Atypical Mycobacterial Infection Research Articles

Atypical gouty tophus masquerading as a foreign body granuloma

Subcutaneous nodular lesions in a patient with significantly elevated inflammatory markers always raise the possibility of infectious diagnoses such as atypical infection, pyogenic abscess, mycobacterial infection, and malignancy. Definitive diagnosis requires tissue biopsy and histopathologic examination. The atypical presentation of a foreign body granuloma with concurrent intraoperative findings supports the diagnosis of gouty arthritis.We report a case of a 67-year-old man who presented with an inflammatory nodular lesion on the left elbow that was initially suspected to have an infectious cause. Histopathologic examination of the nodular tissue later revealed that the patient had a foreign body granuloma due to urate crystal deposition. The atypical appearance of the gouty arthritis, the low serum urate level, the negative crystal identification in the synovial fluid, and the markedly elevated inflammatory markers, which did not respond to the previous antibiotic and steroid therapy, raised the suspicion of atypical infection in this case.

Bakteriální infekce kůže III. - infekce vyvolané Mycobacterium tuberculosis a atypické mykobakteriální infekce kůže

Bakteriální infekce kůže III. - infekce vyvolané Mycobacterium tuberculosis a atypické mykobakteriální infekce kůže

Atypical Mycobacterial Infections of the Spine: Evaluation and Management.

Atypical mycobacterial infections of the spine can be difficult to treat and represent a subset of the vertebral osteomyelitis and diskitis spectrum often requiring early and aggressive surgical intervention. The purpose of this review is to improve the understanding of and approach to disease management from the perspective of the spine surgeon. Debridement or excision of the affected levels may be necessary to decrease mycobacterial loads and restore biomechanics. A close relationship with the patient's internal medicine and infectious disease specialists should be maintained to ensure disease eradication or remission. Long-term suppressive antibiotic therapy may be required for infection control. Atypical mycobacterial spine infections are rare, complex, and difficult to eradicate. Our institution proposes a collaborative effort among the spine surgeon, infectious disease specialists, and internal medicine specialists to best approach the work-up, diagnosis, and treatment of these infections. [Orthopedics. 2024;47(2):e61-e66.].

Dermatology practice updates in mycobacterial disease.

Atypical mycobacterial infections are commonly acquired through exposure to water, and tuberculosis remains highly endemic in many parts of the world. In this era of global connection, travel, and immigration, it is more important than ever to maintain a high index of suspicion for infection from cutaneous tuberculosis and atypical mycobacteria. Epidemics related to surgical procedures have been related to inadequate sterilization, as almost 50% of public water supplies harbor mycobacteria. Improved diagnostic techniques for these microbes, including Auramine-Rhodamine staining and rapid detection of mycobacteria and drug susceptibilities through PCR and MALDI-TOF, have improved detection and treatment outcomes. Given an increasing number of patients on immunosuppressive therapies, clinicians must remain vigilant.

Phage Therapy in Lung Transplantation: Current Status and Future Possibilities.

Patients with chronic lung disease and lung transplantation have high rates of colonization and infection from multidrug-resistant (MDR) organisms. This article summarizes the current state of knowledge regarding phage therapy in the setting of lung transplantation. Phage therapy has been used in several lung transplant candidates and recipients on a compassionate use basis targeting mostly MDR gram-negative infections and atypical mycobacterial infections with demonstrated clinical safety. Phage biodistribution given intravenously or via nebulization has not been extensively studied, though preliminary data are presented. Phage interacts with both the innate and adaptive immune system; current literature demonstrates the development of serum neutralization in some cases of phage therapy, although the clinical impact seems variable. A summary of current clinical trials involving patients with chronic lung disease is presented, though none are specifically targeting lung transplant candidates or recipients. In addition to treatment of active infections, a variety of clinical scenarios may benefit from phage therapy, and well-designed clinical trials involving this vulnerable patient population are needed: pre- or peritransplantation use of phage in the setting of MDR organism colonization may lead to waitlisting of candidates currently declined by many centers, along with potential reduction of waitlist mortality rates and posttransplant infections; phage may be used for biofilm-related bronchial stent infections; and, finally, there is a possibility that phage use can affect allograft function and chronic rejection.

