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Renfree KJ, Scott KL, Polveroni TM, Mead-Harvey C, Vikram HR. Nonmarinum, Nontuberculous Mycobacterial Infections of the Upper Extremity: A Multi-Institutional Descriptive Report. J Hand Surg Am 2023; 48:1159.e1-1159.e10. [PMID: 35637039 DOI: 10.1016/j.jhsa.2022.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 02/03/2022] [Accepted: 03/16/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE We analyzed patient demographic factors involved in the development of nonmarinum, nontuberculous mycobacterial infections (NTMI) involving the upper extremity, and assessed diagnostic and prognostic values of commonly used preoperative laboratory and imaging studies, as well as factors related to recurrence of disease and patient outcomes. METHODS Patients from 2 academic, tertiary facilities with culture-proven, nonmarinum NTMI involving the upper extremity were reviewed. Patient-related factors and clinical outcomes were extracted. The analysis was based on pathogen identification (rapid- vs slow-growing subspecies) and immune status. RESULTS Our 76 patients had a mean age of 59 years, and 65% were male. Forty-eight percent reported an injury, and hands were frequently involved (58%). Forty-one percent were immunosuppressed (19% organ transplant recipients). The mean symptom duration prior to presentation was 203 days. The culture identification took a mean of 33 days, with 25 different species identified (subcategorized as rapid or slow growers). Seventy-seven percent had solitary lesions, with a cutaneous or subcutaneous location most common. Immunosuppressed patients were treated longer with antibiotics (243 vs 155 days in immunocompetent patients) and experienced higher rates of side effects, complications, and recurrence. All patients underwent debridement to control infection, including 4 individuals who required amputations. One-third experienced complications and/or recurrence, regardless of the organism type. CONCLUSIONS Upper-extremity nonmarinum NTMI is often misdiagnosed, causing management delays. Early consideration in differential diagnoses of chronic, painful swelling, nodular or inflammatory lesions, or septic arthritis is crucial. Tissue biopsy with specimens for histopathology and microbiological analysis (mycobacterial smear, cultures, and broad range polymerase chain reaction) and early involvement with an infectious disease specialist are recommended. Empiric antibiotic therapy is not standard. Debridement and prolonged, directed combination antimicrobial therapy is required; however, adverse reactions are commonly encountered. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
| | - Kelly L Scott
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ
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Kim DH, Park JY, Won HC, Park JS. Nontuberculous Mycobacterial Tenosynovitis of the Hand: A 10-Year Experience at Two Centers in South Korea. Clin Orthop Surg 2023; 15:477-487. [PMID: 37274504 PMCID: PMC10232306 DOI: 10.4055/cios22248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 12/15/2022] [Accepted: 12/15/2022] [Indexed: 06/06/2023] Open
Abstract
Background The aim of this study was to investigate the clinical characteristics of nontuberculous mycobacterial tenosynovitis and to report the process of diagnosis and the outcomes of surgical debridement and drug administration in South Korea. Methods Between 2010 and 2019, 23 patients (10 men and 13 women) with nontuberculous tenosynovitis of the hand were treated at two centers. Their average age was 64 years, and the average duration of symptoms was 8 months (range, 1-36 months). Eight patients had a history of trauma or surgery. The average number of corticosteroid injections before diagnosis was 2.6 for 7 patients. All 23 patients were treated with a combination of extensive tenosynovectomy and antibiotics. Results Of the 23 patients, 20 were available for the final follow-up (1, lost to follow-up; 1, transferred to another hospital; and 1, died from a comorbidity). The most common species was Mycobacterium intracellulare (70%), followed by Mycobacterium abscessus (10%). The frequency of involvement of the extensor/flexor tendon was similar to that of the wrist/finger. The mean number of surgical debridement operations was 2.2. The average duration of antibiotic administration was 9.8 months. At the last follow-up, 3 patients were symptom-free with full range of motion at the involved site, 1 patient complained of localized swelling or pain with full range of motion, 1 patient was found to have a recurrence of infection in a finger, and 15 complained of restricted joint motion. Conclusions The most common species noted in patients with nontuberculous mycobacterial tenosynovitis was M. intracellulare. Patients with only 1 finger involved showed good range of motion at the final follow-up. Most patients experienced delayed wound healing and adverse effects from drug therapy during treatment and limited joint motion at the final follow-up.
