Cutaneous infection with Mycobacterium abscessus

Effect of Amoxicillin in combination with Imipenem-Relebactam against Mycobacterium abscessus

Infections caused by Mycobacterium abscessus are increasing in prevalence in cystic fibrosis patients. This opportunistic pathogen's intrinsic resistance to most antibiotics has perpetuated an urgent demand for new, more effective therapeutic interventions. Here we report a prospective advance in the treatment of M. abscessus infection; increasing the susceptibility of the organism to amoxicillin, by repurposing the β-lactamase inhibitor, relebactam, in combination with the front line M. abscessus drug imipenem. We establish by multiple in vitro methods that this combination works synergistically to inhibit M. abscessus. We also show the direct competitive inhibition of the M. abscessus β-lactamase, Bla_Mab, using a novel assay, which is validated kinetically using the nitrocefin reporter assay and in silico binding studies. Furthermore, we reverse the susceptibility by overexpressing Bla_Mab in M. abscessus, demonstrating relebactam-Bla_Mab target engagement. Finally, we highlight the in vitro efficacy of this combination against a panel of M. abscessus clinical isolates, revealing the therapeutic potential of the amoxicillin-imipenem-relebactam combination.

Two Episodes of Cutaneous Non-Tuberculous Mycobacterial Infection in a Patient with Psoriasis

Non-tuberculous mycobacteria (NTM) are a group of environmental pathogens, which cause a broad spectrum of disease. The incidence of NTM infection is increasing, especially in immunocompromized patients. The past three decades also saw a rapid increase in the incidence of NTM infection involving otherwise healthy subjects. We report a case of cutaneous NTM infection in a 79-year-old Chinese woman, who was receiving methotrexate for psoriasis. Mycobacterial culture grew Mycobacterium abscessus, and the lesions cleared with a combination of oral clarithromycin, ciprofloxacin and doxycycline. Interestingly, she then developed a second episode of cutaneous NTM infection with Mycobacterium haemophilum over the same body region, five years after stoppage of methotrexate. Both episodes were separated in time and involved different species, indicating that they were independent from each other. We further discuss the risk factors for cutaneous NTM infection, treatment, and highlight the need for diagnostic vigilance.

Mycobacterium abscessus peritonitis associated with laparoscopic gastric banding

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.

Drosophila melanogaster model for Mycobacterium abscessus infection

Mycobacterium abscessus is a human pathogen that is responsible for a broad spectrum of tissue infections and disseminated infections in immunodeficient patients. This pathogen is one of the most resistant organisms to chemotherapeutic agents. Therefore, we tested the hypothesis that the fruit fly, Drosophila melanogaster, is a genetically tractable model host for M. abscessus. In this context, we infected D. melanogaster with M. abscessus. This M. abscessus infection results in dissemination in the fly body, followed by death, which is accompanied by severe indirect flight muscle and brain damage. Our data show that M. abscessus can grow and replicate in D. melanogaster w(1118) and that it elicited a humoral immune response, especially of the Toll antimicrobial peptide pathway. To the best of our knowledge, this is the first report that mycobacteria induce the production of antimicrobial peptides in D. melanogaster.

Nontuberculous mycobacterial infection after frontalis sling surgery using silicone rod

PURPOSE

The purpose of this study is to report a case of nontuberculous mycobacterial infection after frontalis sling surgery.

METHOD

A 65-year-old man presented with bilateral painful, erythematous lesions in the brow and upper eyelids. He had a history of frontalis sling surgery for myopathic ptosis 2 years back and all lesions were found localized to the tract of the silicone rod used in the previous frontalis sling surgery.

RESULT

Incision and drainage of the lesions with microbiological analysis revealed significant growth of coagulase negative staphylococcus and Mycobacterium fortuitum. Sensitivity-based antibiotic treatment with intravenous amikacin was started, but poor response necessitated eventual explantation of both silicone rods for relief of symptoms. Culture of the explanted rods revealed similar results of M. fortuitum infection. Five months after the acute presentation, the patient is asymptomatic.

CONCLUSION

Nontuberculous mycobacterial infection may be a delayed onset complication in frontalis sling surgery using silicone rods.