An insight into outbreak of atypical mycobacterial infection following percutaneous nephrolithotomy - Role of cleaning and sterilization techniques inspected

Background: Atypical wound infections following minimal access surgery continue to affect smooth recovery. Percutaneous nephrolithotomy (PCNL) for renal stones involves various small-sized nephroscopes and accessories. Improper cleaning and disinfection of which may result in bacterial biofilms formation and infections. Aims and Objectives: We inspected an outbreak of atypical wound infection after PCNL to find the responsible factor. Materials and Methods: This retrospective observational study had three groups based on cleaning and sterilization methods. In group A, manual cleaning of instruments was done followed by high-level disinfection using glutaraldehyde 2% solution with 20 min submersion. In group B, manual cleaning was supplemented with multienzyme cleaning with 10 min submersion but disinfection method was same as in group A. In group C, manual and enzyme cleaning was combined with ethylene oxide (ETO) sterilization. The outcome was assessed as wound infection occurrence at 1-month follow-up. Results: The study had 81 participants with 61 male and 20 females. The mean age was 36±16 years. Group A, B, and C had 32, 24, and 25 participants, respectively. Pre-operative parameters were comparable among the groups. Late wound infection (at 1-month follow-up) occurred in 11 cases from group A, but none from others (P=0.004). Culture-revealed atypical mycobacterial growth in four cases, while Staphylococcus in another. Rests were sterile. Six patients were relieved after clarithromycin course for 1–5 months. Three patients needed scar excision. Conclusion: Manual cleaning with high-level disinfection is not adequate against atypical mycobacterial infections. A combination of enzymatic cleaning and high-level disinfection with glutaraldehyde or ETO sterilization effectively minimizes these infections.

CPC04 A rare rupioid rash

Abstract A 59-year-old man was referred to an urgent skin cancer dermatology clinic with a 4-month history of multiple skin lesions on his trunk, arms and face. The lesions were painful, increasing in size, bleeding and oozing serous fluid. The patient reported being otherwise systemically well, with a history of mild eczema and a background of high alcohol intake. On examination, he had a striking rash with numerous large rupioid plaques with thick crusting and surrounding erythema on the trunk and limbs. Smaller plaques were seen on the face and neck. An infective aetiology was favoured with an initial differential diagnosis of ecthyma or atypical mycobacterial infection. A biopsy was taken, as well as screening blood tests. Treponemal antibodies were detected; rapid plasma reagin was reactive (1 : 32), as was Serodia Treponema pallidum particle agglutination test (1 : 1280), suggesting active syphilis infection. His biopsy demonstrated granulomatous inflammation, associated with neutrophils, plasma cells and increased mucin deposition. Immunohistochemical staining for T. pallidum confirmed corkscrew-like organisms within the basal epidermis and upper dermis, consistent with secondary syphilis; screening for concurrent HIV infection was negative. The patient was referred to a local genitourinary clinic for treatment with benzylpenicillin and for full sexual health screening. The word ‘rupioid’ describes oyster or limpet shell-shaped thick keratotic lesions and is derived from the Greek word rhupos, meaning ‘filth’. Differential causes for rupioid lesions include cutaneous T-cell lymphoma, psoriasis, scabies and syphilis. Rupioid syphilis is also termed ‘malignant syphilis’ or ‘Lues maligna’, describing well-demarcated plaques with thick, lamellate and adherent crusts. It is most frequently encountered in HIV-positive patients; in HIV-negative patients, the associated comorbidities are diabetes, alcoholism, drug abuse, psoriasis and hepatitis. Typically, there is rapid clinical improvement once antibiotic treatment is administered, but episodes of Jarisch Herxheimer reaction are reported. Syphilis diagnoses have tripled over the last 10 years, with cases in the heterosexual population rising most rapidly. Dermatologists have a pivotal role to play in diagnosing primary and secondary syphilis, thereby preventing the long-term sequelae of tertiary syphilis and controlling the rising prevalence of the disease in the general population. This case highlights a striking and rare manifestation of secondary syphilis which, once seen, will not be forgotten.

