem cell transplantation (HSCT) recipients represent a diagnostic and therapeutic challenge. Here, we aimed to review and analyze current literature on incidence, clinical presentation, and outcome of NTM infection after allogeneic HSCT. METHODS We performed a systematic review and meta-analysis of available literature regarding NTM infection in children and adults receiving allogeneic HSCT. RESULTS We identified 56 articles eligible for the analysis. Among 15 studies, describing 15,798 allogeneic HSCT, we estimated a prevalence of 1.26% (95% CI 0.72, 1.93) of NTM after transplant. Analysis of 175 patients with NTM infection showed a median time of diagnosis of 318 days after HSCT, an increased prevalence in adults (82.9%), and a most frequent pulmonary involvement (44%). Comparison between children and adults revealed an earlier post-transplant disease onset (median 130 days vs 287 days) and most frequent non-pulmonary presentation in children. A vast heterogeneity of therapeutic approach reflected the lack of universal recommendations regarding drug combination and duration of therapy. Overall, NTM-related mortality accounted for 33% in this systematic review. CONCLUSION Although rare, NTM infections can complicate post-transplant course with a high mortality rate in children and adults. The lack of prospective studies and guidelines prevents identification of risk factors and therapeutic recommendations.
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Affiliation(s)
- Bianca Laura Cinicola
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giorgio Ottaviano
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Ilie Fadzilah Hashim
- Primary Immunodeficiency Diseases Group, Department of Clinical Medicine, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia
| | - Zarina Thasneem Zainudeen
- Primary Immunodeficiency Diseases Group, Department of Clinical Medicine, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia
| | - Intan Juliana Abd Hamid
- Primary Immunodeficiency Diseases Group, Department of Clinical Medicine, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia.
| | - Reem Elfeky
- Department of Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, UK.
- GOS Hospital for Children NHS Foundation Trust, University College London GOS Institute of Child Health, and NIHR GOSH BRC, London, UK.
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Friedland AE, Maziarz EK, Wolfe CR, Patel CB, Patel P, Milano CA, Schroder JN, Daneshmand MA, Wallace RJ, Alexander BD, Baker AW. Epidemiology, management, and clinical outcomes of extrapulmonary Mycobacterium abscessus complex infections in heart transplant and ventricular assist device recipients. Am J Transplant 2023; 23:1048-1057. [PMID: 37059177 PMCID: PMC10330292 DOI: 10.1016/j.ajt.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/07/2023] [Accepted: 04/07/2023] [Indexed: 04/16/2023]
Abstract
Nontuberculous mycobacteria are emerging pathogens, yet data on the epidemiology and management of extrapulmonary nontuberculous mycobacteria infections in orthotopic heart transplantation (OHT) and ventricular assist device (VAD) recipients are scarce. We retrospectively reviewed records of OHT and VAD recipients who underwent cardiac surgery at our hospital and developed Mycobacterium abscessus complex (MABC) infection from 2013 to 2016 during a hospital outbreak of MABC linked to heater-cooler units. We analyzed patient characteristics, medical and surgical management, and long-term outcomes. Ten OHT patients and 7 patients with VAD developed extrapulmonary M. abscessus subspecies abscessus infection. The median time from presumed inoculation during cardiac surgery to the first positive culture was 106 days in OHT and 29 days in VAD recipients. The most common sites of positive cultures were blood (n = 12), sternum/mediastinum (n = 8), and the VAD driveline exit site (n = 7). The 14 patients diagnosed when alive received combination antimicrobial therapy for a median of 21 weeks, developed 28 antibiotic-related adverse events, and underwent 27 surgeries. Only 8 (47%) patients survived longer than 12 weeks after diagnosis, including 2 patients with VAD who experienced long-term survival after an explantation of infected VADs and OHT. Despite aggressive medical and surgical management, OHT and VAD patients with MABC infection experienced substantial morbidity and mortality.
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Affiliation(s)
- Anne E Friedland
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
| | - Eileen K Maziarz
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chetan B Patel
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Priyesh Patel
- Wake Forest University School of Medicine Department of Cardiology, Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Carmelo A Milano
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mani A Daneshmand
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina, USA; Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Richard J Wallace
- Mycobacteria/Nocardia Research Laboratory, Department of Microbiology, University of Texas Health Science Center, Tyler, Texas, USA
| | - Barbara D Alexander
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA; Duke University Clinical Microbiology Laboratory, Durham, North Carolina, USA
| | - Arthur W Baker
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
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Marty PK, Yetmar ZA, Gerberi DJ, Escalante P, Pennington KM, Mahmood M. Risk factors and outcomes of non-tuberculous mycobacteria infection in lung transplant recipients: A systematic review and meta-analysis. J Heart Lung Transplant 2023; 42:264-274. [PMID: 36334962 DOI: 10.1016/j.healun.2022.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/23/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Patients with structural lung disease and immunocompromised status are at increased risk of pulmonary non-tuberculous mycobacteria (NTM) infection. However, literature on NTM in lung transplant recipients (LTR) is limited. We sought to systematically review the literature and perform a meta-analysis to examine associations with NTM disease and isolation in LTRs and their influence on mortality and chronic lung allograft dysfunction (CLAD). METHODS A literature search of MEDLINE and Embase was performed on February 23, 2022. NTM disease was defined according to international guidelines. Isolation was defined as any growth of NTM in culture. Odds ratios (OR) were pooled for risk factors of NTM disease or isolation, and hazard ratios (HR) were pooled for mortality or CLAD. RESULTS Eleven studies totaling 3,371 patients were eligible for inclusion, 10 of which underwent meta-analysis. Cystic fibrosis (OR 1.84, 95% confidence interval [CI] 1.03-3.30; I2 = 0%) and pre-transplant NTM isolation (OR 2.40, 95% CI 1.20-4.83; I2 = 0%) were associated with NTM disease. Only male sex was associated with NTM isolation (OR 1.45, 95% CI 1.01-2.10; I2 = 0%). NTM disease was associated with increased mortality (HR 2.69, 95% CI 1.70-4.26; I2 = 0%) and CLAD (HR 2.11, 95% CI 1.03-4.35; I2 = 44%). NTM isolation was not associated with mortality in pooled analysis or CLAD in 1 included study. CONCLUSIONS NTM disease, but not isolation, is associated with worse outcomes. Several factors were associated with development of NTM disease, including cystic fibrosis and pretransplant NTM isolation. Strategies to optimize prevention and treatment of NTM disease in lung transplant recipients are needed.