Case series of mycobacterium abscessus infections associated with a trigger point injection and epidural block at a rural clinic

OBJECTIVES

The aim of this report is to investigate Mycobacterium abscessus infections at a rural clinic and carry out a surveillance program to determine the extent and source of these infections.

METHODS

The authors conducted an active surveillance investigation of 36 patients who had visited the clinic since 1 July 2008. Clinical specimens were collected from the patients and an envirnmental investigation. Pulsed-field gel elctrophoresis (PFGE) was performed for comparing with M. abscessus isolates from the patients.

RESULTS

Six specimens were obtained from the 6 patients respectively and 22 environmental samples were obtained. M. abscessus was isolated from the wounds of two patients, and various nosocomial pathogens, but not M. abscessus, were isolated from the surrounding environment. Two strains of M. abscessus from patients were identical as a result of PFGE.

CONCLUSION

Infection control education including proper hand hygiene should be emphasized for physicians performing invasive procedures. There also needs to be more attention for invasive procedures management, including trigger point injection and epidural block in rural clinics.

A Case of Skin and Soft Tissue Infection Caused by Mycobacterium abscessus

Mycobacterium abscessus (M. abscessus) is an acid-fast bacillus that's classified as a pathogenic "rapid growing" nontuberculous mycobacteria. It is an uncommon cause of human disease, but it can cause skin and soft tissue infection after skin injury following inoculation, minor trauma and surgery. The single most important factor for determining the course and prognosis of a M. abscessus infection is the underlying immune status of the host. We report here on a 71-year-old female who presented with multiple painful erythematous cutaneous nodules on her left forearm. She had diabetes mellitus and had taken oral steroid by herself for two years because of her osteoarthritis. Histologically, granulomas and inflammatory cell infiltration were observed and M. abscessus was identified via the mycobacterial culture. We performed curettage and drainage, followed by 6 months of oral clarithromycin and the patient's disease completely healed.

Atypische Mykobakteriose der Haut durch Mycobacterium abscessus bei einer immunkompetenten Frau

Mycobacterium abscessus is the most pathogenic of the fast-growing mycobacteria, and it is resistant to most of the antimicrobial and tuberculostatic drugs available. This non-tuberculous mycobacterium is significant in medicine because it can contaminate post-traumatic wounds and be a causative agent in chronic skin and soft tissue infection after surgical procedures.A 60-year-old immunocompetent woman was suffering from chronic ulcers and abscesses on the heels and malleoli of both feet. Histological examination revealed a granulomatous inflammation with detection of acid-fast rods, albeit without fibrinoid necrosis. The repeated detection of atypical mycobacteria, which were ultimately identified as Mycobacterium abscessus, allowed the diagnosis of an atypical mycobacteriosis of the skin. This was successfully treated first with clarithromycin and rifabutin and later with a combination of ethambutol, minocycline, clofazimine and azithromycin.

Cutaneous Infection with Mycobacterium abscessus in a child

Nontuberculous mycobacteria can cause cutaneous infections in both children and adults. Localized nontuberculous mycobacterial infections of the skin have been reported in children following injections or surgical procedures. We report a child who developed a cutaneous nontuberculous mycobacterial infection after exposure of a skin wound to pond water. Cutaneous infection with the rapidly growing mycobacteria Mycobacterium abscessus was demonstrated by clinical and histologic evaluation on the lower leg of an otherwise healthy 12-year-old Caucasian boy. We describe this as an instance of an unusual acquisition of cutaneous M. abscessus infection in a child.

Iatrogenic Mycobacterium abscessus infection associated with acupuncture: clinical manifestations and its treatment

BACKGROUND

Mycobacterial infections transmitted by acupuncture are an emerging problem. There have been two reports of mycobacterial infections complicating acupuncture in the English literature.

AIM

To describe the clinical manifestations and treatment of patients who acquired localized Mycobacterium abscessus infection in the process of acupuncture.

METHODS

Clinical manifestations and responses to different methods of treatment were reviewed in 40 patients who developed various skin lesions after acupuncture at a Korean oriental medicine clinic. Results The morphology of the lesions which developed at the acupuncture sites varied. Although the lesions disappeared with the combined administration of clarithromycin and amikacin for 3 months in most cases, five out of 25 patients (20%) showed residual lesions at the end of treatment, and had to be treated with a higher dosage of clarithromycin or alternative antibiotics based on sensitivity tests.