Atypical Mycobacterial Infection in Post Abdomino-Thoracic Trauma: A Case Report

Objective/Background: SSIs remain a significant cause of morbidity and mortality after surgery. One in eight patients develop SSI after exploratory laparotomies making it one of the major factors responsible for post-operative mortality and morbidity. Atypical mycobacteria are responsible for a spectrum of diseases ranging from superficial skin infections to widely disseminated systemic infections. Health care associated infections due to non-tuberculous mycobacteria is on the rise due to contaminated hospital water supplies, solutions, improperly sterilized instruments and devices. Our case is of an atypical mycobacterial infection in a patient with abdomino-thoracic trauma who underwent multiple surgeries. Case presentation: A 24 year old gentleman presented with a penetrating stab injury to the abdomen and left hemi-thorax following an assault. Patient underwent an emergency exploratory laparotomy which revealed a 4 x 4 cm defect in the left hemi-diaphragm, through which the stomach was herniating into the left thoracic cavity. During the 2nd post-operative week, patient developed empyema thorax, for which pigtail drain was placed initially and later thoracotomy with decortication and intercostal drainage were performed. Following discharge after 2 weeks, he presented with fever, body pain and pus discharge from the previously inserted intercostal drain site. Pus obtained was positive for acid fast bacilli and gene expert was negative. Atypical mycobacterial infection was diagnosed based on high index of suspicion and he received treatment for 6 months. Conclusion: This case highlights that identification of atypical mycobacterial infections in post-operative patients require a high index of suspicion. Management requires multi-drug approach and surgical intervention wherever necessary. Even with the existing sterilization techniques and preventive measure, atypical mycobacterial infection cannot be completely eliminated from a hospital set-up and hence must be considered in all nosocomial infections.

Port-site Infection with Atypical Mycobacteria Post-laparoscopic Procedure: A Case Series

Surgical site infections with atypical mycobacteria are uncommon but not unheard of. Atypical mycobacteria are abundantly present in soil and water and can cause infections when the immune system is compromised. We present four cases of atypical mycobacterial infections at the port site following laparoscopy. In the first case, a laparoscopic cholecystectomy, there was histopathologic evidence of mycobacterial infection, although the smear and culture tests were negative. The second case, post- laparoscopic sterilisation, also showed histopathologic evidence, but the smear test was negative. Similarly, the third case, post- laparoscopic appendectomy, had histopathologic evidence but a negative smear. The fourth case, a post-laparoscopic hernia repair, had histopathologic evidence, a positive smear, and positive culture. The Catridge-Based Nucleic Acid Amplification Test (CBNAAT) for Mycobacterium Tuberculosis (MTB) was negative for all four patients, indicating the absence of tuberculous infection. The first three patients were treated with conventional anti-tubercular treatment using four drugs: Isoniazid (INH), rifampicin, ethambutol, and pyrazinamide, along with an additional quinolone. The fourth patient was treated with a combination of Ciprofloxacin, Clarithromycin, and doxycycline. All four patients responded well to treatment. The use of tap water to dilute disinfectants is considered a risk factor for atypical mycobacterial infection.

1423. A Rare Case of Mycobacterium chelonae Septic Joint

Abstract Background Nontuberculous mycobacteria (NTM) are ubiquitous environmental organisms that can cause chronic soft tissue infections and which may affect underlying joints and bone by direct extension. NTM septic joint infections are rare and literature on their management is scarce. Methods Here we describe a case of septic ankle due to M. chelonae, a rapid grower NTM, and review treatment of these infections. Results An 86-year-old man presented to our hospital with complaints of a painful left ankle. Three months prior he noticed a pimple on his left foot after tripping over a lawnmower. The lesion evolved into erythema and painful swelling of the left ankle. Magnetic resonance imaging (MRI) of the left lower extremity revealed a fracture of the distal tibial metaphysis. Turbid joint fluid was aspirated showing 211,450 white blood cells with 97% neutrophils. Patient underwent partial removal of the left tibia with insertion of a drug implant device. Culture results showed acid fast bacilli at day three and the pathology report confirmed atypical mycobacterial infection (Fig 1, 2). Empiric meropenem, linezolid, and azithromycin were initiated until the identification of M. chelonae was obtained. Based on susceptibilities meropenem was discontinued and ciprofloxacin was added. A repeat MRI showed osteomyelitis and small abscesses about the left ankle leading to repeat debridement. Cultures from debridement were negative. Tobramycin IV three times a week was added and ciprofloxacin was discontinued. Patient soon developed acute renal failure, NSTEMI, and lactic acidosis. After a goals of care discussion with patient’s family, antibiotics were discontinued. He passed away soon thereafter. The backbone of NTM treatment usually consists of a macrolide plus 2-3 other agents but susceptibilities can be misleading. Data correlating outcomes of in vitro susceptibility and clinical response is mixed. Consequently, management of NTM infections is often derived from case reports and from the tuberculosis literature. As seen in this patient, effective treatment can be elusive. Neutrophils surround vacuoles filled with acid-fast staining organisms on Fite staining H&E Stain shows pink stained organisms in vacuoles Conclusion NTM infections are often resistant to antimycobacterial therapy and require multi-drug regimens with surgical intervention. Due to this complexity, a multidisciplinary approach is vital to improve outcomes. Disclosures All Authors: No reported disclosures.

