Disseminated Mycobacterium intracellulare from a Deep Cutaneous Infection
01 Jan 2019-The International Journal of Mycobacteriology (Int J Mycobacteriol)-Vol. 8, Iss: 1, pp 98-100
TL;DR: A case of a 70-year-old female with systemic sclerosis and severe tumoral calcinosis that developed disseminated MAC infection secondary to deep cutaneous disease is described.
Abstract: Primary cutaneous Mycobacterium avium complex (MAC) infection is a rare diagnosis in both immunocompetent and immunocompromised hosts. Disseminated MAC almost always occurs in the setting of advanced HIV infection and typically results from initial pulmonary or gastrointestinal disease. We describe a case of a 70-year-old female with systemic sclerosis and severe tumoral calcinosis that developed disseminated MAC infection secondary to deep cutaneous disease. Treatment was complicated by multiple significant drug interactions, patient comorbidities, as well as an inability to safely and completely surgically resect her infected soft tissue for source control.
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TL;DR: The results of the application of a range of typing procedures to the identification and classification of 6,264 cultures of nontuberculous mycobacteria from human sources and the environment are reported, and the rank order of frequency of occurrence of individual organisms within the entire group of isolates was Mycobacterium avium complex serovar 4.
Abstract: The results of the application of a range of typing procedures to the identification and classification of 6,264 cultures of nontuberculous mycobacteria from human sources and the environment are reported. Seroagglutination, an enzyme-linked immunosorbent assay applied to whole bacteria or the glycolipid typing antigens and based on serovar-specific polyclonal or monoclonal antibodies, thin-layer chromatography of these antigens, and gas chromatography of their specific sugar determinants were used to arrive at identifications. As a result of this comprehensive approach, 4,452 (71%) of all cultures and 88% of those of samples from patients with AIDS proved to be typeable. The rank order of frequency of occurrence of individual organisms within the entire group of isolates was Mycobacterium avium complex serovar 4 greater than serovar 8 greater than serovar 1 greater than serovar 9 greater than serovar 6 greater than serovar 14 greater than serovar 2 greater than M. fortuitum greater than M. kansasii greater than M. xenopi greater than an apparent mixture of serovar 4 and M. xenopi greater than a mixture of serovar 4 and serovar 8. These results were similar but not identical to the pattern observed for isolates obtained from patients with AIDS; the order was M. avium complex serovar 4 greater than serovar 8 greater than serovar 1 greater than a mixture of serovar 4 and M. xenopi, a mixture of serovar 4 and serovar 8 greater than serovar 9 greater than serovar 2 greater than serovar 6. Serotyping was also used to demonstrate the possible clinical significance of nontuberculous mycobacteria recovered from different body sites. Other information on the distribution of M. avium serovars in patients from different geographical environments is provided.
108 citations
"Disseminated Mycobacterium intracel..." refers background in this paper
...[3] Glycolipid typing has divided MAC into 28 serovars; serovars 1, 4, and 8 cause most cases of disseminated disease and have appeared more virulent in animal infection models.[4] A greater amount of bacteremia has been found to incur a worse prognosis....
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TL;DR: Treatment outcomes for many patients with Mycobacterium avium complex (MAC) disease remain suboptimal, so new drugs and treatment regimens are greatly needed.
Abstract: Mycobacterium avium complex (MAC) comprises at least ten named species of environmental mycobacteria that exhibit ecological and geographic diversity. The prominent human pathogens are M. avium, M. intracellulare, and M. chimaera. MAC virulence factors and host susceptibility contribute to pathogenesis. The diagnosis of pulmonary disease requires satisfaction of clinical, microbiologic, and radiographic criteria. Disseminated and localized extrapulmonary diseases are diagnosed by culture of blood or tissue. Treatment of all forms of MAC disease involves protracted administration of multiple antibiotics, including a macrolide. This therapeutic approach achieves initial success in patients with macrolide-susceptible, treatment-naive pulmonary disease, but microbiologic recurrence is common. Inadequate treatment regimens increase the risk of emergent macrolide resistance which carries a poor prognosis. Parenteral therapy and surgical resection are beneficial for certain forms of pulmonary and extrapulmonary disease. Prophylaxis against MAC infection is strongly recommended in HIV-AIDS.
74 citations
"Disseminated Mycobacterium intracel..." refers background in this paper
...Disseminated MAC in HIV‐negative patients has been documented with identified risk factors including high‐dose cor t icosteroid therapy, hematological malignancy, and cytotoxic chemotherapy.[3,6] Various other immunocompromised states have had isolated cases reported including idiopathic T‐cell lymphopenia, end‐stage renal disease, renal transplantation, and myelodysplastic syndrome....
