Mycobacterium Chelonae Abscessus Lower Extremity Infection in the Double Transplant Patient
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- Mycobacterium chelonae abscessus is a rare but drug-resistant bacterial infection that caused pain and swelling in the right fourth toe of a 56-year-old male double transplant patient. - Six weeks of IV antibiotics did not improve the infection. Further testing identified M. chelonae abscessus and long-term combination antibiotic therapy along with wound care was started. - M. chelonae abscessus has a propensity for infecting immunocompromised patients like solid organ transplant recipients. It is a challenging infection to diagnose and treat due to its drug resistance and variable treatment durations needed.
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Mycobacterium Chelonae Abscessus Lower Extremity Infection in the Double Transplant Patient
- 1. Cleveland Clinic/Kaiser Permanente Residency Program M.chelonae abscessus Lower Extremity Infection in the DoubleTransplant Patient Jennifer Gerres DPM, PGY-2
- 2. Objectives ✤ Mycobacterium chelonae abscessus is a rare cause of human infection ✤ Present an atypical manifestation in an immunosuppressed patient ✤ Review of the literature ✤ Proclivity for the renal transplant patient
- 3. Case Study
- 4. History of Present Illness ✤ December 2010, a 56yo male presents with pain to the right 4th MTPJ ✤ 2 months prior ✤ Clipping toenails and accidentally clipped right 4th toe ✤ Developed pain and edema ✤ Saw his local podiatrist in Michigan ✤ I&D performed, and per patient, purulent material was expressed, but no culture taken
- 5. History of Present Illness ✤ 2 weeks after I&D ✤ Noticed increased pain and erythema at anesthetic injection site of the right 4th toe ✤ Returned to podiatrist, who prescribed empiric Augmentin x 10 days without improvement ✤ Epsom salt soaks twice daily ✤ Radiograph of right foot: calcified vessels ✤ ABI/PVR: small vessel disease
- 6. History of Present Illness ✤ The patient describes the pain thusly: ✤ It begins at night, worsens until the morning, and resolves by midmorning ✤ Sharp, “tight-feeling” at the base of the right 4th toe ✤ Review of Systems ✤ Denies n/v/f/c/night sweats/weight change/loss of appetite ✤ Previous right foot surgery ✤ Distal chevron bunionectomy ✤ “It took 6 months for the incision to heal”
- 7. Past Medical History ✤ DM Type I x 35 years ✤ Status-post cadaveric pancreas transplant 10 years prior ✤ Status-post living-donor kidney transplant 10 years prior ✤ Aortic Stenosis ✤ Glaucoma (legally blind) ✤ Hypothyroidism ✤ Irritable bowel syndrome
- 8. ✤ Past Surgical History ✤ Cadaveric pancreas transplant ✤ Living-donor kidney transplant ✤ Multiple eye surgeries ✤ Right HAV surgery 3 years prior ✤ Allergies ✤ No known drug allergies
- 9. Medications ✤ Prednisone ✤ Tacrolimus anhydrous (Prograf) ✤ Mycophenolate mofetil (Cellcept) ✤ Bupropion ✤ Zetia ✤ Prilosec ✤ Synthroid ✤ Betimol 0.5% eye drops ✤ Lotemax 0.5% eye drops ✤ Aspirin 81mg ✤ Calcium carbonate/VitD3
- 10. ✤ Social History ✤ Lives by Lake Michigan ✤ Often spends his summers on the beaches ✤ Illicit drug use: denies