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Affiliation(s)
- Paige K Marty
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota
| | - Dana J Gerberi
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota
| | - Patricio Escalante
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kelly M Pennington
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Maryam Mahmood
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota
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4
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Case series of Rapidly growing mycobacterial Post-Operative surgical site infection in Kidney transplant recipients. IDCases 2022; 30:e01640. [DOI: 10.1016/j.idcr.2022.e01640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 10/10/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
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Ebisu Y, Natori Y, Rosello G, Anjan S, Simkins J, Camargo JF, Morris MI, Martinez OV, Abbo LM. Mycobacterium abscessus infections in Solid Organ Transplant Recipients. Single Center Experience in the United States, 2013-2018. Open Forum Infect Dis 2022; 9:ofac254. [PMID: 35854996 PMCID: PMC9290548 DOI: 10.1093/ofid/ofac254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/16/2022] [Indexed: 11/14/2022] Open
Abstract
Background Mycobacterium abscessus is increasingly recognized as a human pathogen causing life-threatening infections in immunocompromised patients. There is a paucity of data around this topic in solid organ transplant (SOT) recipients. Methods This work was a single-center retrospective cohort study of all SOT recipients with a positive culture for M abscessus between 2013 and 2018. Results A total of 20 patients (55% female) met inclusion criteria, including 1 kidney recipient (5.0%), 2 liver recipients (10.0%), 12 lung recipients (60.0%), 1 heart recipient (5.0%), and 4 combined organ recipients (20.0%). The median time from SOT to infection was 100 days (range, 30–431 days). Thirteen (65.0%) patients (1 kidney, 1 heart, 7 lung, 1 liver, 1 intestine, and 2 multivisceral) were treated with a median duration of 185 antibiotic days (range, 20–523 days). Among them, M abscessus was isolated from respiratory samples in 8 and nonrespiratory samples in 5; 4 of 13 (30.8%) patients had treatment failure and 3 of 13 (23.1%) had unrelated deaths within 1 year after diagnosis. Seven patients (5 lung transplant recipients) with the organism isolated from respiratory samples were not treated as their cultures represented airway colonization or contamination; of those, 2 (28.6%) died (unrelated to infection) and 5 (71.4%) were alive without the infection after 1 year of follow-up. Conclusions Mycobacterium abscessus infections affect SOT recipients with a high proportion of clinical failures. However, in lung recipients, not all positive cultures correlated with infection, and without treatment some patients had good clinical outcomes. Thus, differentiating colonization from infection is important, and infection prevention measures and novel therapeutic agents are needed for SOT recipients.
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Affiliation(s)
- Yosuke Ebisu
- Division of Infectious Diseases, Department of Medicine, Kameda Medical Center, Chiba, Japan
| | - Yoichiro Natori
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine Miami, FL, USA
- Miami Transplant Institute, Jackson Health System, Miami, FL, USA
| | - Gemma Rosello
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Shweta Anjan
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine Miami, FL, USA
- Miami Transplant Institute, Jackson Health System, Miami, FL, USA
| | - Jacques Simkins
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine Miami, FL, USA
- Miami Transplant Institute, Jackson Health System, Miami, FL, USA
| | - Jose F. Camargo
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine Miami, FL, USA
| | - Michele I. Morris
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine Miami, FL, USA
| | | | - Lilian M Abbo
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine Miami, FL, USA
- Miami Transplant Institute, Jackson Health System, Miami, FL, USA
- Jackson Health System, Miami, FL, USA
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Vanhooteghem O, Theate I, De Schaetzen V. Periungual Mycobacterium marinum Infection following a Fish Manicure. Skin Appendage Disord 2021; 7:393-396. [PMID: 34604330 DOI: 10.1159/000514853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/26/2021] [Indexed: 01/11/2023] Open
Abstract
Fish pedicures and/or fish manicures are treatments performed in spas involving the use of the living fish Garra rufa. In the last decade, the use of G. rufa for cosmetic and therapeutic reasons has become increasingly popular. The patients are placed into a bath to control psoriasis, eczema, or other skin conditions, but there is no scientific proof of their effectiveness. Most of the infections described in association with fish spas result from minor skin injury and contact with fish carrying such bacteria as Staphylococcus aureus, Aeromonas sobria, and Mycobacterium marinum. Therefore, fish spas in general should not be recommended, particularly for diabetic patients, immunocompromised patients, or patients treated with biological agents.
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Affiliation(s)
- Olivier Vanhooteghem
- Department of Dermatology, CHU UCL Namur - Sainte Elisabeth Hospital, Namur, Belgium
| | - Ivan Theate
- Department of Pathology, Institute of Pathology and Genetics, Gosselies, Belgium
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Locatelli ME, Tosto S, D'Agata V, Bonaventura P, Grasso RS, Marino A, Pampaloni A, Scuderi D, Cosentino F, Cacopardo B. Disseminated Disease by Mycobacterium abscessus and Mycobacterium celatum in an Immunocompromised Host. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e921517. [PMID: 32255770 PMCID: PMC7161942 DOI: 10.12659/ajcr.921517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Nontuberculous mycobacteria (NTM) are environmental pathogens that cause an increasing number of diseases, in particular in immunosuppressed patients. Diagnosing NTM infections may be difficult because clinical presentation is unspecific and resembles other conditions such as tuberculosis, lymphomas, or septicemia. CASE REPORT We report the case of a 62-year-old male with a recent history of autologous bone marrow transplantation for a follicular lymphoma admitted to our department for long-lasting remittent fever and abscess-like splenic nodules. The patient was diagnosed with mixed systemic infection by Mycobacterium abscessus and Mycobacterium celatum localized in spleen, bone marrow and kidneys. CONCLUSIONS In this case a rare disseminated atypical mycobacteriosis was diagnosed and treated. As far as we know this is the first case in the literature of M. abscessus localization either in the spleen or in the bone marrow. Our patient underwent a complex long-term therapy and had a complete resolution of the disease.
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Affiliation(s)
- Maria Elena Locatelli
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, Catania, Italy
| | - Salvatore Tosto
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, Catania, Italy
| | - Vincenzo D'Agata
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, Catania, Italy
| | - Paolo Bonaventura
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, Catania, Italy
| | - Rosaria S Grasso
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, Catania, Italy
| | - Andrea Marino
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, Catania, Italy
| | - Alessio Pampaloni
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, Catania, Italy
| | - Daniele Scuderi
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, Catania, Italy
| | - Federica Cosentino
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, Catania, Italy
| | - Bruno Cacopardo
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, Catania, Italy
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Longworth SA, Daly JS. Management of infections due to nontuberculous mycobacteria in solid organ transplant recipients-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13588. [PMID: 31077618 DOI: 10.1111/ctr.13588] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/06/2019] [Indexed: 01/06/2023]
Abstract
These updated guidelines from the American Society of Transplantation Infectious Diseases Community of Practice review the epidemiology, diagnosis, prevention, and management of nontuberculous mycobacterial infections in the pre- and post-transplant period. NTM commonly cause one of five different clinical syndromes: pleuropulmonary disease, skin and soft tissue infection, osteoarticular infection, disseminated disease, including that caused by catheter-associated infection, and lymphadenitis. Diagnosis of these infections can be challenging, particularly when they are isolated from nonsterile spaces, owing to their ubiquity in nature. Consequently, diagnosis of pulmonary infections with these pathogens requires fulfillment of microbiologic, radiographic, and clinical criteria to address this concern. A combination of culture and molecular diagnostic techniques is often required to make a species-level identification. Treatment varies depending on the species isolated and is complex, owing to drug toxicities, need for long-term multidrug regimens, and consideration of complex drug-drug interactions between antimicrobials and immunosuppressive agents. Given these treatment challenges, efforts should be made in both the hospital and community settings to limit exposure to these pathogens to the extent feasible.
