Mycobacterium kansasii septic arthritis: French retrospective study of 5 years and review

Toto, we're not in Kansas anymore: First reported case of M. persicum septic arthritis

In this report, we describe a case of septic arthritis caused by the newly described Mycobacterium persicum (formerly Mycobacterium kansasii complex). The patient's only significant exposure was home gardening. To our knowledge, this represents the first documented case of M. persicum infection in the United States and first septic arthritis.

Mycobacterium kansasii arthritis of the elbow in an immunocompetent patient with a suspected soft-tissue tumor

Mycobacterium kansasii is one of the major non-tuberculous mycobacteria species that typically cause pulmonary diseases. M. kansasii is known to cause septic arthritis as an extrapulmonary disease in immunosuppressed patients or chronic skin disease. Herein, we present a case of M. kansasii arthritis involving the elbow of an immunocompetent patient, which was initially suspected to be a soft-tissue tumor. A 70-year-old man presented with a swollen left elbow that had progressed for 18 months with deteriorating arthralgia and limited range of motion. Magnetic resonance imaging revealed filling of the intra-articular space of the elbow and surrounding of the radial head with a soft tissue mass with mixed signal intensity. Initial incisional biopsy was performed via the lateral approach to the elbow joint, and pathological examination of the mass did not reveal any evidence of malignancy. One year after the first operation, arthroscopic surgery was performed to excise the mass following the recurrence of swelling and limited function of the elbow. Pathological examination of the resected synovium revealed epithelioid granulomas containing a multinucleated giant cell and inflammatory cell infiltration, characteristic of mycobacterial infection. M. kansasii was cultured after 2 weeks of incubation of the synovial sample. He experienced full resolution of the swelling and limited function following a combination of synovectomy and multidrug antimycobacterial treatment (rifampin 600 mg/day, clarithromycin 800 mg/day, and ethambutol 750 mg/day). This case highlights the need to consider this rare infection in the differential diagnosis of intra-articular soft tissue tumor-like lesions even in immunocompetent patients.

Chronic Tenosynovitis due to Mycobacteria kansasii in an Immunocompetent Host

We report a case of a healthy 56-year-old male who presented with chronic swelling and erythema in his right hand. He had a prior chemical exposure several years ago and subsequent exposure to freshwater, fish tank, and soil. Laboratory data showed a slightly elevated CRP. An MRI was consistent with suggestive of flexor tenosynovitis. He underwent surgical debridement and was diagnosed with Mycobacterium kansasii. He was treated with clarithromycin, rifampin, and isoniazid, but subsequent susceptibility testing revealed resistance to isoniazid. Isoniazid was switched to ethambutol, but further susceptibility testing also suggested resistance to ethambutol. Antimicrobial therapy was stopped at 6 months due to clinical recovery, and the patient is currently doing well as of 6 months postdiscontinuation of therapy.

Mycobacterium kansasii

The incidence of Mycobacterium kansasii varies widely over time and by region, but this organism remains one of the most clinically relevant isolated species of nontuberculous mycobacteria. In contrast to other common nontuberculous mycobacteria, M. kansasii is infrequently isolated from natural water sources or soil. The major reservoir appears to be tap water. Infection is likely acquired through the aerosol route, with low infectivity in regions of endemicity. Human-to-human transmission is thought not to occur. Clinical syndromes and radiological findings of M. kansasii infection are mostly indistinguishable from that of Mycobacterium tuberculosis, thus requiring microbiological confirmation. Disseminated disease is uncommon in HIV-negative patients and usually associated with severe immunosuppression. The majority of patients with M. kansasii pulmonary disease have underlying pulmonary comorbidities, such as smoking, chronic obstructive pulmonary disease, bronchiectasis, and prior or concurrent M. tuberculosis infection. Surveys in Great Britain, however, noted higher rates, with 8 to 9% of M. kansasii infections presenting with extrapulmonary disease. Common sites of extrapulmonary disease include the lymph nodes, skin, and musculoskeletal and genitourinary systems. The specificity of gamma interferon release assays (IGRAs) for M. tuberculosis may be reduced by M. kansasii infection, as M. kansasii encodes CFP-10 and ESAT-6, two antigens targeted by IGRAs. A study conducted to evaluate the therapy in rifampin-resistant disease found that patients with acquired rifampin resistance were treated with daily high-dose ethambutol, isoniazid, sulfamethoxazole, and pyridoxine combined with aminoglycoside therapy. Given the potential toxicities, particularly with aminoglycoside therapy, clarithromycin and/or moxifloxacin therapy could be considered as alternatives.

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.

