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

Upper Extremity Infections in the Transplant Population

PURPOSE

As the duration of lifetime survival after organ transplantation continues to increase, the consequences of long-term immunosuppression, such as opportunistic and rare infections, are a high-risk reality. This study examined upper extremity infections in the transplant population to determine the current clinical risk profile, management, and outcomes.

METHODS

An institutional database of 16,640 patients who underwent transplantation was queried for upper extremity infections from 2005 to 2017, defined as the presence of infection from the shoulder to the fingertips. The resulting data were analyzed using multivariable linear and logistic regression modeling.

RESULTS

A total of 230 eligible patients experienced upper extremity infections at a mean age of 54.1 ± 15.3 years, occurring, on average, 7.9 ± 8.6 years after transplantation. The most commonly transplanted organ was the kidney (51.3%), followed by the liver (20%). The most common location of infection was the forearm (31.7%), digits (27.4%), and upper arm (17%). The most common types of infection were cellulitis (69.1%), abscess (33.5%), joint sepsis (6.5%), infectious tenosynovitis (3.9%), and osteomyelitis (1.3%). Patients taking an antifungal medication, those who had a joint infection, or those who had undergone lung transplantation had an approximately 2.5-day longer stay in the hospital. For every 1-year increase in age at the time of transplantation, the time from transplantation to infection decreased by 0.21 years. Those who had undergone bone marrow transplantation or those who were taking tacrolimus were expected to have approximately 8- and 6-year decreases, respectively, in the time from transplantation to infection.

CONCLUSIONS

Upper extremity infections should be individually evaluated and treated because of the heterogeneity of transplant type, immunosuppression medications, the age of the patient, and infection characteristics.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Chronic Tenosynovitis of the Upper Extremities Caused by Mycobacterium kansasii : A Clinical Case and Systematic Review of Literature

Background  Chronic tenosynovitis of the upper extremities caused by Mycobacterium kansasii ( M. kansasii ) is uncommon, but symptoms may overlap with other more common diseases. Late diagnosis and treatment can lead to disfiguration of structures and rupture of tendons, resulting in worse cosmetic outcomes after reconstruction. Methods  We present a clinical case and literature review of M. kansasii in patients with chronic tenosynovitis of upper extremities. PubMed was queried for cases of upper extremities tenosynovitis caused by M. kansasii . The keywords " M. kansasii ," "tenosynovitis" and synonyms were used for search in different combinations. Manuscripts, with no specific data or another condition, where the infection was not located in the upper extremities, were reviews, or not in English, were excluded from the study. Results  We described 23 reported cases of tenosynovitis of the upper extremity caused by M. kansasii . An immunosuppressed state was present in eight (34.8%) cases, and 12 (52.2%) patients received immunosuppressive treatment. A long-time period between the first appearance of symptoms and the definitive diagnosis was identified (median: 7 months, interquartile range: 9). The most frequent symptoms were local swelling (65.2%), pain (56.5%), mass effect (26%), and stiffness (13%). Tendon rupture was found in three (13%) patients as a complication of the disease. Moreover, seven (30.4%) patients underwent previous surgeries to try to relieve the symptoms before definitive diagnosis was achieved. Conclusion M. kansasii is an important differential causal pathogen for tenosynovitis of the upper extremities. Although rare, raising awareness about this infectious disease is imperative to avoid inadequate management and hazardous aesthetic sequelae.

Histopathological Features of Mycobacterium chelonae Infection in Two Farmed Japanese Pufferfish (Takifugu rubripes)

Granulomatous lesions were observed in the swim bladder, kidney, spleen and gills of two farmed Japanese pufferfish (Takifugu rubripes) infected with Mycobacterium chelonae. Three types of lesions were noted: unencapsulated clusters of epithelioid cells without central necrosis (type 1), encapsulated granulomas without central necrosis (type 2) and encapsulated granulomas with central necrosis (type 3). Type 3 lesions occurred most frequently in the swim bladder, while type 1 and type 2 lesions occurred frequently in the kidney and spleen, and the gills exhibited mostly type 1 lesions. This suggests that the lesions in the swim bladder were more fully developed than those occurring elsewhere and that the swim bladder may be more susceptible to infection with M. chelonae. This is the first report describing the histopathological features of M. chelonae infection in Tetraodontidae.

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.

An unusual lung mass post stem cell transplantation

We report a case of Mycobacterium kansasii presenting as an obstructing endobronchial mass in a patient post stem cell transplant. The patient had a complete clinical, microbiological, and radiological response to anti-tuberculous treatment. To our knowledge, this is the first case of M. kansasii presenting post transplant with an obstructing lung mass simulating relapse or post-transplant lymphoma.