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Affiliation(s)
- Sarah A Longworth
- Division of Infectious Disease, Hospital of University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer S Daly
- UMass Memorial Health Care, University of Massachusetts Medical School, Worcester, Massachusetts
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Kotecha S, Smibert OC, Doi A, Gooi J, Morrissey O, Paraskeva M, Snell GI, McGiffin D. A successful aggressive surgical and medical approach to pulmonary artery obstruction due to Mycobacterium abscessus infection post lung transplantation. Transpl Infect Dis 2018; 20:e12838. [PMID: 29359876 DOI: 10.1111/tid.12838] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/17/2017] [Accepted: 10/15/2017] [Indexed: 12/27/2022]
Abstract
Mycobacterium abscessus infection following lung transplantation has historically been associated with poor outcomes. We report a case of bilateral lung retransplantation complicated by obstruction of the right pulmonary artery secondary to M. abscessus mycotic aneurysm. Aggressive surgical management, including reconstruction of the right pulmonary artery, was undertaken with prolonged antimicrobial therapy. Thirty-six months later, antibiotics have been discontinued and the patient has stable soft tissue chest wall disease with good graft function. Mortality and morbidity associated with M. abscessus infection is considerable but this case illustrates that with aggressive early management, outcomes may be favorable.
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Affiliation(s)
- Sakhee Kotecha
- Lung Transplant Service, The Alfred Hospital, Melbourne, Australia
| | - Olivia C Smibert
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Australia
| | - Atsuo Doi
- Department of Cardiothoracic Surgery, Princess Alexandra Hospital, Brisbane, Australia
| | - Julian Gooi
- Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Australia
| | - Orla Morrissey
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Australia
| | | | - Greg I Snell
- Lung Transplant Service, The Alfred Hospital, Melbourne, Australia
| | - David McGiffin
- Lung Transplant Service, The Alfred Hospital, Melbourne, Australia
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Osmani M, Sotello D, Alvarez S, Odell JA, Thomas M. Mycobacterium abscessus infections in lung transplant recipients: 15-year experience from a single institution. Transpl Infect Dis 2018; 20:e12835. [PMID: 29359872 DOI: 10.1111/tid.12835] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/19/2017] [Accepted: 09/24/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate our institutional experience with Mycobacterium abscessus infections occurring in lung transplant recipients (LTR). METHODS We retrospectively reviewed our prospectively collected institutional adult lung transplant database from 2001 to 2015 to identify patients with M. abscessus or Mycobacterium chelonae/abscessus infection before or after transplantation. Untreated, colonized patients were excluded from the study. Electronic health records of nine out of 516 lung recipients (1.74%) with clinical infection were reviewed to determine outcomes. RESULTS Seven patients acquired the infection after transplantation. Indications for transplantation were: idiopathic pulmonary fibrosis (in 6), chronic obstructive pulmonary disease (in 2), and cystic fibrosis (in 1). Five patients (55.5%) underwent bilateral lung transplantation; one patient required bilateral re-transplantation for complications from infection. M. abscessus was isolated from the respiratory tract with a median time of 7.5 months (range: 3 days to 13 months) from transplantation. All patients were treated using a multidrug regimen, with durations ranging from 3 days to 12 months. Complications from infection included death in one patient, bronchial anastomotic dehiscence in one patient, delayed bronchial occlusions in two patients, and osteomyelitis of the knee in one patient. Median survival time from transplantation was 39 months (range: 11-96 months) and from the date of first positive culture was 58 months (range: 3-91 months). Five patients (55.5%) were cured but two had re-infections >1 year later. CONCLUSIONS Mycobacterium abscessus infection in LTR is rare and can lead to severe complications. Eradication is difficult and usually requires prolonged combination antibiotic therapy and occasionally surgical management.
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Affiliation(s)
- Morsal Osmani
- Clinical Research Internship Summer Program, Mayo Clinic, Jacksonville, FL, USA
| | - David Sotello
- Department of Infectious Diseases, Mayo Clinic, Jacksonville, FL, USA
| | - Salvador Alvarez
- Department of Infectious Diseases, Mayo Clinic, Jacksonville, FL, USA
| | - John A Odell
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
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11
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Song Y, Zhang L, Yang H, Liu G, Huang H, Wu J, Chen J. Nontuberculous mycobacteriuminfection in renal transplant recipients: a systematic review. Infect Dis (Lond) 2018; 50:409-416. [PMID: 29400108 DOI: 10.1080/23744235.2017.1411604] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Yan Song
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Li Zhang
- Kidney Disease Department, The Fourth Affiliated Hospital, College of Medicine, Zhejiang University, Yiwu, PR China
| | - Hao Yang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Guangjun Liu
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Hongfeng Huang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Jianyong Wu
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
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Dal Molin M, Gut M, Rominski A, Haldimann K, Becker K, Sander P. Molecular Mechanisms of Intrinsic Streptomycin Resistance in Mycobacterium abscessus. Antimicrob Agents Chemother 2018; 62:e01427-17. [PMID: 29061744 PMCID: PMC5740355 DOI: 10.1128/aac.01427-17] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/17/2017] [Indexed: 12/29/2022] Open
Abstract
Streptomycin, the first drug used for the treatment of tuberculosis, shows limited activity against the highly resistant pathogen Mycobacterium abscessus We recently identified two aminoglycoside-acetylating genes [aac(2') and eis2] which, however, do not affect susceptibility to streptomycin. This suggests the existence of a discrete mechanism of streptomycin resistance. M. abscessus BLASTP analysis identified MAB_2385 as a close homologue of the 3″-O-phosphotransferase [APH(3″)] from the opportunistic pathogen Mycobacterium fortuitum as a putative streptomycin resistance determinant. Heterologous expression of MAB_2385 in Mycobacterium smegmatis increased the streptomycin MIC, while the gene deletion mutant M. abscessus ΔMAB_2385 showed increased streptomycin susceptibility. The MICs of other aminoglycosides were not altered in M. abscessus ΔMAB_2385. This demonstrates that MAB_2385 encodes a specific and prime innate streptomycin resistance determinant in M. abscessus We further explored the feasibility of applying rpsL-based streptomycin counterselection to generate gene deletion mutants in M. abscessus Spontaneous streptomycin-resistant mutants of M. abscessus ΔMAB_2385 were selected, and we demonstrated that the wild-type rpsL is dominant over the mutated rpsLK43R in merodiploid strains. In a proof of concept study, we exploited this phenotype for construction of a targeted deletion mutant, thereby establishing an rpsL-based counterselection method in M. abscessus.
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Affiliation(s)
- Michael Dal Molin
- Institut für Medizinische Mikrobiologie, Universität Zürich, Zürich, Switzerland
| | - Myriam Gut
- Institut für Medizinische Mikrobiologie, Universität Zürich, Zürich, Switzerland
| | - Anna Rominski
- Institut für Medizinische Mikrobiologie, Universität Zürich, Zürich, Switzerland
| | - Klara Haldimann
- Institut für Medizinische Mikrobiologie, Universität Zürich, Zürich, Switzerland
| | - Katja Becker
- Institut für Medizinische Mikrobiologie, Universität Zürich, Zürich, Switzerland
| | - Peter Sander
- Institut für Medizinische Mikrobiologie, Universität Zürich, Zürich, Switzerland
- Nationales Zentrum für Mykobakterien, Zürich, Switzerland
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Abstract
Mycobacterium abscessus complex (MAbsC) disease in lung transplant recipients is increasingly being recognized as an important cause of graft function decline and suboptimal outcomes. Lung transplant recipients appear to be at the highest risk of MAbsC among solid organ transplant recipients, as they have more intense immunosuppression, and the organisms preferentially inhabit the lungs. MAbsC is the most resistant species of rapidly growing mycobacteria and difficult to treat, causing considerable mortality and morbidity in immunocompetent and immunosuppressed patients. Herein we describe the risk factors, epidemiology, clinical features, diagnostics, and treatment strategies of MAbsC in lung transplant candidates and recipients.