- 11. Physical Exam: Right Foot ✤ Vascular: DP/PT pulses palpable. No edema. No dependent rubor ✤ Neurological: Light touch intact. SWMF 5.07 intact to all sites ✤ Musculoskeletal: Pain with ROM of the 4th MTPJ ✤ Pain on palpation at the 4th MTPJ and the 3rd interspace ✤ Negative Mulder’s click ✤ No pain to palpation of the 4th toe ✤ Dermatological: telangiectasias to dorsal forefoot ✤ No palpable mass ✤ Erythema to the distal pulp of the 4th toe as well as to the dorsal 4th MTPJ ✤ The erythema is blanchable
- 12. Ancillary Studies ✤ MRI without contrast ✤ Nonspecific soft tissue edema ✤ No focal soft tissue abnormality ✤ ABI/PVR ✤ Right: 1.16 TBI: 0.42 small vessel disease ✤ Left: 1.1 TBI: 0.63
- 13. Plan ✤ ADMISSION ✤ Course of IV antibiotics ✤ IV Zosyn and Vancomycin ✤ During admission ✤ Patient remained afebrile ✤ Minimal resolution of erythema to the 4th MTPJ, but no resolution of pain ✤ Labs ✤ No leukocytosis ✤ ESR: 2 ✤ CRP: 0.1 ✤ Uric acid: wnl
- 14. ✤ Six-week course of IV antibiotics ✤ Despite the six-week course of IV antibiotics... ✤ The erythema failed to improve ✤ Patient continued to have pain at the right 4th MTPJ After Discharge
- 15. SixWeeks After Discharge ✤ Evaluated by Podiatry and Infectious Disease ✤ Plan ✤ Admission ✤ Underlying ischemia? ✤ Multidisciplinary approach
- 16. During Admission ✤ Vitals: afebrile ✤ Physical exam remained unchanged ✤ Labs ✤ No leukocytosis ✤ ESR: 1 ✤ CRP: 0.1 ✤ Procalcitonin: <0.05 ✤ MRI with contrast ✤ Mild, nonspecific subcutaneous and muscular edema
- 17. ✤ After a multidisciplinary discussion, it was determined to halt the current administration of antibiotics ✤ Evaluate the patient in the outpatient setting ✤ Weekly photographs and phone calls ✤ The patient provided weekly updates until February 2011
- 18. Two Months from Initial Presentation ✤ Increased pain to the right 4th MTPJ ✤ New complaint of a “lump” to the area ✤ Denied n/v/f/c/night sweats
- 19. PLAN
- 20. Plan ✤ Aspiration ✤ Anaerobe/aerobe ✤ AFB stain and culture ✤ Fungal culture and smear ✤ Nocardia ✤ Mycoplasma ✤ Admission
- 21. During Admission ✤ Patient remained afebrile ✤ Labs ✤ No leukocytosis ✤ ESR and CRP remained unchanged ✤ Microbiology ✤ Rapid-growing, acid fast bacilli
- 22. At Discharge ✤ Final cultures demonstrated ✤ Mycobacterium chelonae abscessus ✤ S: clarithromycin/azithromycin, linezolid, tigecycline ✤ Antibiotic regimen ✤ Tigecycline 50mg IV q12h ✤ Azithromycin 500mg PO ✤ Linezolid 600mg PO q12h ✤ Local wound care for ulceration
- 23. At Six Months
- 24. Discussion
- 25. Mycobacterium chelonae abscessus ✤ Multi-drug resistant, rapid-growing acid fast bacilli ✤ Chopra et al. J Antimicrob Chemother, 2011: ✤ Systematic review, screening 1040 approved drugs, antimicrobial and non-antimicrobial ✤ Discovered 32 compounds with significant antimicrobial activity ✤ Illustrated the resilience of this group ✤ Biofilm ✤ Ubiquitous and fastidious ✤ Found: water
- 26. Mycobacterium chelonae abscessus ✤ Cause of nosocomial, post-surgical wound, and post-injection abscesses ✤ Clustered cases of infection ✤ Foot baths, contaminated water supply or injected material ✤ Infrequently, a cause of infection ✤ Immunocompromised ✤ Solid organ transplants ✤ Cutaneous lesions of the extremities ✤ Arthritis and tenosynovitis; meningitis; and disseminated infection
