Disseminated Cutaneous Infection with Mycobacterium chelonae in a Renal Transplant Recipient Paraskevi Chatzikokkinou, MD; Roberto Luzzati, MD; Konstantinos Sotiropoulos, MD; Andreas Katsambas, MD; Giusto Trevisan, MD PRACTICE POINTS • Nontuberculous mycobacteria (NTM) are environmental saprophytes that can cause infection in immunosuppressed individuals as well as immunocompetent individuals with certain predisposing factors. • It is important for clinicians to consider NTM in the differential diagnosis for patients who present with chronic skin or soft tissue infections. • Histologic examination and culture of a biopsy specimen followed by copypolymerase chain reaction assay for genotyping of the specimen are recommended to determine the responsible Mycobacterium species. • New molecular genetic strip tests can differentiate NTM species more quickly. not Mycobacterium chelonae belongs to a rapidlyDo following solid organ transplantation) as well as growing group of nontuberculous mycobacteria in immunocompetent patients with certain pre- (NTM). These organisms are environmental sap- disposing factors (eg, recent history of a trau- rophytes that can cause infection in humans. matic wound, recent drug injections, impaired Nontuberculous mycobacteria infections have cell-mediated immunity). Due to the increasing been described in immunosuppressed patients prevalence of immune deficiency disorders as (eg, in the setting of AIDS or immunotherapy well as the rising number of cosmetic procedures performed on healthy individuals, NTM may CUTIS become a frequent cause of serious morbidity, causing chronic infections of the skin, soft tis- sue, and lungs. We report a case of M chelonae infection in a 61-year-old woman who was receiv- ing immunosuppressive therapy following renal transplantation 6 years prior to presentation. Drs. Chatzikokkinou, Luzzati, and Trevisan are from the University It is important for clinicians to consider NTM in Hospital of Trieste, Ospedale Maggiore, Italy. Drs. Chatzikokkinou the differential diagnosis for patients who pres- and Trevisan are from the Department of Dermatology and ent with chronic skin or soft tissue infections. Venereology and Dr. Luzzati is from the Infectious Diseases Unit. Cutis. 2015;96:E6-E9. Dr. Sotiropoulos is from the Second Department of Internal Medicine–Propaedeutic, Athens University Medical School, Attikon University Hospital, Greece. Dr. Katsambas is from the Department of Dermatology and Venereology, School of Medicine, National and ycobacterium chelonae, along with Kapodistrian University of Athens, Andreas Syggros Hospital. Mycobacterium fortuitum and Mycobacterium The authors report no conflict of interest. abscessus, belongs to a rapidly growing group Correspondence: Paraskevi Chatzikokkinou, Department of M Dermatology and Venereology, University Hospital of Trieste, of nontuberculous mycobacteria (NTM), which are Ospedale Maggiore, Via Stuparich 1, I-34100 Trieste, Italy classified as environmental saprophytes found in soil, ([email protected]). water, and dust. Under certain circumstances, NTM E6 CUTIS® WWW.CUTIS.COM Copyright Cutis 2015. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Mycobacterium chelonae Infection can cause infection in humans. Nontuberculous previous trauma to the lower legs. Her body tem- mycobacteria are known to cause infection in immu- perature was measured at 37.9°C and no regional nosuppressed patients (such as in the setting of lymphadenopathy or any other physical abnormali- AIDS or immunotherapy following solid organ ties were observed. Multiple blood culture samples transplantation); however, they can also cause seri- were negative for bacteria, fungi, and mycobacteria. ous morbidity in immunocompetent patients with During her 2 weeks in the hospital, the patient’s certain predisposing factors (eg, recent history of a tacrolimus and methylprednisolone dosages were traumatic wound, recent drug injections, impaired decreased to 2 mg daily. Routine laboratory tests and cell-mediated immunity).1-4 serum chemistry were normal with the exception We present the case of a patient who presented of elevated creatinine levels (1.88 mg/dL [reference with multiple reddish blue, nodular, suppurative range, 0.6 to 1.2 mg/dL]). Chest radiography and lesions on the bilateral legs of 1 month’s duration. interferon-γ release assay were negative. A punch The patient had a history of renal transplanta- biopsy from a sample nodule was performed and tion 6 years prior followed by immunosuppressive revealed granulomatous inflammation surrounded by therapy. A punch biopsy of a sample nodule was giant cells on histopathology. Microscopic examina- performed, followed