CONCLUSIONS

We recommend at least 3 months of treatment with clarithromycin for treating skin infections caused by M. abscessus, with supplementary antibiotics selected based on patients' drug sensitivity tests.

Therapy of nontuberculous mycobacterial infections

Mycobacterial infections are increasing in incidence worldwide, partly as a result of the increase in immunocompromised individuals. They cause a large number of cutaneous infections with a broad array of manifestations. Because of their diverse manifestations and sometimes fastidious nature, infections with mycobacteria are often misdiagnosed, leading to delay in and sometimes failure of therapy. In addition, many mycobacteria display both in vitro and in vivo drug resistance to antimicrobial agents. Early recognition of affected patients, initiation of appropriate antimicrobial therapy based on current guidelines, and tailoring of therapy after susceptibility testing is available are therefore essential to the successful treatment of mycobacterial infections.

Subcutaneous Infection with Mycobacteriumabscessus in a Renal Transplant Recipient

Transplant recipients show a high incidence of infections, often with atypical manifestations mainly because of drug-related immunosuppression. Mycobacterial infections can be life-threatening in immunosuppressed patients due to the risk of dissemination. There have been only few reports of cutaneous infections with Mycobacterium abscessus among immunosuppressed patients. We present a rare case with a sporotrichoid skin infection with M. abscessus in a renal recipient. The value of immunohistochemical detection of mycobacteria using an anti-BCG antibody in the diagnostic work-up skin biopsies is demonstrated. Long-term antibiotic treatment resulted in complete remission, although recurrences with atypical presentation were observed.

Mycobacterium abscessus cellulitis and multifocal abscesses of the breasts in a transsexual from illicit intramammary injections of silicone

We report the case of a 29-year-old transsexual who developed Mycobacterium abscessus infection after receiving intramammary liquid silicone injections in the nonphysician office setting. Our patient represents 1 of 14 confirmed and 11 suspected cases in New York City of M abscessus infection after illicit cosmetic procedures. As injectable cosmetic procedures are becoming increasingly popular, dermatologists should be aware of both the common and unusual complications. Furthermore, all physicians should be alerted to the current cluster of M abscessus infections after injections for cosmetic purposes by nonmedical practitioners in New York City.

Lumps and Bumps:

Late postsurgical infectious or inflammatory complications after facial surgery present a difficult challenge. These complications occur at least 2 weeks after surgical procedures and are often attributable to unique causes, in contrast to complications within the first postoperative week. The most worrisome complications in this period are caused by mycobacterial infections, because these infections can be severe and require a protracted treatment course. A high degree of suspicion is required early in presentation because these lesions can be subtle and similar to other infectious or inflammatory lesions. The authors discuss the clinical manifestations and diagnostic and treatment rationale for late postoperative infectious and inflammatory lesions. The authors also demonstrate and compare the clinical manifestations of mycobacterial infections, bacterial infections, and sterile inflammatory reactions. In addition, the treatment rationale for mycobacterial infections is reviewed. Late postoperative infections caused by mycobacteria are reported with increasing frequency in the cosmetic literature. These cases illustrate diverse challenges in the identification and treatment of late postoperative lesions.

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.

Atypical mycobacterial infection of the periocular region after periocular and facial surgery

PURPOSE

To delineate the clinicopathologic features of patients who have atypical mycobacterial infections of the periorbital region after periocular and facial surgery and to define the sequelae after treatment and their management.

METHODS

A case series of patients from 7 practices of ophthalmic plastic and reconstructive surgeons was analyzed retrospectively.

RESULTS

Thirteen patients had infection in the following clinical settings: 8 patients had infections after blepharoplasty, 2 patients had infections that involved the anophthalmic socket, 1 patient had orbital cellulitis after orbital fracture repair with an alloplastic implant, and 2 patients had infections involving the lacrimal system, one after silicone tube insertion and the other after dacryocystorhinostomy with silicone tube intubation. Sequelae of infection included eyelid retraction and ectropion requiring surgical repair (two patients) and enophthalmos (one patient). Twelve of 13 patients required extensive antibiotic therapy. One infection resolved after local excision of eyelid lesions. Another patient had recurrent infection after 4 weeks of antibiotic treatment.