ATYPICAL PRESENTATION OF GRANULOMATOUS INFLAMMATION

ATYPICAL PRESENTATION OF GRANULOMATOUS INFLAMMATION

S2840 Hepatic Tuberculoma Caused by Mycobacterium Fortuitum: A Rare Case Diagnosed by EUS-FNA

Introduction: Mycobacterium fortuitum is a type of nontuberculous mycobacteria belonging to a group classified as Rapidly Growing Mycobacteria (RGM), along with Mycobacterium abscessus and Mycobacterium chelonae. M. fortuitum is predominantly associated with skin, soft tissue, and surgical-wound infections. Catheter-related sepsis and disseminated disease can also occur. Isolated liver involvement by atypical mycobacterial infection is exceedingly rare. Here we describe a case of M. fortuitum presenting as an asymptomatic liver mass. Case Description/Methods: A 67-year-old male was referred for endoscopic ultrasound (EUS) to evaluate a gastric body subepithelial lesion (SEL) and a 3 cm incidental liver mass. He was asymptomatic. Percutaneous CT-guided biopsy was performed, but pathologic results were nondiagnostic. Patient was thus referred for EUS to evaluate the gastric SEL and determine if the liver mass represented metastasis. A 14 by 4 mm elongated intramural hypoechoic mass arising from the muscularis propia highly suggestive of a leiomyoma or GIST was identified. A heterogeneous mass with cystic spaces and echogenic foci in the left liver lobe measuring 27 by 20 mm was sampled using a 22g FNA needle. Pathology revealed granulomatous inflammation with necrosis. An AFB stain was positive for acid fast bacilli. PCR analysis of the specimen detected M. fortuitum DNA. Patient was treated with levofloxacin 750 mg daily plus trimethoprim and sulfamethoxazole (Septra DS) 800 mg - 160 mg twice daily. Follow-up contrast-enhanced MRI revealed complete resolution of liver lesion after 3 months of antibiotics. Discussion: Isolated liver involvement by nontuberculous mycobacteria is uncommon, usually asymptomatic, and its diagnosis can easily be missed or mistaken. We report the first case of a hepatic tuberculoma caused by M. fortuitum diagnosed by EUS-FNA. Precise and accurate recognition by a minimally invasive technique via EUS-FNA resulted in prompt treatment and resolution of the disease.

Partial human Janus kinase 1 deficiency predominantly impairs responses to interferon gamma and intracellular control of mycobacteria.