Mycobacterium kansasii causing chronic monoarticular synovitis in a patient with HIV/AIDS

Mycobacterium kansasii is a nontuberculous mycobacterium that primarily causes pulmonary disease in AIDS patients, however it has also been known, rarely, to result in skeletal infection. When skeletal infection occurs, the time from onset of symptoms to diagnosis is up to 5 years in previously reported cases. We describe a 48-year-old woman with HIV/AIDS who presented with chronic, isolated left knee pain and swelling of over two decades which had recently worsened. Radiographs and magnetic resonance imaging demonstrated marked subarticular erosions, synovial thickening, and bone marrow edema, which had progressed compared with prior imaging done seven years earlier. Synovial biopsy grew Mycobacterium kansasii. Following the presentation of our case, clinical and imaging findings, including the differential diagnosis, of monoarticular arthritis caused by Mycobacterium kansasii are reviewed and discussed.

A case of wrist tenosynovitis caused by Mycobacterium kansasii in a renal transplant recipient

Mycobacterial infection in an organ transplant recipient is a diagnostic and therapeutic challenge. Diagnosis is often delayed, resulting in significant morbidity. Anti-microbial chemotherapy needs careful selection to prevent potentially significant complications, such as organ rejection and dose-related toxicities. We present the case of a 61-year-old Caucasian male kidney transplant recipient with chronic tenosynovitis of the left wrist. Histological findings of the synovial biopsy revealed multinucleated giant cell epithelioid granuloma. Culture of synovial fluid grew Mycobacterium kansasii. Treatment with rifampicin, ethambutol, and clarithromycin proved curative, but the patient developed irreversible ethambutol-related optic neuritis.

Mycobacterium kansasii pericarditis in a kidney transplant recipient: a case report and comprehensive review of the literature

Mycobacterium kansasii is the second most common non-tuberculous mycobacteria in kidney transplant recipients (KTRs) and has been reported to cause disseminated infection in KTRs. We report the first case to our knowledge of M. kansasii pericarditis after kidney transplantation in a 54-year-old man. The patient was admitted with a 2-month history of intermittent fever and myalgia, treated with oral prednisolone and mycophenolate mofetil prior to admission. Chest computed tomography showed enlarged mediastinal lymph node and small amount of pericardial effusion. Mediastinoscopic biopsy of mediastinal lymph node revealed reactive hyperplasia, without evidence of granuloma, but acid-fast bacilli stain of pericardial fluid reported positive finding and pericardial fluid culture identified M. kansasii. The patient has been treated successfully with rifabutin-based combination therapy. All available cases of M. kansasii infection in kidney transplant patients and M. kansasii pericarditis in human immunodeficiency virus-infected patients are comprehensively reviewed.

Recurrent fluctuant mass of the wrist and forearm associated with chronic tenosynovitis by Mycobacterium kansasii

This article presents a case of a painless fluctuant mass on the volar aspect of the wrist and forearm of an immunocompetent 45-year-old man with no history of significant underlying disease. This mass proved to be a chronic tenosynovitis associated with Mycobacterium kansasii infection. The patient, who had a history of multiple minor cuts and abrasions plus exposure to an aquatic environment, had a wide resection of the lesion and elective tenosynovectomy. Operative findings revealed a marked tenosynovitis of flexor tendons. Several rice bodies lesions were also observed along the course of the involved flexor tendons.Biopsy showed a granulomatous inflammatory reaction. Specimens of affected tissue were sent to a laboratory for solid (at 30°C and at 37°C) and liquid (at 37°C) mycobacterial culture. The initial Ziehl-Neelsen stain for acid-fast bacilli was positive. After 8 days of incubation, acid-fast bacilli were recovered. In accordance with the diagnosis of M kansasii tenosynovitis and the results of antibiotic susceptibility testing, triple therapy with rifampicin, isoniazid and clarithromycin was initiated. After 3 months of therapy, the patient experienced improvement in the swelling and is due to receive 12 months of antibiotic therapy. Despite awareness of atypical mycobacterial infections, diagnosis is frequently delayed, leading to increased morbidity. Patients with exposure to these atypical pathogens require a broadened differential to include appropriate testing and culture of specimens to obtain an accurate diagnosis.

Septic arthritis caused by Mycobacterium fortuitum and Mycobacterium abscessus in a prosthetic knee joint: case report and review of literature

Nontuberculous mycobacterium (NTM) is an infrequent cause of prosthetic knee joint infections. Simultaneous infection with different NTM species in a prosthetic knee joint has not been previously reported. A case of prosthetic knee joint infection caused by Mycobacterium abscessus and M. fortuitum is described in this report. The patient was successfully treated with adequate antibiotics and surgery. The clinical features of sixteen previously reported cases of prosthetic knee joint infection caused by NTM are reviewed.

Current treatment of atypical mycobacteriosis

BACKGROUND

Atypical mycobacteria are a heterogeneous group of organisms that are of increasing importance because of the growing number of infections they cause. This rising rate of infection is due mainly to the increase in the number of susceptible (and especially immunosuppressed) patients.