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Kishida D, Sato M, Kobayashi C, Ueno KI, Kinoshita T, Kodaira M, Shimojima Y, Ishii W, Ushiki A, Ikeda SI. Intractable Cutaneous Nontuberculous Mycobacteriosis (Mycobacterium abscessus) during Treatment for Systemic Lupus Erythematosus. Intern Med 2017; 56:1253-1257. [PMID: 28502947 PMCID: PMC5491827 DOI: 10.2169/internalmedicine.56.8053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Mycobacterium abscessus infection tends to occur in patients with an advanced immunocompromised status. We encountered a case of intractable cutaneous M. abscessus infection that developed in a patient with systemic lupus erythematosus (SLE) during maintenance therapy. A 28-year-old woman developed a fever and redness of the skin on her buttocks. General antibacterial therapy was ineffective, and acid-fast bacteria were detected in the biopsy that was conducted to differentiate the dermal symptoms of SLE. The clinical findings eventually improved; however, the symptoms recurred multiple times during treatment. Despite recent advances in SLE treatment, M. abscessus infection remains a considerable complication of SLE.
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Affiliation(s)
- Dai Kishida
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Japan
| | - Mitsuto Sato
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Japan
| | - Chinatsu Kobayashi
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Japan
| | - Ken-Ichi Ueno
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Japan
| | - Tomomi Kinoshita
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Japan
| | - Minori Kodaira
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Japan
| | - Wataru Ishii
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Japan
| | - Atsuhito Ushiki
- First Department of Internal Medicine, Shinshu University School of Medicine, Japan
| | - Shu-Ichi Ikeda
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Japan
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15
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Mougari F, Guglielmetti L, Raskine L, Sermet-Gaudelus I, Veziris N, Cambau E. Infections caused by Mycobacterium abscessus: epidemiology, diagnostic tools and treatment. Expert Rev Anti Infect Ther 2016; 14:1139-1154. [PMID: 27690688 DOI: 10.1080/14787210.2016.1238304] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Mycobacterium abscessus is an emerging mycobacteria that is responsible for lung diseases and healthcare-associated extrapulmonary infections. Recent findings support its taxonomic status as a single species comprising 3 subspecies designated abscessus, bolletii and massiliense. We performed a review of English-language publications investigating all three of these subspecies. Areas covered: Worldwide, human infections are often attributable to environmental contamination, although the isolation of M. abscessus in this reservoir is very rare. Basic research has demonstrated an association between virulence and cell wall components and cording, and genome analysis has identified gene transfer from other bacteria. The bacteriological diagnosis of M. abscessus is based on innovative tools combining molecular biology and mass spectrometry. Genotypic and phenotypic susceptibility testing are required to predict the success of macrolide (clarithromycin or azithromycin)-based therapeutic regimens. Genotyping methods are helpful to assess relapse and cross-transmission and to search for a common source. Treatment is not standardised, and outcomes are often unsatisfactory. Expert commentary: M. abscessus is still an open field in terms of clinical and bacteriological research. Further knowledge of its ecology and transmission routes, as well as host-pathogen interactions, is required. Because the number of human cases is increasing, it is also necessary to identify more active treatments and perform clinical trials to assess standard effective regimens.
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Affiliation(s)
- Faiza Mougari
- a Centre National de Référence des Mycobactéries et Résistance des Mycobactéries aux Antituberculeux (CNR-MyRMA) , Assistance publique-Hôpitaux de Paris (APHP) , Paris , France.,b AP-HP, Hôpital Lariboisière-Fernand Widal , Service de Bactériologie , Paris , France.,c IAME, UMR 1137, INSERM , Université Paris Diderot, Sorbonne Paris Cité , Paris , France
| | - Lorenzo Guglielmetti
- a Centre National de Référence des Mycobactéries et Résistance des Mycobactéries aux Antituberculeux (CNR-MyRMA) , Assistance publique-Hôpitaux de Paris (APHP) , Paris , France.,b AP-HP, Hôpital Lariboisière-Fernand Widal , Service de Bactériologie , Paris , France.,d Sorbonne Universités, UPMC Université Paris 06, CR7, Centre d'Immunologie et des Maladies Infectieuses, CIMI, team E13 (Bacteriology) , Paris , France.,e INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, CIMI, team E13 (Bacteriology) , Paris , France
| | - Laurent Raskine
- a Centre National de Référence des Mycobactéries et Résistance des Mycobactéries aux Antituberculeux (CNR-MyRMA) , Assistance publique-Hôpitaux de Paris (APHP) , Paris , France.,b AP-HP, Hôpital Lariboisière-Fernand Widal , Service de Bactériologie , Paris , France
| | - Isabelle Sermet-Gaudelus
- f AP-HP, Groupe Hospitalier Necker-Enfants Malades , Centre de Ressources et de Compétences pour la Mucoviscidose (CRCM) et Centre de Formation de Traitement à Domicile Chez l'Enfant (CFTDE) , Paris , France
| | - Nicolas Veziris
- a Centre National de Référence des Mycobactéries et Résistance des Mycobactéries aux Antituberculeux (CNR-MyRMA) , Assistance publique-Hôpitaux de Paris (APHP) , Paris , France.,d Sorbonne Universités, UPMC Université Paris 06, CR7, Centre d'Immunologie et des Maladies Infectieuses, CIMI, team E13 (Bacteriology) , Paris , France.,e INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, CIMI, team E13 (Bacteriology) , Paris , France.,g AP-HP, Hôpital Pitié-Salpêtrière , Laboratory of Bacteriology , Paris , France
| | - Emmanuelle Cambau
- a Centre National de Référence des Mycobactéries et Résistance des Mycobactéries aux Antituberculeux (CNR-MyRMA) , Assistance publique-Hôpitaux de Paris (APHP) , Paris , France.,b AP-HP, Hôpital Lariboisière-Fernand Widal , Service de Bactériologie , Paris , France.,c IAME, UMR 1137, INSERM , Université Paris Diderot, Sorbonne Paris Cité , Paris , France
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16
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Mycobacterium abscessus. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2016. [DOI: 10.1097/ipc.0000000000000385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Abad CL, Razonable RR. Non-tuberculous mycobacterial infections in solid organ transplant recipients: An update. J Clin Tuberc Other Mycobact Dis 2016; 4:1-8. [PMID: 31723683 PMCID: PMC6850244 DOI: 10.1016/j.jctube.2016.04.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 04/05/2016] [Accepted: 04/08/2016] [Indexed: 11/21/2022] Open
Abstract
Non-tuberculous mycobacteria are ubiquitous environmental organisms that are now increasingly recognized as important causes of clinical disease in solid organ transplant recipients. Risk factors of non-tuberculous mycobacteria infection are severe immunologic defects and structural abnormalities. Lung transplant recipients are at higher risk for non-tuberculous mycobacterial disease compared to recipients of other solid organs. The clinical presentation could be skin and soft tissue infection, osteoarticular disease, pleuropulmonary infection, bloodstream (including catheter-associated) infection, lymphadenitis, and disseminated or multi-organ disease. Management of non-tuberculous mycobacteria infection is complex due to the prolonged treatment course with multi-drug regimens that are anticipated to interact with immunosuppressive medications. This review article provides an update on infections due to non-tuberculous mycobacteria after solid organ transplantation, and discusses the epidemiology, risk factors, clinical presentation, and management.