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...It is acquired, usually via inhalation or ingestion, from many environmental sites including from water, soil, and animals.[3] Glycolipid typing has divided MAC into 28 serovars; serovars 1, 4, and 8 cause most cases of disseminated disease and have appeared more virulent in animal infection models....
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University of Pennsylvania1, National Institutes of Health2, Harvard University3, Yeshiva University4, Oregon State University5, University of Southern California6, Oregon Health & Science University7, Rutgers University8, Case Western Reserve University9, Ohio State University10, University of Texas Southwestern Medical Center11
TL;DR: Results suggest an early stage of tissue dissemination preceding persistent bacteremia, and mucosal entry without persistence of colonization, and MAC-specific T cell responses apparently develop and persist during DMAC, but are dysfunctional or too infrequent to prevent persistence.
Abstract: The clinical, microbiologic, and immunologic parameters in HIV-infected subjects first presenting with disseminated Mycobacterium avium complex (DMAC) were determined. Four HIV-positive groups not yet on DMAC treatment were enrolled: 19 subjects with CD4 lymphocyte counts < or =50/microl thought to have DMAC on clinical grounds; 18 subjects newly found to have a positive blood culture for MAC; 25 asymptomatic controls (CD4 cell counts < or =50); and 25 asymptomatic controls (CD4 counts 100-250/microl). Outcome measures include comparisons between groups for clinical characteristics; results of cultures from blood, marrow, and gastrointestinal and respiratory tracts; immunological markers from staining of marrow and flow cytometry of circulating lymphocytes; and cytokine production of PBMCs. Only 21% of the 19 patients entered on suspicion of having DMAC grew MAC from blood or marrow. Neither clinical presentation nor laboratory tests differentiated those culture-positive from those culture-negative patients. However, prior PCP or multiple other opportunistic infections were more common in the DMAC group. MAC was isolated from 82% of marrow and 50% of blood specimens from the DMAC group. Respiratory or gastrointestinal colonization was present in 36% of DMAC subjects, but only 5% of non-DMAC subjects with CD4 counts <50 cells/microl. CD8+ cells were more frequent in bone marrow, and CD4 cells recognizing MAC antigen were more frequent in blood from DMAC subjects vs. controls. Results suggest an early stage of tissue dissemination preceding persistent bacteremia, and mucosal entry without persistence of colonization. MAC-specific T cell responses apparently develop and persist during DMAC, but are dysfunctional or too infrequent to prevent persistence.
14 citations
"Disseminated Mycobacterium intracel..." refers background in this paper
...[4] A greater amount of bacteremia has been found to incur a worse prognosis.[5] Disseminated MAC occurs almost solely in acquired immunodeficiency syndrome (AIDS), usually with a CD4+ cell count <20/mm3....
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...[5] Disseminated MAC occurs almost solely in acquired immunodeficiency syndrome (AIDS), usually with a CD4+ cell count <20/mm3.[5] This has become a largely uncommon occurrence due to improved treatment strategies and antiretroviral therapy for HIV infection....
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Journal Article•
TL;DR: The English-language literature on primary cutaneous MAC in patients who were neither immunocompromised nor pharmacologically immunosuppressed is reviewed.
Abstract: Nontuberculous mycobacteria (NTM) are becoming increasingly important cutaneous pathogens as the number of susceptible patients increases. Nevertheless, primary cutaneous infection by one particular species, Mycobacterium avium complex (MAC), remains relatively unusual, particularly in immunocompetent patients. We review the English-language literature on primary cutaneous MAC in patients who were neither immunocompromised nor pharmacologically immunosuppressed. We offer an additional report of a healthy patient who presented to our clinic with primary cutaneous MAC following seemingly innocuous trauma to the leg.
13 citations
"Disseminated Mycobacterium intracel..." refers background in this paper
...Although usually occurring in the setting of advanced immunosuppression or HIV infection, a case in an immunocompetent recreational gardener and another occurring postskin lesion excision has been documented.[9,10] Abnormal skin architecture and integument barrier function and a large inoculum of Mycobacterium are thought to be crucial in early pathogenesis....
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TL;DR: Clinicians should remember to consider MAC infection in patients with acid-fast-positive skin lesions, as the selection of appropriate antibiotic therapy is species specific.
Abstract: Background:Although most commonly encountered in patients with human immunodeficiency virus infection, disseminated Mycobacterium avium complex (MAC) is becoming more common in patients receiving i...
11 citations
"Disseminated Mycobacterium intracel..." refers background in this paper
...[9,10] Abnormal skin architecture and integument barrier function and a large inoculum of Mycobacterium are thought to be crucial in early pathogenesis.[11] None of these cases reported secondary dissemination....
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