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Int.J.Curr.Microbiol.App.Sci (2021) 10(02): 476-482 International Journal of Current Microbiology and Applied Sciences ISSN: 2319-7706 Volume 10 Number 02 (2021) Journal homepage: http://www.ijcmas.com Case Study https://doi.org/10.20546/ijcmas.2021.1002.056 A Rare Case of Olecranon Bursitis caused by Mycobacterium abscessus Treated with Surgical Intervention Sneha Bowalekar* and Rahul Gadkari 1Consultant Microbiologist, Dr. Jariwala Laboratory, 1st floor, Rasraj Heights, Rokadia Lane, Near Gokul Hotel, Boriwali West, Mumbai, Maharashtra, India 2Consultant Orthopedic Surgeon, Sailee Hospital and Diagnostic Centre, Prathamesh Horizon, New Link Road, Boriwali West, Mumbai, Maharashtra, India *Corresponding author ABSTRACT K e yw or ds The present case of Mycobacterium abscessus olecranon bursitis in an M. abscessus , immunocompetant male treated with surgical drainage without requirement of Olecranon bursitis, antimycobacterial therapy. Nontuberculous mycobacteria are widely listed as Immunocompetant an infective cause of olecranon bursitis and other skin and soft tissue Article Info infections. Direct inoculation of the organism during trauma leads to musculoskeletal infections in particular. We could not find any other case Accepted: report of olecranon bursitis caused by M. abscessus in the literature. This case 07 January 2021 extends the view about nontuberculous mycobacterial infections in Available Online: 10 February 2021 immunocometant adults with co-morbid condition such as diabetes. Introduction olecranon bursitis caused by NTM identified as Mycobacterium abscessus. The infection Nontuberculous mycobacteria (NTM) are was treated with surgical drainage of increasingly being reported as cause of olecranon bursa fluid. Clinical follow up of infections in immunocompromised as well as patient was uneventful. immunocompetant patients. They are ubiquitously present in the environment thus Case report contributing to accidental inoculation and infection at pulmonary as well as 57 year old male, presented to an extrapulmonary sites. Diagnosis of NTM orthopedician with acute onset swelling and infections takes a long course and advanced pain over left elbow. He was afebrile at identification techniques have to be presentation. Draining lymph node implemented for early reporting, clinical enlargement was not seen. He had history of correlation and follow up. We report a case of fall one and half months back when he had 476 Int.J.Curr.Microbiol.App.Sci (2021) 10(02): 476-482 injured his left elbow joint. He had taken palisades, cording noted at some places. The symptomatic treatment from a general bacilli were slender, 6-8 µm in size, some physician and improved. Later when the filamentous. Simultaneously, subculture from swelling developed, he again consulted the MGIT broth was done on Blood Agar Plate general practitioner who prescribed him with and LJ agar. Tab. Augmentin 650mg BD for 10 days. The swelling continued to be the same despite the Blood Agar plate incubated at 37°C showed antibiotic treatment. The patient was then shiny, grayish white growth after 4 days of referred to the orthopedician who surgically incubation. Individual colonies after further drained the olecranon bursa fluid in minor incubation were small, round, about 3-4mm in OT. He was not prescribed with any diameter, white non-pigmented, smooth, antibiotics by the orthopedician. The fluid convex with defined margins. Gram Staining aspirated from olecranon bursa was sent to of growth revealed Gram positive bacteria our laboratory for AFB Culture. approximately 6-8µm in size, arranged in needles. ZN staining carried out on same Specimen was 1.5 ml, reddish, thin purulent growth revealed Acid Fast bacilli 6-8 µm in liquid. Primary smear findings were not size, arranged in cords and needles. significant. Gram stained smear showed presence of few pus cells with no organism. LJ agar showed yellowish white, slightly ZN staining was unremarkable for presence of elevated colonies after 5 days of incubation at acid and alchohol fast bacilli. 37°C. ZN staining showed presence of long, filamentous acid fast bacilli in clumps. The fluid was treated with NALC-NAOH (4%) for decontamination and then mixed Growth on Blood agar plate was sent to with 50 ml of sterile phosphate buffer solution reference laboratory where it was identified as (PBS) (pH 6.8) and centrifuged at 5500 rpm Mycobacterium abscessus. The identification for 15 minutes. Supernatant was decanted and was carried out by MALDITOF-MS (Matrix the deposit was resuspended in PBS to Assisted Laser Desorption Ionisation – Mass achieve volume of 3ml. Spectrometry). 