OBJECTIVE

To revise the currently used treatment schemes of the most commonly isolated atypical mycobacteria.

METHODS

Literature review using reference books and PubMed with specific keywords for each mycobacteria.

RESULTS/CONCLUSION

The first important step in the management of atypical mycobacteria is to recognize the true infections caused by these organisms. The treatment required varies according to species. Well-characterized combinations exist for most common isolates, with the use of first-line antituberculous drugs (isoniazid, rifampin, ethambutol), clarithromycin, aminoglycosides and/or quinolones for slowly growing species (Mycobacterium avium complex, Mycobacterium kansasii, Mycobacterium xenopi, Mycobacterium ulcerans, Mycobacterium marinum, Mycobacterium lentiflavum, Mycobacterium malmoense) and macrolides, quinolones, amikacin and other antibiotics for rapidly growing mycobacteria (Mycobacterium abscessus, Mycobacterium chelonae, Mycobacterium fortuitum). Surgical therapy is also important for some species (Mycobacterium ulcerans, Mycobacterium scrofulaceum) and for localized infections. The treatment of uncommon species is not well defined and is determined by the results of in vitro tests of individual strains. Because of the increasing number of resistant strains, new antibiotics need to be used for the treatment of these strains.

Mycobacterium kansasii causing septic arthritis and osteomyelitis in a child

We present the case of a boy with a 3-year history of relapsing/remitting monoarthritis of the ankle joint. Despite negative cultures at first presentation, synovial fluid examination revealed Mycobacterium kansasii. This is the youngest reported case of M. kansasii septic arthritis in a child.

[Cervical adenitis caused by Mycobacterium kansasii: advantage of the INNO-LiPA V2 test in diagnosis of nontuberculous mycobacterial diseases]

Mycobacterium kansasii is one of the main mycobacterial species. Among the numerous subtypes, I and II subtypes are the only pathogens ones. A 56 years old woman has been under observation during her hospitalization for a cervical adenitis check-up; these one having been evolving for 2 months, without inflammatory syndrome. The failures of various antibiotics treatments lead one to withdraw some cervical ganglions whose histopathologic aspect reminds tuberculosis. These adenitis being isolated. An INH, rifampin, and ethambutol associated treatment is set up. After 2 weeks, the different cultures enable to isolated numerous photochromogenic colonies; a positive result is obtained with M. kansasii probe (Accuprobe). The identification is confirmed in 24 hours time with another molecular hybridation test (INNO-LiPA V2); the various specific probes of the different M. kansasii subtypes show it's not a I or II subtype (subtype IV by sequence analysis). This observation underlines the advantage and rapidity of the new diagnosis methods for nontuberculous mycobacterial diseases.

Mycobacterium kansasii olecranon bursitis

A case is reported of a post-traumatic olecranon bursitis caused by Mycobacterium kansasii following an injury sustained in a public swimming pool. It responded to surgical debridement and combined rifampicin, isoniazid, pyrazinamide and ethambutol antimicrobial therapy. A literature search was performed and a treatment regimen for this uncommon condition is suggested.

Septic arthritis caused by Mycobacterium kansasii in a prosthetic knee joint

Mycobacterium kansasii is a relatively common cause of nontuberculous mycobacterial pulmonary infection. Septic arthritis caused by Mycobacterium kansasii, on the other hand, is rare. Reported here for the first time is the case of an 82-year-old patient with an infection of a prosthetic knee joint with Mycobacterium kansasii.

Disseminated Mycobacterium kansasii infection in an HIV-negative patient presenting with mimicking multiple bone metastases

We report a patient with disseminated Mycobacterium kansasii infection, but with no underlying disease, presenting with mimicking multiple bone metastases with cancer of unknown primary site. Disseminated M. kansasii infection is rare in HIV-negative patients without underlying diseases. This patient had disseminated M. kansasii infection manifested with vertebral osteomyelitis, sacroiliitis, psoas abscess, bone marrow granuloma, liver granuloma, and possible spleen abscesses. The clinical manifestations are described and discussed in details.

Epidemiological, clinical and therapeutic features of AIDS-related Mycobacterium kansasii infection during the HIV pandemic: an 11-year follow-up study

OBJECTIVES

Optimal diagnosis and timely treatment of atypical mycobacteriosis, and especially Mycobacterium kansasii disease, remain a serious challenge for clinicians engaged in the management of the immunocompromised host.

METHODS AND RESULTS

From more than 2700 hospitalizations (over 1800 patients) attributable to HIV-associated disorders over an 11-year period, 12 patients were found to have a confirmed M. kansasii infection. This reflects the recent reduction in the frequency of this HIV-related complication, which virtually disappeared after the introduction of potent antiretroviral combinations in 1996. In the early 1990s, the lack of effective antiretroviral regimens made frequent the association with AIDS, a mean CD4 lymphocyte count of nearly 20 cells/microL, and an extremely variable chest X-ray features. The recent detection of a further case was attributable to late recognition of very advanced HIV disease, complicated by multiple opportunistic disorders.