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Affiliation(s)
- Dong Hee Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jun Yong Park
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Hee-Chan Won
- Department of Orthopedic Surgery, Gyeongsang National University Hospital, Gyeongsang University School of Medicine, Jinju, Korea
| | - Jin Sung Park
- Department of Orthopedic Surgery, Yeson Hospital, Bucheon, Korea
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McLaughlin CM, Schade M, Cochran E, Taylor KF. A Case Report of a Novel Atypical Mycobacterial Infection: Mycobacterium Chimaera Hand Tenosynovitis. JBJS Case Connect 2022; 12:01709767-202209000-00046. [PMID: 36137058 DOI: 10.2106/jbjs.cc.22.00292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/15/2022] [Indexed: 06/16/2023]
Abstract
CASE A 76-year-old fisherman with a history of diabetes mellitus, coronary artery bypass grafting, and a previous ipsilateral elbow wound presented with a 1-year history of hand pain and swelling. Anti-inflammatories and antibiotics were administered without improvement. Magnetic resonance imaging and ultrasound demonstrated flexor tenosynovitis. Intraoperative cultures revealed Mycobacterium chimaera. The treatment course included 2 tenosynovectomies and a 1-year course of triple antimycobacterial therapy. CONCLUSION Nontuberculous mycobacteria infections should be considered in cases of indolent tenosynovitis. M. chimaera should be considered in patients with a history of cardiopulmonary bypass given its association with cardiopulmonary heater-cooler units.
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Affiliation(s)
- C M McLaughlin
- Penn State Hershey Medical Center, Department of Surgery, Division of Plastic and Reconstructive Surgery, Hershey, Pennsylvania
| | - M Schade
- Penn State Hershey Medical Center, Department of Internal Medicine, Division of Infectious Disease, Hershey, Pennsylvania
| | - E Cochran
- Penn State Hershey Medical Center, Department of Pathology, Hershey, Pennsylvania
| | - K F Taylor
- Penn State Hershey Medical Center, Department of Orthopaedics and Rehabilitation, Division of Hand Surgery, Hershey, Pennsylvania
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Li W, Li M, Liu M, Ma J. Mycobacterium mucogenicum Infection in a Patient with an Open Fracture: A Case Report. Lab Med 2021; 53:e4-e7. [PMID: 34386825 DOI: 10.1093/labmed/lmab031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Mycobacterium mucogenicum is a nontuberculous mycobacterium that is ubiquitous in nature. However, M. mucogenicum infection in patients with orthopedic trauma is rarely reported in the literature. Herein, we describe a 48 year old male Han Chinese patient whose right leg was squeezed by agricultural machinery, resulting in open tibial fractures. Postoperative antimicrobial treatment was administered because the wound had been contaminated by soil. However, no long-term wound closure occurred, and a culture of the wound exudation tested positive for M. mucogenicum. We established the clinical treatment plan according to the characteristics and drug sensitivity test results of M. mucogenicum, and the patient was discharged uneventfully. Increasingly, more reports of infection caused by nontuberculous mycobacteria are being published; however, to our knowledge, this is the first report of an orthopedic infection caused by M. mucogenicum. Because the treatment process of M. mucogenicum infection is long and complex, isolation and identification of M. mucogenicum are of great significance to effective clinical treatment.
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Affiliation(s)
- Wanxiang Li
- Department of Clinical Laboratory, Weifang People's Hospital, Weifang, Shandong, China
| | - Min Li
- Department of Clinical Laboratory, Weifang People's Hospital, Weifang, Shandong, China
| | - Mi Liu
- Department of Clinical Laboratory, Weifang People's Hospital, Weifang, Shandong, China
| | - Jie Ma
- Department of Clinical Laboratory, Weifang People's Hospital, Weifang, Shandong, China
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Turner NA, Sweeney MI, Xet-Mull AM, Storm J, Mithani SK, Jones DB, Miles JJ, Tobin DM, Stout JE. A Cluster of Nontuberculous Mycobacterial Tenosynovitis Following Hurricane Relief Efforts. Clin Infect Dis 2021; 72:e931-e937. [PMID: 33136139 DOI: 10.1093/cid/ciaa1665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/26/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Nontuberculous mycobacteria (NTM) are a rare cause of infectious tenosynovitis of the upper extremity. Using molecular methods, clinical microbiology laboratories are increasingly reporting identification down to the species level. Improved methods for speciation are revealing new insights into the clinical and epidemiologic features of rare NTM infections. METHODS We encountered 3 cases of epidemiologically linked upper extremity NTM tenosynovitis associated with exposure to hurricane-damaged wood. We conducted whole-genome sequencing to assess isolate relatedness followed by a literature review of NTM infections that involved the upper extremity. RESULTS Despite shared epidemiologic risk, the cases were caused by 3 distinct organisms. Two cases were rare infections caused by closely related but distinct species within the Mycobacterium terrae complex that could not be differentiated by traditional methods. The third case was caused by Mycobacterium intracellulare. An updated literature review that focused on research that used modern molecular speciation methods found that several species within the M. terrae complex are increasingly reported as a cause of upper extremity tenosynovitis, often in association with environmental exposures. CONCLUSIONS These cases illustrate the importance of molecular methods for speciating phenotypically similar NTM, as well as the limitations of laboratory-based surveillance in detecting point-source outbreaks when the source is environmental and may involve multiple organisms.