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Affiliation(s)
- Cybele L Abad
- Division of Infectious Diseases and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, 55905 MN, United States
| | - Raymund R Razonable
- Division of Infectious Diseases and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, 55905 MN, United States
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18
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Smibert O, Snell GI, Bills H, Westall GP, Morrissey CO. Mycobacterium abscessus Complex - a Particular Challenge in the Setting of Lung Transplantation. Expert Rev Anti Infect Ther 2016; 14:325-33. [PMID: 26732819 DOI: 10.1586/14787210.2016.1138856] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Mycobacterium abscessus complex is an emerging pathogen in lung transplant candidates and recipients. M. abscessus complex is widespread in the environment and can cause pulmonary, skin and soft tissue, and disseminated infection, particularly in lung transplant recipients. It is innately resistant to many antibiotics making it difficult to treat. Herein we describe the epidemiology, clinical manifestations, diagnosis and treatment of M. abscessus with an emphasis on lung transplant candidates and recipients. We also outline the areas where data are lacking and the areas where further research is urgently needed.
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Affiliation(s)
- O Smibert
- a Department of Infectious Diseases , Alfred Health and Monash University , Melbourne , Australia
| | - G I Snell
- b Department of Allergy, Immunology and Respiratory Medicine , Alfred Health and Monash University , Melbourne , Australia
| | - H Bills
- c Faculty of Medicine , Nursing and Health Sciences, Monash University , Clayton , Australia
| | - G P Westall
- b Department of Allergy, Immunology and Respiratory Medicine , Alfred Health and Monash University , Melbourne , Australia
| | - C O Morrissey
- a Department of Infectious Diseases , Alfred Health and Monash University , Melbourne , Australia
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19
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Jankovic Makek M, Pavlisa G, Jakopovic M, Redzepi G, Zmak L, Vukic Dugac A, Hecimovic A, Mazuranic I, Jaksch P, Klepetko W, Samarzija M. Early onset of nontuberculous mycobacterial pulmonary disease contributes to the lethal outcome in lung transplant recipients: report of two cases and review of the literature. Transpl Infect Dis 2016; 18:112-9. [PMID: 26556693 DOI: 10.1111/tid.12481] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 09/21/2015] [Accepted: 09/21/2015] [Indexed: 11/29/2022]
Abstract
Lung transplant (LuTx) recipients represent a population at risk of nontuberculous mycobacterial pulmonary disease (NTM-PD). Yet the risk factors, the timing of NTM-PD after transplantation, and the association with allograft dysfunction all remain poorly defined. We report 2 cases of early-onset NTM-PD and review the literature, focusing on NTM-PD in LuTx recipients not colonized with NTM prior to transplantation. In addition, we summarize the main characteristics and differences between early- and late-onset disease.
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Affiliation(s)
- M Jankovic Makek
- Department for Lung Diseases, University Hospital Centre Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - G Pavlisa
- Department for Lung Diseases, University Hospital Centre Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - M Jakopovic
- Department for Lung Diseases, University Hospital Centre Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - G Redzepi
- Department for Lung Diseases, University Hospital Centre Zagreb, Zagreb, Croatia
| | - L Zmak
- National Reference Laboratory for Mycobacteria, National Institute of Health, Zagreb, Croatia
| | - A Vukic Dugac
- Department for Lung Diseases, University Hospital Centre Zagreb, Zagreb, Croatia
| | - A Hecimovic
- Department for Lung Diseases, University Hospital Centre Zagreb, Zagreb, Croatia
| | - I Mazuranic
- School of Medicine, University of Zagreb, Zagreb, Croatia.,Department of Thoracic Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - P Jaksch
- Department of Surgery, Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - W Klepetko
- Department of Surgery, Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - M Samarzija
- Department for Lung Diseases, University Hospital Centre Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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20
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Tennant SJ, Forster DW, Burgess DR, Huaman MA. Mycobacterium abscessus prosthetic valve endocarditis in a patient with Marfan syndrome. JMM Case Rep 2015. [DOI: 10.1099/jmmcr.0.000084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sarah J. Tennant
- Pharmacy Services, University of Kentucky HealthCare, 800 Rose Street, H110, Lexington, KY 40536, USA
| | - Derek W. Forster
- Division of Infectious Diseases, University of Kentucky, 740 South Limestone, K512, Lexington, KY 40536, USA
| | - Donna R. Burgess
- Pharmacy Services, University of Kentucky HealthCare, 800 Rose Street, H110, Lexington, KY 40536, USA
| | - Moises A. Huaman
- Division of Infectious Diseases, University of Kentucky, 740 South Limestone, K512, Lexington, KY 40536, USA
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21
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Silva JT, López-Medrano F, Fernández-Ruiz M, San-Juan R, Ruiz-Cano MJ, Delgado JF, Aguado JM. Mycobacterium abscessus pulmonary infection complicated with vertebral osteomyelitis in a heart transplant recipient: case report and literature review. Transpl Infect Dis 2015; 17:418-23. [PMID: 25816889 DOI: 10.1111/tid.12381] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 10/02/2014] [Accepted: 02/22/2015] [Indexed: 11/30/2022]
Abstract
Infections produced by Mycobacterium abscessus are emerging in immunosuppressed patients, such as solid organ transplant recipients. We report the first case, to our knowledge, of a vertebral osteomyelitis caused by M. abscessus in a heart transplant recipient, and review the risk factors, manifestations, and therapeutic approaches to this uncommon disease.