CONCLUSIONS

Mycobacterium kansasii respiratory or disseminated infection continues to occur, and poses diagnostic problems in terms of late or missed identification as a result of slow culture and frequently concurrent opportunistic disease. Serious therapeutic difficulties also arise from the unpredictable in vitro antimicrobial susceptibility profile of these organisms, and from the need to start an effective combination therapy that does not interfere with other medications as soon as possible.

Septic monoarthritis of the first carpo-metacarpal joint caused by Mycobacterium Kansasii

A case of septic carpal monoarthritis due to Mycobacterium kansasii developing 16 months after accidental inoculation in a healthy laboratory technician is reported. No predisposing factor such as immunosuppression, preexisting degenerative, inflammatory arthritis or cortisone injection was present. Treatment with antituberculous oral medication alone resulted in resolution of the disease. Synovectomy was unnecessary. Ten years after the initial causative event, the patient remains free of symptoms.

Nontuberculous mycobacterial infection in hematopoietic stem cell and solid organ transplant recipients

Nontuberculous mycobacteria (NTM) are ubiquitous environmental organisms. In immunocompetent hosts, they are a rare cause of disease. In immunocompromised hosts, disease due to NTM is well documented. Reports of NTM disease have increased in hematopoietic stem cell transplant (HSCT) and solid organ transplant (SOT) recipients. This increase may reflect increased numbers of transplants, intensification of immune suppressive regimens, prolonged survival of transplant recipients, and/or improved diagnostic techniques. The difficulty of diagnosis and the impact associated with infections due to NTM in HSCT and SOT recipients necessitates that, to ensure prompt diagnosis and early initiation of therapy, a high level of suspicion for NTM disease be maintained. The most common manifestations of NTM infection in SOT recipients include cutaneous and pleuropulmonary disease, and, in HSCT recipients, catheter-related infection. Skin and pulmonary lesions should be biopsied for histologic examination, special staining, and microbiologic cultures, including cultures for bacteria, Nocardia species, fungi, and mycobacteria. Mycobacterial infections associated with catheters may be documented by tunnel or blood (isolator) cultures. Susceptibility testing of mycobacterial isolates is an essential component of optimal care. The frequent isolation of NTM other than Mycobacterium avium complex (MAC) from transplant recipients limits the extrapolation of therapeutic data from human immunodeficiency virus-infected individuals to the population of transplant recipients. Issues involved in the management of NTM disease in transplant recipients are characterized by a case of disseminated infection due to Mycobacterium avium complex in a lung transplant recipient, with a review of the relevant literature.

A rare combination of sites of involvement by Mycobacterium intracellulare in a hemodialysis patient: multifocal synovitis, spondylitis, and multiple skin lesions

PURPOSE

Atypical mycobacterial infection is a rare but serious hazard in immunocompromised patients including those undergoing maintenance hemodialysis and immunosuppressive therapy. Recognition of unusual involvement patterns is important.

METHODS

We describe an extremely rare combination of complications caused by such an organism in a patient with end-stage renal disease: spinal osteolysis and multiple skin lesions associated with synovitis.

RESULTS

The patient had received a renal allograft 18 years previously but developed infection with Mycobacterium avium-M. intracellulare complex including dermatologic manifestations, spondylitis, and synovitis involving the wrist and lateral malleolus after initiation of hemodialysis when the transplanted kidney failed. An empirical antibiotic regimen failed to alleviate skin lesions or fevers, or to lower an elevated C-reactive protein concentration, until the patient's dose of methylprednisolone was increased to treat mild adrenal insufficiency. The increase resulted in rapid resolution of skin lesions. A compression fracture 6 months later was attributed to spondylitis caused by the same organism.

CONCLUSIONS

We suspect that spondylitis represented the primary focus of M. intracellulare infection.

Nosocomial infections due to nontuberculous mycobacteria

Nontuberculous mycobacteria (NTM) are ubiquitous in the environment and cause colonization, infection, and pseudo-outbreaks in health care settings. Data suggest that the frequency of nosocomial outbreaks due to NTM may be increasing, and reduced hot water temperatures may be partly responsible for this phenomenon. Attention to adequate high-level disinfection of medical devices and the use of sterile reagents and biologicals will prevent most outbreaks. Because NTM cannot be eliminated from the hospital environment, and because they present an ongoing potential for infection, NTM should be considered in all cases of nosocomial infection, and careful surveillance must be used to identify potential outbreaks. Analysis of the species of NTM and the specimen source may assist in determining the significance of a cluster of isolates. Once an outbreak or pseudo-outbreak is suspected, molecular techniques should be applied promptly to determine the source and identify appropriate control measures.