PurposeJanus kinase-1 (JAK1) tyrosine kinase mediates signaling from multiple cytokine receptors, including interferon alpha/beta and gamma (IFN-α/β and IFN-γ), which are important for viral and mycobacterial protection respectively. We previously reported autosomal recessive (AR) hypomorphic JAK1 mutations in a patient with recurrent atypical mycobacterial infections and relatively minor viral infections. This study tests the impact of partial JAK1 deficiency on cellular responses to IFNs and pathogen control.MethodsWe investigated the role of partial JAK1 deficiency using patient cells and cell models generated with lentiviral vectors expressing shRNA.ResultsPartial JAK1 deficiency impairs IFN-γ-dependent responses in multiple cell types including THP-1 macrophages, Epstein-Barr Virus (EBV)-transformed B cells and primary dermal fibroblasts. In THP-1 myeloid cells, partial JAK1 deficiency reduced phagosome acidification and apoptosis and resulted in defective control of mycobacterial infection with enhanced intracellular survival. Although both EBV-B cells and primary dermal fibroblasts with partial JAK1 deficiency demonstrate reduced IFN-α responses, control of viral infection was impaired only in patient EBV-B cells and surprisingly intact in patient primary dermal fibroblasts.ConclusionOur data suggests that partial JAK1 deficiency predominantly affects susceptibility to mycobacterial infection through impact on the IFN-γ responsive pathway in myeloid cells. Susceptibility to viral infections as a result of reduced IFN-α responses is variable depending on cell type. Description of additional patients with inherited JAK1 deficiency will further clarify the spectrum of bacterial and viral susceptibility in this condition. Our results have broader relevance for anticipating infectious complications from the increasing use of selective JAK1 inhibitors.

31911 Postsurgical atypical mycobacterial infection misdiagnosed as pyoderma gangrenosum

Background: Infection must be excluded in the evaluation of pyoderma gangrenosum (PG), and is frequently identified in misdiagnosed cases of PG that are “recalcitrant” to treatment. Biopsy and tissue culture should be taken with special attention given to the prolonged time it may take for atypical mycobacteria to be identified and speciated. Observation: A 50-year-old woman presented with a 7-month history of unilateral erythema, induration, and purulent drainage following breast reduction surgery. She had been treated for presumed PG with a brief course of antibiotics and daily oral prednisone over 4 months. Attempts to wean prednisone below 10 mg daily resulted in worsening disease. Tissue culture revealed mycobacterium growth and the patient was started on minocycline. Mycobacterium abscessus, resistant to minocycline, was subsequently speciated. The patient was referred to infectious disease, who initiated a four-month course of antibiotic therapy with amikacin and omadacycline. Comments: M abscessus represents one of the commonly identified nontuberculous mycobacteria (NTM) species causing severe respiratory, skin, and mucosal disease. Its rising prevalence is complicated by its significant antibiotic resistance. Outbreaks of postsurgical atypical mycobacterial infections have been reported following video-assisted surgical procedures and surgeries requiring the use of nonautoclavable instruments that may be contaminated by M abscessus biofilm. Concern for PG involving a surgical site should raise suspicion for NTM infection, and cultures should be performed.

Hepatitis B Virus Reactivation and Mycobacterial Infections Associated With Ustekinumab: A Retrospective Study of an International Pharmacovigilance Database.

Background: Reports were recently published on hepatitis B virus reactivation (HBVr), tuberculosis (TB), and atypical mycobacterial infection (AMI) in patients with ustekinumab treatment. However, the literature is limited to case reports and series. The study was aimed to investigate their relationships by using an extensive population-based database. Methods: Using the United States Food and Drug Administration Adverse Event Reporting System (FAERS) database, we collected all cases of HBVr, TB, and AMI between 1 January 2009 and 30 September 2021, for ustekinumab and other drugs. Disproportionality was analyzed using the reporting odds ratio (ROR), which was considered significant when the lower limit of the 95% confidence interval (95% CI) was >1. Results: Of the 18,760,438 adverse cases reported to FAERS for all drugs, 56,581 cases had been exposed to ustekinumab. Adverse events of HBVr, TB, and AMI were reported in 21, 210, and 20 cases, respectively. The ROR for HBVr with ustekinumab was 2.33 (95% CI, 1.52–3.58), for TB was 5.09 (95% CI, 4.44–5.84), and for AMI was 2.09 (95% CI, 1.35–3.24). In the ustekinumab exposure group, no death occurred in patients with HBVr, but one patient experienced life-threatening liver failure. For those with TB, 24 cases experienced hospitalization and 2 deaths occurred. No death occurred in patients with AMI but eight experienced hospitalization. Conclusion: We identified positive signals between ustekinumab exposure and HBVr, TB, and AMI in FAERS. Although these complications are rare, clinicians using ustekinumab should be aware of the risks.