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Affiliation(s)
- J T Silva
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre", Universidad Complutense, Madrid, Spain
| | - F López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre", Universidad Complutense, Madrid, Spain
| | - M Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre", Universidad Complutense, Madrid, Spain
| | - R San-Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre", Universidad Complutense, Madrid, Spain.,Department of Microbiology, Hospital Universitario "12 de Octubre", Madrid, Spain
| | - M J Ruiz-Cano
- Department of Cardiology, Hospital Universitario "12 de Octubre", Madrid, Spain
| | - J F Delgado
- Department of Cardiology, Hospital Universitario "12 de Octubre", Madrid, Spain
| | - J M Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre", Universidad Complutense, Madrid, Spain
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22
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Fukui S, Sekiya N, Takizawa Y, Morioka H, Kato H, Aono A, Chikamatsu K, Mitarai S, Kobayashi S, Kamei S, Setoguchi K. Disseminated Mycobacterium abscessus Infection Following Septic Arthritis: A Case Report and Review of the Literature. Medicine (Baltimore) 2015; 94:e861. [PMID: 26020393 PMCID: PMC4616402 DOI: 10.1097/md.0000000000000861] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Mycobacterium abscessus is a rapidly growing mycobacterium found mainly in patients with respiratory or cutaneous infections, but it rarely causes disseminated infections. Little is known about the clinical characteristics, treatment, and prognosis of disseminated M abscessus infection. A 75-year-old Japanese woman who had been treated for 17 years with a corticosteroid for antisynthetase syndrome with antithreonyl-tRNA synthetase antibody developed swelling of her right elbow. X-ray of her right elbow joint showed osteolysis, and magnetic resonance imaging revealed fluid in her right elbow joint. M abscessus grew in joint fluid and blood cultures. She was diagnosed with a disseminated M abscessus infection following septic arthritis. Antimicrobial treatment by clarithromycin, amikacin, and imipenem/cilastatin combined with surgical debridement was administered. Although blood and joint fluid cultures became negative 1 week later, the patient died at 6 weeks from starting antimicrobial treatment. We reviewed 34 cases of disseminated M abscessus infections from the literature. Most of the patients had immunosuppressive backgrounds such as transplantation, use of immunosuppressive agents, hematological malignancy, and end stage renal disease. The duration from onset of symptoms to diagnosis was over 3 months in half of the cases. All fatal cases had positive blood cultures or use of immunosuppressive agents. Clinicians should bear in mind that mycobacterial infections including M abscessus are one of the differential diagnoses in patients with subacute arthritis and soft tissue infections.
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Affiliation(s)
- Shoichi Fukui
- From the Department of Rheumatology (SF, YT, S Kobayashi, S Kamei, KS); Clinical Laboratory (NS, HM, HK), Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo; and Department of Mycobacterium Reference and Research (AA, KC, SM), The Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Kiyose, Japan
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23
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Non-tuberculous mycobacteria in children: muddying the waters of tuberculosis diagnosis. THE LANCET RESPIRATORY MEDICINE 2015; 3:244-56. [DOI: 10.1016/s2213-2600(15)00062-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 01/11/2015] [Accepted: 01/12/2015] [Indexed: 11/24/2022]
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24
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Savoia P, Cavaliere G, Fava P. Risk of infectious diseases and cutaneous tumours in solid organ recipients: A meta-analysis of literature. World J Meta-Anal 2015; 3:11-19. [DOI: 10.13105/wjma.v3.i1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 09/08/2014] [Accepted: 11/19/2014] [Indexed: 02/05/2023] Open
Abstract
AIM: To compare the risk of cutaneous infections and tumours in kidney transplant recipients with data recently published about this topic.
METHODS: In the present work, we evaluated the incidence of bacterial, fungal and viral cutaneous infectious diseases and the development of skin cancers in a cohort of 436 patients who underwent a renal transplantation. The median age at transplantation of our patients was 50 years and the median duration of the immunosuppression was of 7.2 years. Data obtained from our cohort were compared with those obtained by a systematic review of the literature of the last 20 years about the same topic.
RESULTS: Infectious diseases were the most frequent dermatological disorders that were diagnosed after transplantation, affecting about the 16.5% of patients. Herpes virus reactivation occurs in about the 35% of patients and is more common within 6 mo from transplantation, whereas when the immunosuppression is reduced, skin infections are mainly represented by Human Papilloma Virus infections and localized mycosis, such as pityriasis versicolor and superficial candidiasis. Bacterial infections were relatively rare and occur mainly in the first months after transplantation. The cumulative risk to develop skin cancer enhance significantly over the time, as consequence of long-term immunosuppressive regiments. Endogenous and exogenous risk factors, as well as the schedule of immunosuppression can play a role and justify the different incidence of skin cancer in the various series.
CONCLUSION: Skin infections and cancer, commonly diagnosed in transplanted patients, impact on survival and life-quality, justifying the realization of follow-up programs for the early diagnosis and treatment.
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25
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Al-Anazi KA, Al-Jasser AM, Al-Anazi WK. Infections caused by non-tuberculous mycobacteria in recipients of hematopoietic stem cell transplantation. Front Oncol 2014; 4:311. [PMID: 25426446 PMCID: PMC4226142 DOI: 10.3389/fonc.2014.00311] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 10/19/2014] [Indexed: 12/20/2022] Open
Abstract
Non-tuberculous mycobacteria (NTM) are acid-fast bacteria that are ubiquitous in the environment and can colonize soil, dust particles, water sources, and food supplies. They are divided into rapidly growing mycobacteria such as Mycobacterium fortuitum, Mycobacterium chelonae, and Mycobacterium abscessus as well as slowly growing species such as Mycobacterium avium, Mycobacterium kansasii, and Mycobacterium marinum. About 160 different species, which can cause community acquired and health care-associated infections, have been identified. NTM are becoming increasingly recognized in recipients of hematopoietic stem cell transplantation (HSCT) with incidence rates ranging between 0.4 and 10%. These infections are 50–600 times commoner in transplant recipients than in the general population and the time of onset ranges from day 31 to day 1055 post-transplant. They have been reported following various forms of HSCT. Several risk factors predispose to NTM infections in recipients of stem cell transplantation and these are related to the underlying medical condition and its treatment, the pre-transplant conditioning therapies as well as the transplant procedure and its complications. Clinically, NTM may present with: unexplained fever, lymphadenopathy, osteomyelitis, soft tissue and skin infections, central venous catheter infections, bacteremia, lung, and gastrointestinal tract involvement. However, disseminated infections are commonly encountered in severely immunocompromised individuals and bloodstream infections are almost always associated with catheter-related infections. It is usually difficult to differentiate colonization from true infection, thus, the threshold for starting therapy remains undetermined. Respiratory specimens such as sputum, pleural fluid, and bronchoalveolar lavage in addition to cultures of blood, bone, skin, and soft tissues are essential diagnostically. Susceptibility testing of mycobacterial isolates is a basic component of optimal care. Currently, there are no guidelines for the treatment of NTM infections in recipients of stem cell transplantation, but such infections have been successfully treated with surgical debridement, removal of infected or colonized indwelling intravascular devices, and administration of various combinations of antimicrobials. Monotherapy can be associated with development of drug resistance due to new genetic mutation. The accepted duration of treatment is 9 months in allogeneic stem cell transplantation and 6 months in autologous setting. Unfortunately, eradication of NTM infections may be impossible and their treatment is often complicated by adverse effects and interactions with other transplant-related medication.