by histologic examination and tion of the specimen revealed alcohol- and acid- culture of the biopsy specimen, but polymerase resistant bacilli on Ziehl-Neelsen staining. A biopsy chain reaction (PCR) assay for genotyping of the specimen was cultured on Löwenstein-Jensen medium specimen was necessary to determine the responsible at 25°C, 37°C, and 42°C according to NTM detec- Mycobacterium species. tion protocol5 and showed growth of NTM at 37°C. On the basis of the positive culture, genetic analysis Case Report of the specimen was performed using a strip test that A 61-year-old woman was admitted to our hospital permits identificationcopy of 13 common species of NTM. for evaluation and treatment of multiple subcutane- The organism was identified as M chelonae. ous nodules on the bilateral legs. The patient had While awaiting species identification and results undergone successful cadaveric renal transplantation of drug susceptibility testing, treatment with oral 6 years prior due to polycystic kidney disease and was clarithromycinnot 250 mg twice daily was initiated and undergoing maintenance immunosuppressive com- continued for 10 days until the patient developed bination therapy with tacrolimus 4 mg and meth- gastrointestinal adverse effects, at which point oral ylprednisolone 4 mg daily. No other medications or ciprofloxacin 250 mg twice daily was substituted. concomitant diseases were reported. DoIn laboratory testing, the isolated M chelonae strain Physical examination revealed multiple slightly showed sensitivity to ciprofloxacin, clarithromycin, tender, brown to purple papules and nodules on tobramycin, and amikacin at minimum inhibitory the lower legs ranging in size from 2 mm to 1 cm in concentrations of less than 1, 2, 4, and 16, respec- diameter (Figure 1), some of which exhibited central tively. Treatment with ciprofloxacin 250 mg twice necrosis (Figure 2). The patient did not recall any daily was continued for 6 months, which resulted in CUTIS Figure 1. Multiple slightly tender, brown to purple pap- Figure 2. A nodule on the lower right leg exhibited cen- ules and nodules on the lower left leg. tral necrosis. WWW.CUTIS.COM VOLUME 96, NOVEMBER 2015 E7 Copyright Cutis 2015. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Mycobacterium chelonae Infection slow resolution of the lesions until the end of treat- usually is correlated with immunosuppression (such ment (Figure 3). No recurrence of the lesions was as in our patient). Localized infections generally are noted at 24-month follow-up, but areas of hyperpig- observed in immunocompetent hosts.1 mentation were noted at the lesion sites (Figure 4). The exact pathogenetic mechanism of M chelonae infection in our patient is not clear. In patients with Comment suppressed immunity, the variable clinical presenta- Mycobacterium chelonae, a member of the NTM tion of infection with NTM often impedes diagnosis. group, grows rapidly on Löwenstein-Jensen medium, Cutaneous M chelonae lesions may be mistakenly usually following incubation for 5 to 7 days at tem- diagnosed as Kaposi sarcoma or rarely as pyoderma peratures of 28°C to 32°C, and is characterized by its gangrenosum. The differential diagnosis of sub- lack of pigmentation. Nontuberculous mycobacteria, cutaneous nodules includes histoplasmosis, cryp- which are resistant to standard disinfectants such as tococcosis, blastomycosis, coccidioidomycosis, chlorine, organomercurials, and alkaline glutaralde- nocardiosis, mycetoma, sporotrichosis, actinomyco- hydes, may cause nosocomial outbreaks, infecting sis, and tuberculosis. In our patient, approximately otherwise healthy individuals receiving any type 2 months elapsed between presentation of symptoms of injection (eg, in cosmetic procedures), as well as and definitive diagnosis, which was less than that those with suppressed immunity.6 reported in previously published cases.2,7-9 In addition to cutaneous manifestations, NTM Histology and tissue culture followed by proper may cause various extracutaneous diseases, such as genetic analysis remains the gold standard for osteomyelitis, infective bronchiectasis, endocarditis, diagnosing NTM infection.10,11 In the interest pericarditis, lymphadenopathy, and ocular infec- of patients, time-consuming biochemical analyses tions.1-4 The species M chelonae may cause localized should be replaced by molecular genetic diagnostic skin infections, soft tissue lesions (eg, granulomatous strip tests, whichcopy are fast, exact, and available in nodules, ulcers, abscesses, sporotrichoid lesions), and commercial kits for both common mycobacteria cutaneous disseminated infections. and additional species.12 Immunosuppression associated