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Mycobacterium fortuitum skin infections after subcutaneous injections with Vietnamese traditional medicine: a case report
© Lan et al.; licensee BioMed Central Ltd. 2014
Received: 9 June 2014
Accepted: 9 October 2014
Published: 11 November 2014
Iatrogenic skin and soft tissue infections by rapidly growing mycobacteria are described with increasing frequency, especially among immunocompromised patients.
Here, we present an immunocompetent patient with extensive Mycobacterium fortuitum skin and soft tissue infections after subcutaneous injections to relieve joint pains by a Vietnamese traditional medicine practitioner. Moreover, we present dilemmas faced in less resourceful settings, influencing patient management.
This case illustrates the pathogenic potential of rapid growing mycobacteria in medical or non-medical skin penetrating procedures, their world-wide distribution and demonstrates the dilemmas faced in settings with fewer resources.
Mycobacterium fortuitum is a member of the group of non-pigmented Rapidly Growing Mycobacteria (RGM), and is found ubiquitously in nature (soil, dust, and in tap water in biofilms), over a wide geographical area. Infections with non-tuberculous mycobacteria have been described increasingly, especially in immunocompromised patients and as iatrogenic infections in immunocompetent patients, causing a variety of local and disseminated disease. RGM in particular can cause local skin and soft tissue infections (SSTI) and have also been described in outbreak and pseudo-outbreak settings involving infections after surgery or other invasive procedures -. Here, we describe a case from the Hospital of Tropical Diseases in Ho Chi Minh City, Vietnam of M. fortuitum infection of the skin and soft tissues covering several joints after injection of traditional Vietnamese medicine to relieve joint pain. We discuss the diagnostic process and treatment for this patient in a setting with fewer resources.
Laboratory findings showed: procalcitonin 0.083 ng/ml (reference range <0.05 ng/ml), leucocytes 14.8 • 103/μl (6-10 • 103/μl), neutrophiles 81.2% (reference range: 49-65.5%). Blood cultures (BactAlert; bioMérieux, France) were taken and empiric antimicrobial therapy was started with intravenous (i.v.) oxacilline to cover Staphylococcus aureus and group A beta-haemolytic streptococci.
A pulmonary X-ray, and X-ray imaging of hands and feet were unremarkable, and incision and drainage of the abscesses followed. Gram stains of the collected fluids showed slender beaded and fragmentally stained Gram positive rods, suggestive of mycobacteria. This was subsequently confirmed by Ziehl-Neelsen staining (see Figure 1). Because of reported sensitivity loss and the presence of nodules, leprosy was ruled out by investigation of ear lobe skin slits.
Based on microscopy results, a preliminary diagnosis of multiple mycobacterial skin and soft tissue infections (SSTI) with rapidly growing mycobacteria was made, and treatment was initiated with oral clarithromycine (500 mg/b.i.d.) and intramuscular (i.m.) amikacin (500 mg/t.i.d.).
Purulent fluid was cultured on standard culture media (blood agar and McConkey agar) for three days and yielded grey wrinkled colonies on blood agar (no growth on McConkey agar) (see Figure 1), morphologically suspect of Mycobacterium spp. This was confirmed by Gram and ZN staining and the isolate was later genotyped as Mycobacterium fortuitum by 16S DNA PCR and sequencing analysis.
Initial drug susceptibility testing (DST) by disk diffusion on Müller-Hinton agar showed the strain to be resistant to fluoroquinolones (ciprofloxacin, levofloxacin), azithromycin and tobramycin, but susceptible to amikacin, imipenem and amoxicillin-clavulanic acid. Clinical improvement during the 120-day admission was variable and slow, with subfebrile temperatures (38°C) last monitored on day 14, and the appearance of new fluctuating lesions on days 23 (hands/feet), 29 (hands/feet), 32 (right shoulder and hip), and 72 (shoulder), which were incised and drained. M. fortuitum was isolated again from the day-23 and day-29 samples, whilst microscopy and culture remained negative thereafter. Papules and blisters emerged at the sites of formerly drained sites on the hands/feet on day 72 and 80, and healed 5 days later; microbiological investigations were negative. From day 90 onwards, all lesions healed (see Figure 1), and no new skin and soft tissue abnormalities were observed.