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Affiliation(s)
- Khalid Ahmed Al-Anazi
- Section of Adult Hematology and Oncology, Department of Medicine, King Khalid University Hospital, College of Medicine, King Saud University , Riyadh , Saudi Arabia
| | - Asma M Al-Jasser
- Central Regional Laboratory, Ministry of Health , Riyadh , Saudi Arabia
| | - Waleed Khalid Al-Anazi
- Section of Microbiology, Department of Pathology, King Khalid University Hospital, College of Medicine, King Saud University , Riyadh , Saudi Arabia
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26
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[Advances in respiratory health 2010: Techniques and Transplantation Section]. Arch Bronconeumol 2014; 47 Suppl 1:36-40. [PMID: 21300217 DOI: 10.1016/s0300-2896(11)70010-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Five articles and an editorial on interventional pneumology were published in Archivos de Bronconeumología. Two of these articles deal with bronchoscopy, one with lung biopsy with cryoprobes, one with thermoplasty in asthma and the last with tracheobronchomalacia. We also review several publications in international journals, with special emphasis on endobronchial ultrasound. Four original articles on idiopathic pulmonary fibrosis were published in Archivos de Bronconeumología: one special article comparing two treatments and a Cochrane systematic review on the efficacy of non-steroidal drugs in this disease. Finally, we highlight studies in lung transplantation, consisting of 14 publications from different continents and with highly diverse contents: one editorial, one letter to the editor, one procedures manual and nine international publications on donor characteristics, various types of complications, experimental results in the field of preservation, and the casuistics obtained in distinct diseases in which transplantation is an option.
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27
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Update on Nontuberculous Mycobacterial Infections in Solid Organ and Hematopoietic Stem Cell Transplant Recipients. Curr Infect Dis Rep 2014; 16:421. [DOI: 10.1007/s11908-014-0421-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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28
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Clonal relationship and differentiation among Mycobacterium abscessus isolates as determined using the semiautomated repetitive extragenic palindromic sequence PCR-based DiversiLab system. J Clin Microbiol 2014; 52:1969-77. [PMID: 24671795 DOI: 10.1128/jcm.03600-13] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Mycobacterium abscessus is a rapidly growing mycobacterium that causes respiratory tract infections in predisposed patients, such as those with cystic fibrosis and nosocomial skin and soft tissue infections. In order to investigate the clonal relationships between the strains causing epidemic episodes, we evaluated the discriminatory power of the semiautomated DiversiLab (DL) repetitive extragenic palindromic sequence PCR (REP-PCR) test for M. abscessus genotyping. Since M. abscessus was shown to be composed of subspecies (M. abscessus subsp. massiliense, M. abscessus subsp. bolletii, and M. abscessus subsp. abscessus), we also evaluated the ability of this technique to differentiate subspecies. The technique was applied to two collections of clinical isolates, (i) 83 M. abscessus original isolates (43 M. abscessus subsp. abscessus, 12 M. abscessus subsp. bolletii, and 28 M. abscessus subsp. massiliense) from infected patients and (ii) 35 repeated isolates obtained over 1 year from four cystic fibrosis patients. The DL REP-PCR test was standardized for DNA extraction, DNA amplification, and electrophoresis pattern comparisons. Among the isolates from distinct patients, 53/83 (62%) isolates showed a specific pattern, and 30 were distributed in 11 clusters and 6 patterns, with 2 to 4 isolates per pattern. The clusters and patterns did not fully correlate with multilocus sequence typing (MLST) analysis results. This revealed a high genomic diversity between patients, with a discriminatory power of 98% (Simpson's diversity index). However, since some isolates shared identical patterns, this raises the question of whether it is due to transmission between patients or a common reservoir. Multiple isolates from the same patient showed identical patterns, except for one patient infected by two strains. Between the M. abscessus subspecies, the indexes were <70%, indicating that the DL REP-PCR test is not an accurate tool for identifying organisms to the subspecies level. REP-PCR appears to be a rapid genotyping method that is useful for investigating epidemics of M. abscessus infections.
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Vaquero Barrios JM, Redel Montero J, Santos Luna F. Comorbidities Impacting on Prognosis After Lung Transplant. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.arbr.2014.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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30
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Comorbidities impacting on prognosis after lung transplant. Arch Bronconeumol 2013; 50:25-33. [PMID: 24355755 DOI: 10.1016/j.arbres.2013.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 11/17/2013] [Accepted: 11/19/2013] [Indexed: 12/15/2022]
Abstract
The aim of this review is to give an overview of the clinical circumstances presenting before lung transplant that may have negative repercussions on the long and short-term prognosis of the transplant. Methods for screening and diagnosis of common comorbidities with negative impact on the prognosis of the transplant are proposed, both for pulmonary and extrapulmonary diseases, and measures aimed at correcting these factors are discussed. Coordination and information exchange between referral centers and transplant centers would allow these comorbidities to be detected and corrected, with the aim of minimizing the risks and improving the life expectancy of transplant receivers.
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Hakami HI, Alhazmi AA, Alrajhi AA. Mycobacterium abscessus peritonitis associated with laparoscopic gastric banding. BMC Infect Dis 2013; 13:323. [PMID: 23855515 PMCID: PMC3727983 DOI: 10.1186/1471-2334-13-323] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 07/10/2013] [Indexed: 11/10/2022] Open
Abstract
Background Mycobacterium abscessus is a rapidly growing Mycobacterium that is a common water contaminant in the environment. We report a case of M. abscessus infection with band erosion following laparoscopic gastric banding. Case presentation A 34-year-old woman developed insidiously progressing abdominal distension over a period of 1 year associated with abdominal pain, fatigue, night sweating and anorexia 4 years after laparoscopic gastric banding for obesity. Investigation revealed significant ascites with caseating granuloma in peritoneal biopsies from which M. abscessus was isolated. Band erosion with infection and multiple abdominal adhesions were confirmed during laparoscopic removal of the gastric band. To the best of our knowledge, this is the first reported case of M. abscessus infection after laparoscopic gastric banding surgery. We discuss the possible sources of infection, its indolent presentation, and therapeutic challenges. Conclusion It is important to consider environmentally acquired infection in patients with signs and symptoms of infection in the presence of surgical prosthesis.
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Do PCM, Nussbaum E, Moua J, Chin T, Randhawa I. Clinical significance of respiratory isolates for Mycobacterium abscessus complex from pediatric patients. Pediatr Pulmonol 2013; 48:470-80. [PMID: 22833551 DOI: 10.1002/ppul.22638] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 04/24/2012] [Indexed: 01/15/2023]
Abstract
Mycobacterium abscessus complex is the most virulent of rapidly growing mycobacteria causing invasive lung disease. To better delineate clinical pediatric experience and outcomes with M. abscessus complex, we retrospectively gathered 5-year data on M. abscessus complex infection and outcomes in a large, hospital-based pediatric pulmonary center. Patients were selected from the database of the microbiology department at Miller Children's Hospital in Long Beach, CA. Patients had at least one positive pulmonary isolate for M. abscessus complex from February 2006 to May 2011. Treatment modality data were collected and successful therapy of disease was determined as clearance of M. abscessus complex infection after antibiotics proven by culture negative respiratory isolate within at least 12 months of therapy initiation. Two cystic fibrosis patients with M. abscessus complex were identified, one with failed therapy and the other with stable pulmonary status despite persistent isolation. One primary ciliary dyskinesia patient had successful clearance of M. abscessus complex, however is now growing M. avium intracellulare. A patient with no prior medical history was successfully treated with antimycobacterial therapy. Eleven patients with neuromuscular disorders had tracheal aspirates positive for M. abscessus complex. None were treated due to stable lung status and all but two had spontaneous clearance of the mycobacteria. The two remaining persist with sporadic isolation of M. abscessus complex without clinical significance. We concluded that patients with tracheostomy associated M. abscessus complex infections do not appear to require treatment and often have spontaneous resolution. Cystic fibrosis or primary ciliary dyskinesia patients may have clinical disease warranting treatment, but current antimycobacterial therapy has not proven to be completely successful. As M. abscessus complex gains prevalence, standardized guidelines for diagnosis and therapy are needed in the pediatric population. Multicenter cohort analysis is necessary to achieve such guidelines.