500 µl of decontaminated and concentrated The patient had no history of any specimen was inoculated in MGIT immunocompromised condition and he was (Mycobacteria Growth Indicator Tube, not on any immunosuppressive medications. Becton Dickinson) broth and 2-3 drops of The patient was a known diabetic, with treated specimen are inoculated on HbA1c level of 9, was on treatment for the Lowenstein Jensen Medium. MGIT broth same. His Lipid profile was unremarkable. (Middelbrook 7H9 broth) 17 days after His hematologic work up was normal except inoculation and incubation at 37°C showed a for mildly elevated Erythrocyte spectrophotometric reading of 20 (on Sedimentation Rate i.e. 12. Liver Function BACTEC MicroMGIT instrument). The Tests and Renal Function Tests were within MGIT broth had turned turbid. LJ agar normal limits. Serum electrolytes were in showed no growth after 42 days of normal range. Thyroid Function Tests were incubation. normal. Prostate Specific Antigen (PSA) and Carcinoembryonic Antigen (CEA) were not ZN staining from MGIT broth showed elevated. presence of Acid Fast Bacilli in clusters, 477 Int.J.Curr.Microbiol.App.Sci (2021) 10(02): 476-482 The isolate was reported as Non Tuberculous symptoms. The patient was asked to follow Mycobacterium and results were informed to up if any clinical symptoms develop (Fig. 1– orthopedician. After drainage of fluid, patient 7). had recovered and did not show any recurrent Fig.1 Turbidity in MGIT broth Fig.2 ZN stained smear from MGIT broth Fig.3 Growth of NTM (M. abscessus) on Blood Agar 478 Int.J.Curr.Microbiol.App.Sci (2021) 10(02): 476-482 Fig.4 Gram stain of growth from Blood agar plate Fig.5 ZN stain of growth from Blood agar plate Fig.6 Growth of NTM (M. abscessus) on LJ medium Fig.7 ZN staining of smear from LJ agar growth 479 Int.J.Curr.Microbiol.App.Sci (2021) 10(02): 476-482 Nontuberculous mycobacteria are isolated which is difficult to treat (Griffith, et al., from a wide variety of environmental sources 2007). M. abscessus has also increasingly including soil, water, dust, Sphagnum been reported to cause CNS infections in vegetation which might colonize and cause HIV-negative patients, especially in those infection in humans and animals. These who had undergone neurosurgical procedures, infections are increasingly becoming indwelling intracranial catheters and otologic prevalent in immunocompromised hosts, e.g. diseases. (Lee, et al., 2012) Conjunctivitis, HIV, lymphoproliferative disorders or scleritis, keratitis (in hard and soft contact transplants, and those on immunosuppressive lens wearers) and endophthalmitis have also therapy (Brown-Elliott and Wallace. 2002). been reported (Girgis et al., 2012). In transplant patients, most NTM infections The most common site of extra-pulmonary are chronic infections of soft tissues and joints infections being skin and subcutaneous (cutaneous lesions on the extremities, tissues. (Brown-Elliott BA and Wallace Jr RJ, tenosynovitis, arthritis) and osteomyelitis, 2002). Infections are reported following direct often with multifocal involvement. inoculation, through contaminated Constitutional symptoms are absent. Most acupuncture needles, injection solutions, and commonly involved joints are surgical procedures or as a result carpometacarpal, wrist, elbow, ankle and contamination of traumatic wound (Scholze et knee. In the immunocompetent host, NTM al., 2005; Ryu et al., 2005; Yuan et al., 2009; can cause infections in cutaneous, deep soft Schnabel et al., 2016). tissues, lymphatics, and other sites (e.g. skeletal, peritoneal catheter-related, ocular). Disseminated M. abscessus infections have been seen in both immunocompromised as Mycobacterium abscessus is a rapidly well as immunocompetant patients (Meng- growing non-tuberculous mycobacterium Rui Lee et al., 2015) which is an emerging pathogen worldwide. The earliest case of M. abscessus was Our patient reported swelling, erythema and reported in 1951 and described infection tenderness over left elbow one and half month associated with traumatic knee injury. Until following injury to the elbow. Though our recently, M. abscessus was considered a patient had no history of any subspecies of Mycobacterium chelonae. In immunosuppressive condition, he was 1992 genetic analysis demonstrated that it diabetic which could have contributed as a was a distinct species and it was elevated to risk factor for developing an infection. species status. (Ryan and Byrd, 2018) Nontuberculous mycobacteria infections are rare, indolent, and frequently misidentified. Mycobacterium abscessus is implicated in Discrimination between colonization and both pulmonary and extra-pulmonary infection by NTM can be difficult. infections, underlying risk factors for infections include organ transplantation, Many cases of olecranon bursitis caused by rheumatoid arthritis and other autoimmune nontuberculous mycobacteria (M. avium