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Skin and Soft Tissue Infections Due to Rapidly Growing Mycobacteria Comparison of Clinical Features, Treatment, and Susceptibility

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Skin and Soft Tissue Infections Due to Rapidly Growing Mycobacteria Comparison of Clinical Features, Treatment, and Susceptibility STUDY Skin and Soft Tissue Infections Due to Rapidly Growing Mycobacteria Comparison of Clinical Features, Treatment, and Susceptibility Daniel Z. Uslan, MD; Todd J. Kowalski, MD; Nancy L. Wengenack, PhD; Abinash Virk, MD; John W. Wilson, MD Objective: To compare the demographics, clinical fea- more likely to be taking immunosuppressive medica- tures, susceptibility patterns, and treatment for skin and tions (60% vs 17%, P=.002) than patients with M fortui- soft tissue infections due to Mycobacterium fortuitum and tum. Mycobacterium fortuitum tended to manifest as a Mycobacterium chelonae or Mycobacterium abscessus. single lesion (89% vs 38%, PϽ.001), while most M che- lonae or M abscessus manifested as multiple lesions (62% Design: Retrospective medical record review. vs 11%, PϽ.001). More patients with M fortuitum had a prior invasive surgical procedure at the infected site (56% Setting: Mayo Clinic, Rochester, Minn. vs 27%, P=.04). Patients with multiple lesions were more likely to be taking immunosuppressive medications than Patients: All patients seen at our institution with a posi- those with single lesions (67% vs 30%, P=.006). Seven tive culture for M chelonae, M abscessus,orM fortuitum patients failed treatment, several of whom were immu- from skin or soft tissue sources between January 1, 1987, nocompromised and had multiple comorbidities. and October 31, 2004. Conclusions: Skin and soft tissue infections due to rap- Main Outcome Measures: Patient demographics, clini- idly growing mycobacteria are associated with systemic cal characteristics, therapeutic data, microbiological data, comorbidities, including the use of immunosuppressive and outcomes. medications. There are significant differences in the demo- graphic and clinical features of patients who acquire spe- Results: The medical records of 63 patients with skin cific organisms, including association with immunosup- or soft tissue infections due to rapidly growing myco- pression and surgical procedures. bacteria were reviewed. Patients with M chelonae or M abscessus were older (61.5 vs 45.9 years, PϽ.001) and Arch Dermatol. 2006;142:1287-1292 YCOBACTERIUM FORTUI- Although the spectrum and features of tum, Mycobacterium clinical disease due to M chelonae have chelonae, and Mycobac- been described,3 no reports have directly terium abscessus are compared the clinical features of skin and environmental myco- soft tissue infections due to M chelonae, Mbacteria that can cause chronic infections M abscessus, and M fortuitum,toour of the skin, soft tissues, and lungs. These or- knowledge. We retrospectively reviewed ganisms are characterized by rapid all patients with skin and soft tissue iso- growth on standard media and by lack of lates of rapidly growing mycobacteria at pigmentation.1 Clinical manifestations in- our institution to compare the demograph- clude localized abscess formation and ics, clinical features, susceptibility pat- 1,2 Author Affiliations: Division of chronic ulcers. Disseminated infections, terns, and treatment for M fortuitum and Infectious Diseases, Department especially in immunocompromised hosts, M chelonae or M abscessus. of Medicine (Drs Uslan, have been widely described.1,3,4 There are Kowalski, Virk, and Wilson), multiple reports of infection after trauma METHODS and Division of Clinical and surgical or other procedures, includ- Microbiology, Department of ing acupuncture,5 liposuction,6-8 silicone Laboratory Medicine and injection,9 breast implantation,10-12 intra- The medical records of all consecutive patients Pathology (Dr Wengenack), venous catheter use,13 dermatologic having clinical isolates of M chelonae, Mayo Clinic College of M abscessus, and M fortuitum from skin and soft surgery,14,15 pedicures,16-18 exposure to pros- Medicine, Rochester, Minn. 19 20 tissue seen at our institution between January 1, Dr Kowalski is now with the thetic material, pacemaker placement, 1987, and October 31, 2004, were reviewed ret- 21-25 Division of Infectious Disease, and subcutaneous injections. Pulmo- rospectively. All patients had given consent for Gundersen Lutheran Medical nary disease due to M fortuitum has been the use of their medical records for research pur- Center, LaCrosse, Wis. described following hot tub use.26 poses, and our institutional review board ap- (REPRINTED) ARCH DERMATOL/ VOL 142, OCT 2006 WWW.ARCHDERMATOL.COM 1287 ©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/23/2021 RESULTS Table 1. Demographics of 63 Patients With Definite Skin or Soft Tissue Infections by Organism* Seventy-six patients with skin or soft tissue infections due Mycobacterium chelonae or to rapidly growing mycobacteria were identified. Of these, Mycobacterium Mycobacterium 63 were classified as having definite infection and were fortuitum abscessus P included in the analysis. Clinical history was available Demographic (n = 18) (n = 45) Value for all patients. Susceptibility