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Affiliation(s)
- Paul C M Do
- Miller Children's Hospital, School of Medicine, University of California Irvine, Long Beach, California 90806, USA.
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First Report of Lung Transplantation in a Patient With Active Pulmonary Mycobacterium simiae Infection. Transplant Proc 2013; 45:803-5. [DOI: 10.1016/j.transproceed.2012.02.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 02/10/2012] [Accepted: 02/28/2012] [Indexed: 11/18/2022]
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Richey LE, Bahadorani J, Mushatt D. Endovascular Mycobacterium abscessus infection in a heart transplant recipient: a case report and review of the literature. Transpl Infect Dis 2012; 15:208-13. [PMID: 23176090 DOI: 10.1111/tid.12024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 07/10/2012] [Accepted: 07/24/2012] [Indexed: 11/28/2022]
Abstract
Nontuberculous mycobacteria are ubiquitous in the environment. Although rarely a cause of infection in immunocompetent individuals, increased risk and severity of infection are seen in patients who are immunocompromised, such as those with solid organ transplants. In this report, we describe the first case of disseminated endovascular Mycobacterium abscessus in a heart transplant recipient. A review of the literature regarding this infection in heart transplant recipients and its therapeutic options and concerns are summarized.
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Affiliation(s)
- L E Richey
- Adult Infectious Disease Section, Tulane University Medical Center, New Orleans, Louisiana 70112-2699, USA.
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Kothavade RJ, Dhurat RS, Mishra SN, Kothavade UR. Clinical and laboratory aspects of the diagnosis and management of cutaneous and subcutaneous infections caused by rapidly growing mycobacteria. Eur J Clin Microbiol Infect Dis 2012; 32:161-88. [PMID: 23139042 DOI: 10.1007/s10096-012-1766-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 10/15/2012] [Indexed: 10/27/2022]
Abstract
Rapidly growing mycobacteria (RGM) are known to cause pulmonary, extra-pulmonary, systemic/disseminated, and cutaneous and subcutaneous infections. The erroneous detection of RGM that is based solely on microscopy, solid and liquid cultures, Bactec systems, and species-specific polymerase chain reaction (PCR) may produce misleading results. Thus, inappropriate therapeutic measures may be used in dermatologic settings, leading to increased numbers of skin deformity cases or recurrent infections. Molecular tools such as the sequence analyses of 16S rRNA, rpoB and hsp65 or PCR restriction enzyme analyses, and the alternate gene sequencing of the superoxide dismutase (SOD) gene, dnaJ, the 16S-23S rRNA internal transcribed spacers (ITS), secA, recA1, dnaK, and the 32-kDa protein gene have shown promising results in the detection of RGM species. PCR restriction enzyme analyses (PRA) work better than conventional methods at identifying species that are closely related. Recently introduced molecular tools such as matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), pyrosequencing, DNA chip technology, and Beacon probes-combined PCR probes have shown comparable results in the detection of various species of RGM. Closely related RGM species (e.g., Mycobacterium fortuitum, M. chelonae, and M. abscessus) must be clearly differentiated using accurate molecular techniques because their therapeutic responses are species-specific. Hence, this paper reviews the following aspects of RGM: (i) its sources, predisposing factors, clinical manifestations, and concomitant fungal infections; (ii) the risks of misdiagnoses in the management of RGM infections in dermatological settings; (iii) the diagnoses and outcomes of treatment responses in common and uncommon infections in immunocompromised and immunocompetent patients; (iv) conventional versus current molecular methods for the detection of RGM; (v) the basic principles of a promising MALDI-TOF MS, sampling protocol for cutaneous or subcutaneous lesions and its potential for the precise differentiation of M. fortuitum, M. chelonae, and M. abscessus; and (vi) improvements in RGM infection management as described in the recent 2011 Clinical and Laboratory Standards Institute (CLSI) guidelines, including interpretation criteria of molecular methods and antimicrobial drug panels and their break points [minimum inhibitory concentrations (MICs)], which have been highlighted for the initiation of antimicrobial therapy.
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Affiliation(s)
- R J Kothavade
- Microbiology Lab, Epcor, 10065 Jasper Ave NW, Edmonton, AB, T5J 3B1, Canada.
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Biggs H, Chudgar S, Pfeiffer C, Rice K, Zaas A, Wolfe C. Disseminated Mycobacterium immunogenum infection presenting with septic shock and skin lesions in a renal transplant recipient. Transpl Infect Dis 2012; 14:415-21. [DOI: 10.1111/j.1399-3062.2012.00730.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 12/27/2011] [Accepted: 02/14/2012] [Indexed: 12/17/2022]
Affiliation(s)
- H.M. Biggs
- Division of Infectious Diseases; Department of Medicine; Duke University Medical Center; Durham; North Carolina; USA
| | - S.M. Chudgar
- Hospital Medicine Program; Department of Medicine; Duke University Medical Center; Durham; North Carolina; USA
| | | | - K.R. Rice
- Department of Dermatology; Duke University Medical Center; Durham; North Carolina; USA
| | - A.K. Zaas
- Division of Infectious Diseases; Department of Medicine; Duke University Medical Center; Durham; North Carolina; USA
| | - C.R. Wolfe
- Division of Infectious Diseases; Department of Medicine; Duke University Medical Center; Durham; North Carolina; USA
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Current world literature. Curr Opin Organ Transplant 2011; 16:650-60. [PMID: 22068023 DOI: 10.1097/mot.0b013e32834dd969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Nonneoplastic mucocutaneous lesions are frequent in organ transplant recipients. Many of them are caused by a direct toxicity of immunosuppressive drugs, in particular glucocorticoids and cyclosporine. The effects of these agents are dose- and time-dependent. Glucocorticoids can cause acne, Cushingoid appearance, irregular purpuric areas, friable skin, and wide and violaceous stripes. Cyclosporine can cause hypertrichosis, pilosebaceous lesions, and gum hypertrophy. Patients with esthetic changes may show poor adherence to treatment with these immunosuppressive agents that may lead to progressive graft dysfunction. Apart from this direct toxicity, vigorous immunosuppression may render the transplant recipients more susceptible to mucocutaneous infections. Fungal infection, viral warts, and bacterial folliculitis are the most frequent types of mucocutaneous infection. Some fungal infections, such as oral candidiasis and pityriasis versicolor, are relatively trivial, but other mycotic infections can cause severe or disfigurating lesions. Among viral infections, warts and condylomata caused by human papilloma virus are frequent and may favor the development of nonmelanoma skin cancer. Bacterial infections are usually trivial in the early period after transplantation, being represented almost exclusively by folliculitis. However, subcutaneous infections may cause a necrotizing fasciculitis which is a life-threatening disorder, usually sustained by polymicrobial pathogens.
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Affiliation(s)
- Claudio Ponticelli
- Division of Nephrology, Istituto Scientifico Humanitas, Rozzano, Milan, Italy.
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