CONCLUSIONS

Delayed infection with erythematous nodules, particularly when a foreign body is implanted weeks after periocular surgery, should arouse suspicion of an atypical mycobacterial infection. Delayed infection after blepharoplasty may mimic a chalazion, develop in a sutured incision, or occur without any inflammatory signs. Orbital abscess formation may occur in the setting of transconjunctival blepharoplasty. Cultures for acid-fast bacilli and excisional biopsy of nodules with performance of acid-fast stains may be necessary for diagnosis. The selection of systemic antibiotic therapy, usually clarithromycin, and the length of treatment should be guided by results of culture and sensitivity laboratory studies, biopsy results, and clinical response to treatment. Surgical removal of any implanted foreign bodies should be performed expeditiously. Consultation with an infectious disease specialist may be useful in selected cases. Sequelae of infection may include eyelid scarring and retraction and enophthalmos.

Orbital lipogranulomatous inflammation harboring Mycobacterium abscessus

PURPOSE

A case of iatrogenic Mycobacterium abscessus orbital infection is presented to call attention to its distinct histopathologic appearance, mechanism of organism, virulence, and clinical management.

METHODS

Clinicopathologic analysis of an orbital infection caused by M. abscessus is described. Detailed histologic analysis is performed to provide insight into the mechanism of infection and correlate the features of the orbital infection with that of atypical mycobacteriosis at other body sites.

RESULTS

A 71-year-old woman had an orbital mass in the supranasal orbit after a blepharoplasty. The mass consisted of a dimorphic inflammatory reaction with a superficial purulent reaction and a deeper granulomatous process consisting of epithelioid tubercles, each centered about a lipid vacuole. Acid-fast bacilli were found in the lipid vacuoles but not elsewhere in the specimen. Each tubercle was surrounded by a zone of lymphocytes and a desmoplastic reaction. Microbiologic culture studies identified M. abscessus. A combination of surgical intervention and antibiotic therapy for 4 weeks eliminated the infection.

CONCLUSIONS

Acid-fast stains should be performed on any orbital lesion showing an apparent lipogranulomatous reaction. Although clinical management of orbital atypical microbacteriosis is difficult, the combination of surgical and specific antimicrobial intervention is effective. Our study contributes to an evolving understanding of the mechanism of human infectivity of these low-virulence organisms by suggesting that the orbital fat is a source of lipid material that can harbor the organisms, allowing them to escape host immunosurveillance.

Failure of treatment for chronic Mycobacterium abscessus meningitis despite adequate clarithromycin levels in cerebrospinal fluid

We report a case of posttraumatic meningitis due to Mycobacterium abscessus, treated initially with oral clarithromycin and intravenous amikacin plus intrathecal amikacin. Despite cerebrospinal fluid (CSF) levels of clarithromycin and amikacin in excess of their in vitro minimum inhibitory concentrations for the organism, the CSF cultures remained continuously positive for M. abscessus. To our knowledge, this is the first documented case of M. abscessus meningitis and the first report of measured CSF levels of clarithromycin in a patient with meningitis, showing that even therapeutic CSF levels of clarithromycin and amikacin might not be successful in eradicating M. abscessus meningitis.

Mycobacterium abscessus: a cutaneous infection in a patient on renal replacement therapy

We report a 72-year-old man on haemodialysis who presented with multiple abscesses on his lower legs. Routine bacterial culture of abscess pus was reported as 'sterile' after 48 h, leading to the suspicion of a mycobacterial infection. Skin biopsy taken for mycobacterial microscopy and culture isolated a heavy growth of Mycobacterium abscessus.

Mycobacterium abscessus wound infection

We report an isolated case of wound infection due to Mycobacterium abscessus following minor cutaneous surgery. The patient had routine skin cancer surgery in a private dermatology practice setting. He presented 2 weeks later with a wound infection which failed to respond to cephalexin. The patient reported that he had walked through salt water and bushes with exposed surgical wounds 1 week postoperatively. Tissue cultures later grew M. abscessus. The patient was successfully treated with oral clarithromycin 500 mg qid of 6 months duration.