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Affiliation(s)
- Nicholas A Turner
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mollie I Sweeney
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ana M Xet-Mull
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Suhail K Mithani
- Department of Surgery, Division of Plastic, Oral and Maxillofacial Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - David B Jones
- Orthopedic Institute, Sioux Falls, South Dakota, USA
| | | | - David M Tobin
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jason E Stout
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
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Abstract
Background: Nontuberculous mycobacteria are an uncommon pathogen for musculoskeletal infection and are difficult to treat because of delays in diagnosis, prolonged treatment requiring both antimycobacterial therapy and surgical debridement, and high rates of resistance to antimycobacterial therapy. Case Report: We report the case of an 88-year-old male with recurrent Mycobacterium avium complex tenosynovitis despite receiving multiple courses of pharmacologic therapy and surgical debridement. Conclusion: Nontuberculous mycobacterial musculoskeletal infections can be difficult to diagnose and equally difficult to treat. A combination of antimycobacterial therapy and surgical debridement is often required; however, the rate of treatment failure remains high, particularly with rapidly growing mycobacteria such as Mycobacterium avium.
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Diaz MAA, Huff TN, Libertin CR. Nontuberculous mycobacterial infections of the lower extremities: A 15-year experience. J Clin Tuberc Other Mycobact Dis 2019; 15:100091. [PMID: 31720418 PMCID: PMC6830119 DOI: 10.1016/j.jctube.2019.100091] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objectives Nontuberculous mycobacterial infection (NTMI), which is increasing in prevalence, is challenging to diagnose and manage despite the availability of capable laboratories because of subtle and nonspecific clinical findings and nonstandardized treatment guidelines. We aimed to present our experience with lower-extremity NTMI and to compare clinical characteristics and treatment outcomes between immunocompetent and immunocompromised patients. Methods To determine clinical presentations and outcomes, we reviewed electronic health records of all patients with lower-extremity NTMI treated and followed up at our institution from January 2002 through December 2017. Results Twenty-four patients were included in this study. Mean (SD) age was 58 (19) years. Eighteen patients (75%) were men; 13 (54%) were immunocompetent; and 9 (37%) had bone and joint involvement. No significant differences existed between immunocompetent and immunocompromised patients, except immunocompetent patients had significantly more infections at the hip, thigh, and toe. Bone and joint infection required significantly longer treatment time than skin and soft-tissue infection. Conclusions Regardless of immune status, patients with lower-extremity NTMI had similar characteristics, treatments, and outcomes. However, immunosuppression can be a major risk factor in the development of disseminated NTMI and associated complications. Acid-fast bacilli culture is strongly recommended for evaluation of delayed or nonhealing lesions. Aggressive medical and surgical management can be associated with good clinical outcomes.
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Affiliation(s)
- Mark Anthony A. Diaz
- Division of Infectious Diseases, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, United States
| | - Tamara N. Huff
- St. Francis Orthopaedic Institute, St. Francis Medical Group, Columbus, GA, United States
| | - Claudia R. Libertin
- Division of Infectious Diseases, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, United States
- Corresponding author.
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Vargas CR, Kanwar A, Dousa KM, Skalweit MJ, Rowe D, Gatherwright J. Mycobacterial Tenosynovitis After Sea Urchin Spine Injury in an Immunocompromised Patient. Open Forum Infect Dis 2018; 5:ofy285. [PMID: 30515428 PMCID: PMC6262115 DOI: 10.1093/ofid/ofy285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 10/31/2018] [Indexed: 12/02/2022] Open
Affiliation(s)
- Christina R Vargas
- Department of Surgery, Plastic Surgery Section, Louis Stokes Cleveland Veterans Affairs Medical Center, Ohio.,Department of Surgery, Division of Plastic Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Ohio
| | - Anubhav Kanwar
- Department of Medicine, Division of Infectious Diseases, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Ohio
| | - Khalid M Dousa
- Department of Medicine, Division of Infectious Diseases, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Ohio
| | - Marion J Skalweit
- Department of Medicine, Infectious Diseases Section, Louis Stokes Cleveland Veterans Affairs Medical Center, Case Western Reserve University School of Medicine, Ohio
| | - David Rowe
- Department of Surgery, Plastic Surgery Section, Louis Stokes Cleveland Veterans Affairs Medical Center, Ohio
| | - James Gatherwright
- Department of Surgery, Plastic Surgery Section, Louis Stokes Cleveland Veterans Affairs Medical Center, Ohio
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Jones A, Marcos LA. Manifestations of Mycobacterium marinum in the Immunocompromised Host. CURRENT TROPICAL MEDICINE REPORTS 2018. [DOI: 10.1007/s40475-018-0163-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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