Hindawi Publishing Corporation Case Reports in Dermatological Medicine Volume 2015, Article ID 607519, 4 pages http://dx.doi.org/10.1155/2015/607519 Case Report Mixed Cutaneous Infection Caused by Mycobacterium szulgai and Mycobacterium intermedium in a Healthy Adult Female: A Rare Case Report Amresh Kumar Singh,1 Rungmei S. K. Marak,2 Anand Kumar Maurya,3 Manaswini Das,2 Vijaya Lakshmi Nag,3 and Tapan N. Dhole2 1 Department of Microbiology, BRD Medical College, Gorakhpur, Uttar Pradesh 273013, India 2Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India 3Department of Microbiology, All India Institute of Medical Sciences, Jodhpur 342005, India Correspondence should be addressed to Amresh Kumar Singh; [email protected] Received 2 December 2014; Revised 2 February 2015; Accepted 2 February 2015 Academic Editor: Kowichi Jimbow Copyright © 2015 Amresh Kumar Singh et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Nontuberculous mycobacteria (NTMs) are ubiquitous and are being increasingly reported as human opportunistic infection. Cutaneous infection caused by mixed NTM is extremely rare. We encountered the case of a 46-year-old female, who presented with multiple discharging sinuses over the lower anterior abdominal wall (over a previous appendectomy scar) for the past 2 years. Microscopy and culture of the pus discharge were done to isolate and identify the etiological agent. Finally, GenoType Mycobacterium CM/AS assay proved it to be a mixed infection caused by Mycobacterium szulgai and M. intermedium.Thepatient was advised a combination of rifampicin 600 mg once daily, ethambutol 600 mg once daily, and clarithromycin 500 mg twice daily to be taken along with periodic follow-up based upon clinical response as well as microbiological response. We emphasize that infections by NTM must be considered in the etiology of nonhealing wounds or sinuses, especially at postsurgical sites. 1. Introduction and M. abscessus), M. marinum and M. ulcerans,arethe ones most commonly involved. Many of these cutaneous Nontuberculous mycobacteria (NTMs) also known as atyp- mycobacteria, such as the rapidly growing mycobacteria, M. ical mycobacteria or mycobacteria other than tuberculosis marinum, M. avium complex, M. kansasii,andM. xenopi,are (MOTT) have been recognized since the late 19th century distributed worldwide [4]. The incidence of NTM infection but being opportunists, these organisms did not gain much hasincreasedmanifold,somuchsothattheseinfections importance for a long time. However, presently the recovery currently account for 10%–15% of all mycobacterial infections of NTM from clinical specimens from sites where they have [5, 6]. While the Mycobacterium avium complex (MAC) and been proved to cause infections (called “other mycobacte- M. kansasii are responsible for more than 90% of cases of rioses”) is of concern to microbiologists and physicians alike nontuberculous mycobacterial infection, number of clinically [1]. NTMs are ubiquitous organisms that are readily isolated important Mycobacterium species have rapidly increased and from soil, water, domestic and wild animals, milk, and now include species such as M. szulgai [7]. M. szulgai has been other items [2]. NTM on isolation was believed to represent recovered from environmental sources, including a snail, environmental contamination or colonization for a long time; aquarium water, swimming pool water, and tropical fish [8]. itwasonlyduringthelate1950sthatNTMswererecognized The environment is the suspected source of human NTM as potential pathogens [3]. Nearly every pathogenic species infection [9, 10]. M. szulgai is an uncommon mycobacterial of NTM may cause skin and soft tissue infections, but pathogen of humans [11]. It causes pulmonary disease resem- rapidly growing mycobacteria (M. fortuitum, M. chelonae, bling the common type of M. tuberculosis infection, as well 2 Case Reports in Dermatological Medicine b a Figure 1: Clinical photograph showing discharging (serosan- guinous as white arrow) sinuses present over previous-surgical scar with scarring and keloid formation on lower anterior abdominal wall. Figure 2: Showing numerous dry, rough, pigmented colonies of M. szulgai (a: bright orange as white arrow) and M. intermedium as extrapulmonary infections. Cutaneous infection caused by (b: pale/light yellow as black arrow) over Lowenstein-Jensen media M. szulgai was reported in one case which was seen after bone slant. marrow transplantation [12], but mixed infection caused by two NTM species is extremely rare. M. intermedium is an intermediate to slow growing Mycobacterium that was first and clinical chemistry were within normal limits including