Disseminated Mycobacterium abscessus infection manifesting as fever of unknown origin and intra-abdominal lymphadenitis: case report and literature review

Mycobacterium abscessus is a rapidly growing mycobacterium found in soil and water throughout the world. Disease in immunocompetent patients usually consists of localized skin and soft tissue infections. In contrast, disseminated disease is uncommon, usually presents with rash, and almost always occurs in an immunocompromised host. We describe an unusual case of disseminated M. abscessus infection manifesting as fever of unknown origin and intra-abdominal lymphadenitis, but without rash. Our patient responded well to amikacin and clarithromycin therapy. We also review the literature related to the diagnosis and management of this uncommon disease.

Cutaneous Mycobacterium chelonae in a liver transplant patient

A 51-year-old woman with an orthotopic liver transplant on tacrolimus (SKF 506) and prednisone presented with an erythematous ulcerated nodule on the knee. No preceding trauma was noted. A skin biopsy specimen demonstrated beaded gram-positive, acid-fast rods and the skin culture grew Mycobacterium chelonae (formerly M chelonae subsp chelonae ). This report describes the first case in a liver transplant patient of cutaneous Mycobacterium chelonae under the current method of designating atypical Mycobacterium species.

Nontuberculous mycobacterial infections of the skin

Nontuberculous mycobacteria are playing an increasingly important role in human disease owing to higher prevalence of antibiotic resistance and immunodeficiency. These organisms cause a variety of cutaneous findings which are often misdiagnosed by the clinician. Compounding this problem is the fact that most mycobacteria require special culture conditions, which if not specifically requested, are frequently not used. Recognition of susceptible patients is imperative and is not limited to the immunocompromised. Successful treatment of mycobacterial infections requires knowledge of currently available and recommended antibiotics followed by tailoring of the antimicrobial regimen after sensitivity testing is performed.

Disseminated infection due to rapidly growing mycobacteria in immunocompetent hosts presenting with chronic lymphadenopathy: a previously unrecognized clinical entity

Disseminated infection due to rapidly growing mycobacteria is uncommon and occurs mostly in immunocompromised patients. We report 16 cases of such infection with an unusual presentation seen at Srinagarind Hospital, a university hospital in northeastern Thailand. The clinical features were different from those in previous reports. All of the patients presented with chronic bilateral cervical lymphadenopathy. Twelve had mycobacterial involvement of other organs (sinuses, 6 patients; lungs, 4; liver, 4; spleen, 3; skin, 3; bone and joint, 2; and tonsils, 2). An interesting occurrence in 11 patients was 14 episodes of reactive skin manifestations (Sweet's syndrome, 9; generalized pustulosis and erythema nodosum, 2 each; and pustular psoriasis, 1). No identifiable predisposing factors, including human immunodeficiency disease, were found in these patients. However, 8 patients had 11 episodes of prior infection or coinfection with other opportunistic pathogens (salmonellosis, 4; penicilliosis, 3; pulmonary tuberculosis, 2; and melioidosis and cryptococcosis, 1 each). These findings suggest that cell-mediated immunity is defective in these patients.

A surgical wound infection due to Mycobacterium chelonae successfully treated with clarithromycin

BACKGROUND

Mycobacterium chelonae is an uncommon but recognized cause of chronic localized cutaneous infection at a site of penetrating trauma or a surgical wound.

OBJECTIVE

The problem faced by physicians encountering an infection by M. chelonae is often response to therapy, which may be highly variable.

METHODS

We describe an immunocompetent patient who developed a localized infection due to M. chelonae following surgery for a basal cell carcinoma of the lower leg.

RESULTS

The infection responded to treatment with clarithromycin.

CONCLUSION

The clinical efficacy of clarithromycin and the salient features of M. chelonae infection and its treatment are discussed.

Surgical management of cutaneous infection caused by atypical mycobacteria after penetrating injury: the hidden dangers of horticulture

We identified two patients in a 12-month period who presented with cutaneous infection and secondary lymph node involvement from atypical mycobacterial infection after minor gardening injuries. One patient had a coinfection with Nocardia asteroides. Both patients required multiple surgical interventions, despite appropriate antibiotic therapy, before resolution of the disease. The course of the infection was characterized by chronic relapses with complete healing at 12 to 18 months after the original injury. The identification and management of this clinical problem are reviewed.