Cutaneous Mycobacterium chelonae in a liver transplant patient

Dermatological Disorders following Liver Transplantation: An Update

Patients undergoing liver transplantation (LT) are at a high risk of dermatological complications compared to the general population as a result of long-term use of immunosuppressant. However, the risk is not as high as other solid organ transplantations (SOT), particularly for skin cancer. The liver is considered as an immune privileged organ since it has a low prevalence of humoral rejection in contrast to other SOT, and thus, LT requires a minimal amount of immunosuppressants compared to other SOT recipients. However, because of the large volume of the liver, patients with LT have higher donor lymphocytes that sometimes may trigger graft-versus-host-disease, yet it is rare. On the other hand, the vast majority of the nonspecific dermatological lesions linked with cirrhosis improve after removal of diseased liver or due to the immunosuppressant used after LT. Nevertheless, dermatological infections related to bacteria, viruses, and fungus after LT are not uncommon. Additionally, the incidence of IgE-mediated food allergies develops in 12.2% of LT patients and may present as life-threatening conditions such as urticaria and/or angioedema and hypersensitivity. Moreover, skin malignancies after LT are a matter of concern. Thus, posttransplant dermatological care should be provided to all LT patients for any suspicious dermatological lesions. Our goal is to give an outline of the dermatological manifestation associated with LT for the clinicians by collecting the published data from all archived case reports.

Non-tuberculous mycobacterial infections in solid organ transplant recipients: An update

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.

Disseminated cutaneous infection with Mycobacterium chelonae in a patient with steroid-dependent rheumatoid arthritis

Mycobacterium chelonae is a rapidly growing atypical mycobacterium that is a normal commensal of water and soil. We report a case of a 61-year-old man with seronegative rheumatoid arthritis and fibrosing alveolitis on long-term prednisolone who presented with a number of tender, red, subcutaneous nodules on his upper arms and a pustule on his left cheek. Histopathologic examination revealed dense neutrophilic collections within the deep dermis and subcutaneous fat with abscess formation. Long filamentous organisms were seen within these collections and were subsequently identified by special stains and PCR as Mycobacterium chelonae. Treatment was not possible as the patient developed bacteria bronchopneumonia before identification of the organism and he subsequently died. Post-mortem revealed no extra-cutaneous evidence of mycobacterium infection.

Nontumoral dermatologic problems after liver transplantation

The skin, easily accessible for medical examination, is affected in many ways by liver transplantation. Mucocutaneous manifestations of advanced liver disease and dermatologic conditions associated with specific hepatic diagnoses generally improve after liver transplantation. Vasculitic lesions due to cryoglobulinemia associated with hepatitis C, and photosensitivity due to porphyria are occasional exceptions. Dermatologic diseases complicating the posttransplantation course can be challenging. Their presentation is sometimes unusual and their course severe. Infections with rare organisms alone or in combination may occur. Our intent is to provide an overview of the current knowledge regarding nontumoral dermatologic problems associated with liver transplantation by summarizing the available information from all documented case reports.

Disseminated Mycobacterium chelonae cutaneous infection: recalcitrant to combined antibiotic therapy

A 25-year-old Thai housewife had a history of tuberculosis of the lymph nodes for six years that had been successfully treated with a course of anti-TB drugs. She developed several red, circumscribed, infiltrative plaques composed of umbilicated papules and pustules on her face and upper part of the body with cervical lymphadenopathy six months later. A pus smear from the lesion grew acid fast bacilli (AFB). Histopathological examination showed a mixed cell granuloma suggestive of infection. A T cell study showed a low CD4 count, and multi skin tests indicated cutaneous anergy. Culture from a biopsy specimen taken from the skin lesion grew M.chelonae; the cultures from blood, urine, and bone marrow. The lesions were not responsive to an anti TB drug given for 2 months based upon the results of the AFB positive pus smear before the culture and sensitivity reports were obtained. Since then the patient was treated with antibiotics according to the results of the sensitivity tests. A combination of amikacin and clarithromycin was started and hyperthermic therapy was later added with a partial response. Based upon the sensitivity test, kanamycin was introduced but had to be stopped because of ototoxicity. Sparfloxacin was used with an effective result but was discontinued for economic reasons. Finally, clarithromycin in combination with clofazimine and cryotherapy were given for a year before the lesions healed completely. It took a three years duration for the total course of treatment for this patient. She is still in remission after two years of follow-up period. This extensive cutaneous M.chelonae infection needed a prolonged combination of antibiotics with the addition of cryotherapy for the non-responsive lesions.