data were reviewed when Age, mean ± SD, y 45.9 ± 14.3 61.5 ± 13.6 Ͻ.001 available; given the 17-year interval, not all isolates had Female sex 10 (55.6) 25 (55.6) Ͼ.99 been tested against all antimicrobials in the current CLSI Current smoker 3 (16.7) 2 (4.4) .14 guidelines. Any of the following systemic 3 (16.7) 25 (55.6) .006 The patients included 35 women (56%) and 28 men comorbidities Diabetes mellitus 3 (16.7) 12 (26.7) .52 (44%), with a median age of 60 years (age range, 19-88 Malignant neoplasm 0 5 (11.1) .31 years). Patients came from 12 different states, with most Connective tissue disease 0 12 (26.7) .01 from Minnesota (29 patients), Wisconsin (7 patients), End-stage renal disease 1 (5.6) 7 (15.6) .4 Iowa (4 patients), and South Dakota (3 patients), which Congestive heart failure 1 (5.6) 3 (6.7) Ͼ.99 reflects the general patient population at our institu- Organ transplant 1 (5.6) 9 (20.0) .26 tion. Five patients (8%) were current smokers, and 6 pa- Kidney 1 (5.6) 6 (13.3) Liver 0 1 (2.2) tients (10%) were former smokers. In view of the retro- Pancreas 0 3 (6.7) spective nature of the study design and the lack of specific Lung 0 1 (2.2) information available in the medical records, no consis- Heart 0 1 (2.2) tent exposure, occupational, or avocational history (eg, Taking immunosuppressive 3 (16.7) 27 (60.0) .002 hot tub exposure) could be identified that might repre- medications sent risk factors for acquisition of these organisms. Prednisone, Ͼ5 mg 3 (16.7) 24 (53.3) .01 Others 2 (11) 16 (35.6) .06 Seven cultures (11%) were obtained via superficial Prior invasive procedure at 10 (55.6) 12 (26.7) .04 swab of a lesion, 34 (55%) via biopsy of a lesion, and 21 site of infection† (34%) at the time of surgical debridement or resection. Prior trauma at site of 3 (16.7) 3 (6.7) .34 The method of culture was unavailable for 1 patient. infection Smears for acid-fast bacilli were performed in 50 pa- tients; 24 (48%) were positive for organisms. Sixteen cul- *Data are given as number (percentage) unless otherwise indicated. †Includes injection, aspiration, biopsy, or surgical procedures. tures (25%) yielded other bacteria in addition to rapidly growing mycobacteria, including coagulase-negative staphylococci, Staphylococcus aureus, and gram- negative organisms (Klebsiella species, Escherichia coli, proved the study. Information was collected regarding demo- and Proteus species). No patients’ cultures grew mul- graphics, immune status (including the use of immunosuppressive tiple different species of mycobacteria. Skin specimens medications), infection characteristics, site and clinical descrip- from 40 patients had been sent for pathological exami- tion of the lesions, antimicrobial therapy, surgical procedures, and outcome. Definite infection was defined as culture positivity in nation; granulomatous inflammation was observed in 21 the presence of a compatible clinical syndrome, such as chronic patients (53%). ulcers, wound drainage, or abscess. Patients with isolated single Demographics of the 63 patients by organism (M for- colonies in their cultures, in the absence of a compatible clinical tuitum or M chelonae or M abscessus) are given in Table 1. syndrome, were excluded from the analysis. There were 18 M fortuitum infections (29%) and 45 Organisms were identified by our laboratory as rapidly grow- M chelonae or M abscessus infections (71%). There were ing mycobacteria by standard criteria that included growth rate, significant differences noted between patients with Mfor- morphologic structure, mycolic acid analysis, and biochemi- 27 tuitum and M chelonae or M abscessus in their mean age cal test results (arylsulfatase and nitrate reduction). On No- (45.9 vs 61.5 years, PϽ.001), use of immunosuppres- vember 9, 1999, our microbiology laboratory began identify- sive medications at the time of infection (17% vs 60%, ing rapidly growing mycobacteria by 16S ribosomal RNA (rRNA) gene sequencing.28 Mycobacterium chelonae and M abscessus are P=.002), and history of an invasive procedure at the site indistinguishable by 16S rRNA gene sequencing and are re- of diagnosis (56% vs 27%, P=.04), as well as in the pres- ported together (as M chelonae or M abscessus) by most labo- ence of systemic comorbidities (including active malig- ratories, as well as herein. nancies, end-stage renal disease, congestive heart fail- Minimum inhibitory concentrations (MICs) of antimicro- ure, solid organ transplantation, and connective tissue bials were determined using serial 2-fold broth microdilution disease). None of the patients had human immunodefi- in cation-supplemented Mueller-Hinton broth at 30°C, as per ciency virus infection. The median time between the re- guidelines from the Clinical and Laboratory Standards Insti- 29 corded onset of symptoms and the culture of the lesion tute (CLSI). Minimum inhibitory concentration break points was 86 days (intraquartile range [IQR], 38.5-202.5 days). from the CLSI for interpretive criteria for rapidly growing my- There was no difference in the duration of symptoms be- cobacteria were used. Data were analyzed using JMP software (version 5.1.2; SAS fore diagnosis by organism, systemic comorbidities, or Institute, Cary, NC).
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