- 27. Mycobacterium chelonae abscessus ✤ Several reported cases among solid organ transplant patients ✤ Cooper et al. Am J Med, 1989: ✤ Identified 7 renal transplant patients ✤ Distinct pattern emerged: ✤ Indolent, tender nodules isolated to the lower extremities ✤ Absence of systemic symptoms and no leukocytosis ✤ Garrison et al. Transpl Infect Dis, 2009: ✤ Found 25 cases involving solid organ transplant recipients ✤ 4 received renal transplants
- 28. Mycobacterium chelonae abscessus ✤ Diagnosis and treatment are complex ✤ Lesion biopsy and wound culture with susceptibility ✤ Resistance patterns unpredictable ✤ Naturally resistant to conventional anti-TB drugs ✤ No guidelines as to duration of therapy ✤ IDSA ✤ 4 months for skin and soft tissue infections ✤ 6 months for bone infections ✤ Chernenko et al. J Hear Lung Transplant, 2006: ✤ 12 to 18 months of combination therapy in the immunocompromised ✤ Surgical intervention
- 29. Conclusion ✤ Multi-drug resistant acid-fast bacilli with proclivity for the immunocompromised ✤ Treatment of these infections are complex ✤ Culture and sensitivity are imperative ✤ Aspiration and/or debridement necessary to improve outcome
- 30. References ✤ Morales P, Gil A, Santos M. Mycobacterium abscessus infection in transplant recipients. Transplantation Proceedings. 2010;42:3058-306 ✤ Morris-Jones R, Fletcher C, Morris-Jones S, et al. Mycobacterium abscessus : a cutaneous infection in a patient on renal replacement therapy. Clin Exp Dermatol. 2001;26:415-418 ✤ Garrison, AP, Morris MI, Lewis SD, et al. Mycobacterium abscessus infection in solid organ trasnplant recipients : report of three cases and review of the literature. Transpl Infect Dis. 2009;11:541-548 ✤ Moore M, Frerichs JB. An unusual acid-fast infection of the knee with subcutaneous, abscess-like lésions of the gluteal région ; report of a case with a study of the organism, Mycobacterium abscessus, n. sp. J Invest Dermatol. 1953 ;20 :133-169 ✤ Chopra S, Matsuyama K, Hutson C, Madrid P. Identification of antimicrobial activity among FDA-approved drugs for combating Mycobacterium abscessus and Mycobacterium chelonae. J Antimicrob Chemother. 2011;66:1533-1436 ✤ Kwon YH, Lee GY, Kim WS, Kim JK. A case of skin and soft tissue infection caused by mycobacterium abscessus. Ann Dermatol (Seoul). 2009;21(1) :84-87 ✤ Doucette K, Fishman JA. Nontuberculous mycobacterial infection in hematopoietic stem cell and solid organ transplant recipients. Clin Infect Dis. 2004;38(10):1428-1439 ✤ Galil K, Miller LA, Yakrus MA, et al. Abscesses due to Mycobacterium abscessus linked to injection of unapproved alternative medication. Emerg Infect Dis. 1999;5:681-687 ✤ Cooper JF, Lichtenstein MJ, Graham BS, Schaffner W. Mycobacterium chelonae: A cause of nodular skin lesions with a proclivity for renal transplant recipients. Am J Med. 1989;86(2):173-177 ✤ Prinz BM, Michaelis S, Kettelhack N, et al. Subcutaneous infection with Mycobacterium abscessus in a rental transplant recipient. Dermatology. 2004;208(3)259-261 ✤ Scholze A, Loddenkemper C, Grumbaum M, et al. Cutaneous Mycobacterium abscessus infection after kidney transplantation. Nephrol Dial Transplant. 2005;20(8): 1764-1765 ✤ Chernenko SM, Humar A, Hutcheon M, et al. Mycobacterium abscessus infections in lung transplant recipients : the international experience. J Hear Lung Transplant. 2006;25(12):1447-1455
- 31. ThankYou