Clinical course and therapy
Start of symptoms
Treatment at local clinic
Admission, drainage of lesions
Acid-fast bacilli in ZN slide
Amikacin IV, clarithromycin
Amikacin IV, doxycyclin, co-trimoxazole
Imipenem IV, tid
New lesions on hands/feet
Acid-fast bacilli in ZN slide
New lesions on hands/feet
Acid-fast bacilli in ZN slide
New lesions on shoulder/hip
Imipenem IV, qid
New lesions on shoulder
Papules on hands/feet
Papules on hands/feet
All lesions healed
Stop after 4 months
Our patient was not immunocompromised, as were 21/29 cases described by Lee et al., yet had extensive lesions which were spreading, even during therapy . The number and location of lesions on initial presentation correlated with the received subcutaneous injections. Guevara-Patinos et al. describe M. fortuitum infection with multiple skin lesions after acupuncture. This was treated with doxycycline and ciprofloxacin for three months which led to full recovery . Pai et al. describe a case of recurrent subcutaneous abscesses of unknown aetiology that did not respond to empiric antibiotic treatment and later was diagnosed as a M. fortuitum SSTI . Because of side effects, this patient was eventually successfully treated with surgical excisions. The development of several new nodules/abscesses during antimicrobial therapy was worrisome in our case, as this could be indicative of failure of antimicrobial therapy due to misinterpretation of the susceptibility results, resistance development or dissemination in an ongoing extensive infection ,. The gold standard for susceptibility testing of RGM is the broth dilution method as described by the CLSI . In our setting, broth dilution was unavailable. For imipenem an E-test was performed, for ciprofloxacin, levofloxacin, tobramycin, azithromycin, co-trimoxazole, amikacin and amoxicillin-clavulanic acid disk diffusion was performed on Müller-Hinton agar.
Our patient’s treatment regimen was altered on many occasions, but overall, 105 days of imipenem monotherapy was prescribed, in addition to the 14 days of amikacin therapy and 4 months of amoxicillin-clavulanic acid, for which the isolate was sensitive according to disk diffusion. After discharge and an 8 months follow-up period, she remained free of symptoms.
In conclusion, M. fortuitum and other RGM are not very pathogenic, but can cause infections after direct inoculation into sterile sites, e.g. trauma with skin damage, use of contaminated surgical instruments or fluid for injection or after use of contaminated tap water during invasive procedures . Infections with M. fortuitum appear to occur in younger patients who are generally not immunocompromised, and manifest more often after surgical procedures . M. fortuitum is more sensitive to antibiotics than the related M. abscessus or M. chelonae and infections have a better recovery rate . In our case, the isolate was relatively resistant by disk diffusion tests and only susceptible to amikacin, imipenem and amoxicillin-clavulanic acid. The patient clinically recovered after more than 12 weeks of antimicrobial therapy, which was continued for a total of 8 months. This case illustrates the pathogenic potential of RGM in medical or non-medical skin penetrating procedures and their world-wide distribution. Additional dilemmas faced in this setting with less resources were the limited availability of (biochemical) typing and susceptibility testing methods, of required antibiotics and of insurance coverage.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
NVVC and DHL were responsible for patient treatment, NPHL, NTT, JC and HRVD participated in the described diagnostic process, NVD and MEK collected data and information and drafted the report, HRVD finalized the manuscript, all authors have seen and approved the manuscript.
NVD, NTT and HRVD were funded by the Wellcome Trust of Great Britain, grant 089276/Z/09/Z. JIC was supported by the European Union FP7 project “European Management Platform for Emerging and Re-emerging Infectious Disease Entities (EMPERIE)” (no. 223498). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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