reported in 1993 [13]. We present here a case of an apparently blood sugar. HIV ELISA negative by two kits, C-reactive pro- immunocompetent patient with a history of previous surgery tein normal and the ESR, was peaked at 22 mm. Pus from the presenting with a mixed infection of the skin and soft tissue discharging sinus was collected and processed using standard caused by M. szulgai and M. intermedium. procedures. Gram stained smear showed plenty of pus cells with Gram variable bacilli (many of which were Gram posi- 2. Case Report tive) and on Ziehl–Neelsen staining numerous acid fast bacilli couldbeobserved.Thedischargewasculturedonbloodagar, A 46-year-old nondiabetic woman from a middle-class fam- MacConkey medium, and Lowenstein-Jensen medium and ily, presented with discharging sinuses over the lower anterior inoculated into a BacT/ALERT MP bottle, which was incu- abdominalwallforthepast2years.Therewasnorise bated in the BacT/ALERT 3D system (bioMerieux, USA). The of temperature or weight loss. Her incision wound from blood agar and MacConkey medium were incubated under ∘ laparoscopic appendectomy in 1998 did not heal properly aerobic conditions at 37 C. The blood agar plate showed and the surgical site was reopened after 1 month. There numerous dry, small nonhemolytic colonies after 72 hours was no healing of the incision wound after reexcision. After but there was no growth on the MacConkey medium. The that the whole area started to become erythematous and BacT/ALERT MP showed positive growth in 5 days for acid indurated and later on a keloid started developing over the fast bacilli, which on further subculture onto L-J medium scar.Alargesinusdevelopedovertheoperationscarand gave dry, rough, pigmented, and yellow to orange colonies the other stitch sites also developed into sinuses discharging after one-week period (Figure 2). They were found to be ∘ pus. However, there was no history of cough, haemoptysis, scotochromogenic at 37 C. Speciation for the isolate was breathlessness, and anorexia. There was no history of intake confirmedbytheGenoTypeMycobacteriumCM/ASassay of any immunosuppressive drugs/corticosteroids, any local based on Mycobacterium DNA strip technology (Hain Life- trauma/injury, or tuberculosis. She had been treated off and science, Nehren, Germany), [14]followingmanufacturer’s on without having any definitive microbiological diagnosis instructions. It showed a mixed infection caused by two NTM with multiple injectable and oral antibiotics before consul- species, that is, Mycobacterium szulgai and M. intermedium. tation at this hospital. She did not have any contact with Toconfirm microbiological result, culture from repeat sample tuberculosis patients. after one week showed the same dual infection caused by On examination, a previous-surgical scar was present Mycobacterium szulgai and M. intermedium by the GenoType overwhichalargekeloidhadformed,ontheloweranterior Mycobacterium CM/AS assay. Drug susceptibility testing abdominal wall in the midline (although a little more towards (DST)wasperformedbystandarddiskdiffusionmethodover theright).Therewasnoapparentmassovertheabdomen,but Middlebrook 7H10 agar supplemented with OADC (oleic 6 sinus openings were noted over the lower anterior abdom- acid, dextrose, and citrate) and the following results were inal wall (Figure 1). At the time of presentation a single sinus obtained: sensitive to linezolid, levofloxacin, clarithromycin, was discharging pus. On palpation, tenderness was noted amikacin, and ciprofloxacin and found to be resistant to over and around the sinuses. The sinus opening was bluish, cotrimoxazole. DST for 1st and 2nd line antitubercular drugs wide, and undermined and it was discharging a serosan- were done by the GenoType MTBDRplus and MTBDRsl guinous exudate admixed with pus. Complete haemogram assay (Hain Lifescience, Nehren, Germany) which showed Case Reports in Dermatological Medicine 3 resistance to isoniazid and sensitive to rifampicin, fluoro- 97.0–98.9% and 88.9–92.4% and of the AS strip 99.3-99.4 quinolones, aminoglycosides/cyclic peptides, and ethambu- and 99.4–100%, respectively [21, 22]. Consequently, even one tol. positive culture under appropriate clinical circumstances may The patient was advised a combination of rifampicin suffice for diagnosing M. szulgai infection. In the present case, 600 mg once daily, ethambutol 600 mg once daily, and clar- cultures of the sinus exudate from the anterior abdominal ithromycin500mgtwicedailytobetakenalongwithperiodic wall revealed mixed infection caused by M. szulgai and follow-up based upon clinical response as well as microbio- M. intermedium.Thesourceofinfectioninthepatient