Dépistage et prévention des neuropathies optiques toxiques aux anti-mycobactériens : proposition de recommandations

While treatment of pulmonary infections by Mycobacterium tuberculosis is currently only rarely the cause of iatrogenic complications, treatment of atypical mycobacterial infections often requires prolonged treatment duration, which can lead to toxic optic neuropathies. This review summarizes the indications for such prolonged treatment and risk factors for toxic optic neuropathies when using ethambutol, isoniazid and/or linezolid and proposes customized screening recommendations.

Outcomes of surgical management of post laparoscopy atypical myco-bacterial port site infections: Is early surgery a better alternative?

The number of surgeries undertaken by laparoscopic modality is increasing. This has correspondingly led to an increase in the number of laparoscopy specific complications. Port site infection by atypical mycobacteria constitutes one of the rare and challenging complications to treat. Improper sterilization techniques are an important cause of such infections. Use of disposable trocars is the best solution to avoid this complication. This is study aims to report our experience with diagnosis and management of this unusual complication in context of the available literature. At our institute we encountered 9 patients who presented with port site discharging sinuses after laparoscopic procedures. Diagnosis was confirmed by relevant investigations as applicable. All patients were treated with oral anti-mycobacterial antibiotics. Majority of patients in our study required surgical excision of the port site sinus. Early surgery was associated with less morbidity and patient satisfaction. Port site atypical mycobacterial infections are a rare but serious occurrence. Proper sterilization of laparoscopic instruments is mandatory. We recommend early surgical excision to overcome the morbidity associated with it.

Clinical Phenotypes of Cystic Fibrosis Carriers.

Cystic fibrosis (CF) is an autosomal recessive genetic disorder caused by mutations in CFTR, the cystic fibrosis transmembrane conductance regulator gene. People with CF experience a wide variety of medical conditions that affect the pulmonary, endocrine, gastrointestinal, pancreatic, biliary, and reproductive systems. Traditionally, CF carriers, with one defective copy of CFTR, were not thought to be at risk for CF-associated diseases. However, an emerging body of literature suggests that heterozygotes are at increased risk for many of the same conditions as homozygotes. For example, heterozygotes appear to be at increased risk for chronic pancreatitis, atypical mycobacterial infections, and bronchiectasis. In the United States alone, there are almost 10 million CF carriers. Universal newborn screening and prenatal genetic screening will identify more. Thus, there is a critical need to develop more precise estimates of health risks attributable to the CF carrier state across the lifespan.

Atypical mycobacterial cutaneous infection caused by mycobacterium abscessus complex: An unusual presentation masquerading actinomycosis

Atypical mycobacterial infections are caused by mycobacteria other than those from the Mycobacterium tuberculosis complex and Mycobacterium leprae. They are ubiquitous, aerobic, nonmotile, and acid-fast bacilli seen in soil and water. Here, we report the case of a 31-year-old married female who presented with multiple painful pus-filled lesions over both the breast, abdomen, and back associated with yellow-colored discharge for 6 months. Tuberculosis-polymerase chain reaction revealed the presence of atypical mycobacteria which on further investigation with matrix-assisted laser desorption/ionization-time of flight isolated Mycobacterium abscessus species.

Mycobacterium avium pelvic abscess with vaginocutaneous fistula after transobturatory sling surgery

This study presents a rare case of abscess associated with vaginocutaneous fistula due to atypical mycobacterial infection after sling surgery, which was successfully treated. Abscesses and fistulas are rare postoperative complications in treatment of stress urinary incontinence by transobturatory sling surgery, due to its high rate of positive outcomes in the treatment of urinary incontinence in women. These complications are considered to be related to the composition of the mesh and bacterial infection. We report a case of a 50-year-old patient who developed, in the 7th postoperative year of perineoplasty with sling placement, pelvic abscess and cutaneous fistula in the left thigh. Microbiological examination of the lesion revealed infection by Mycobacterium avium. Antibiotic therapy plus abscess drainage surgery and surgical correction of the fistulous pathway were the treatment of choice. During the surgery, a vaginal opening of the cutaneous fistula was evidenced, originating from the sling mesh, which was removed and later proved to be colonized by M. avium. The patient became asymptomatic after 1 year of postoperative follow-up.