Mycobacteriumchelonae is one of the rapidly growing non-tuberculous mycobacteria that can be isolated from water, soils and aerosols. Localised infections have been reported associated with tattoo parlours, pedicures and cosmetic procedures. But disseminated infection is usually associated with individuals who are immunocompromised, predominantly affecting limbs but sparing abdomen and back. We herein present a case where patient was on immunosuppressive therapy and developed locally severe infection around right ankle. A 69-year-old woman known to rheumatology presents in outpatients with severe pain in right ankle, unable to bear weight, oedematous right foot and lower leg. There was extensive erythematous cellulitic skin rash around right ankle and lower leg. She had background history of systemic lupus erythematosus with previous history of cardiac myositis and left foot drop. She had six cycles of cyclophosphamide for flare of lupus and after last cycle developed this presentation. Skin biopsy was arranged with dermatologist, cultures from which grew M.chelonae. She was admitted and started on triple regimen for M.chelonae as per Microbiology guidelines with intention to complete 6–12 months treatment. Patient responded very well to treatment but unfortunately, she died after 5 months on treatment due to other comorbidities and likely cause of death was cardiac arrhythmia.
Background The British Society for Rheumatology has recently issued Choosing Wisely guidance on ANA testing, to avoid unnecessary testing and inappropriate use of resources. Currently there are no local guidelines on ANA testing. The aim of this audit was to use the BSR guidance as best practice to assess current local testing and then develop guidelines. The standards assessed were as follows: testing ANA should be reserved for patients suspected to have a diagnosis of a connective tissue disease, e.g. lupus. Testing ANA should be avoided in the investigation of widespread pain or fatigue alone. Repeat testing is not normally indicated unless the clinical picture changes significantly. Methods Retrospective data collection of ANA requests at East Kent Hospitals University & Foundation Trust was extracted from the pathology IT system (Apex) from January to March 2019. The clinical indications entered for electronic requesting were recorded. All ANA requests were recorded as ‘appropriate’, ‘inappropriate’ or having ‘insufficient documentation’. A request was considered appropriate if it documented one of the following indications/suspected diagnoses: inflammatory arthritis, connective tissue features - Raynaud’s, vasculitis/photosensitive rash, scleroderma, clinical myositis, autoimmune haemolytic anaemias, cytopenia, Suspected autoimmune liver disease, pleurisy, pulmonary fibrosis, pericarditis, serositis, autoimmune renal disease, autoimmune neurologic disease, BILAG registered patients, patients on/requiring biologics. All other requests which did not meet these standards were considered inappropriate. Results There were 1,517 requests made in 3 months; 180 requests (11.86%) were positive and 1,337 (88.14%) were negative. 61% of ANA requests were from outpatients, 25% were inpatient requests and 14% were requests from GPs. Outpatients requests: neurology, rheumatology, gastroenterology, respiratory and renal medicine (in order of frequency). Only 17% of requests met the set standards; 41% were inappropriate requests and 42% were requests with insufficient details. Conclusion ANA testing is relatively expensive compared to other routine screening tests. The assay is time consuming and labour-intensive, and due to the volume of requests made, 2 batches are tested daily in East Kent. With only 17% of the 1,517 tests meeting the standards, this suggests the majority were inappropriately requested. There were >15,000 requests from East Kent and nearby trusts from April 2018 to December 2018. At £2.50 per test, adhering to guidelines could save potentially £12,000 per year. Local guidelines have now been devised based on the Choosing Wisely standards, indications & suspected diagnoses documented. ANA testing will be re-audited in 6 months. Disclosures S. Rasool None. K. Beharry None. A. Afifi None. F. Shahzad None. R. mahadi None. D. De Lord None.
Background Mycobacterium chelonae is a rapidly growing non-tuberculous mycobacteria that can be isolated from water, soils and aerosols. Localised infection has been reported associated with surgical and cosmetic procedures. Disseminated infection is rare and usually occurs in individuals who are immunocompromised. We present a patient with severe SLE on immunosuppressive therapy who developed localised severe cutaneous infection of the foot. Methods A 69-year-old lady with complex SLE - RNP+, Raynaud's, arthritis, stable for several years had deteriorated within the last year with cardiac myositis and, peripheral neuropathy. Three months pulsed intravenous cyclophosphamide (EUROLUPUS regime) was completed in November 2018. Five weeks later she developed severe pain, inability to weight-bear and extensive erythema and swelling of the right ankle and lower leg. An MRI showed extensive skin thickening especially dorsally in the R foot and anteriorly in distal leg. There was also increased signal in the distal achilles tendon. Orthopedic review confirmed no evidence of septic arthritis or osteomyelitis. A skin biopsy was performed, cultures from which grew Mycobacterium chelonae. She was admitted and started on tobramycin, on which she developed long QTc, linezolid which caused thrombocytopenia and clarithromycin. In March 2019 she was re-admitted with confusion, weakness and AKI, secondary to clarithromycin. She was, then switched to clofazimine and low dose clarithromycin, on which she was stabilized. MRI brain scan was normal, lumbar puncture was negative for M chelonae PCR and MRI spine confirmed cervical cord compression and cervical and lumbar canal stenosis due to osteophytes and disc disease. Results The infection improved considerably after 5 months of successful mycobacterial treatment. It was then possible to treat with rituximab for a deteriorating peripheral neuropathy confirmed on EMG and cardiac myositis. Sadly, whilst awaiting rehabilitation, the patient died unexpectedly in April 2019 from an arrhythmia. Conclusion Mycobacterium chelonae is an uncommon cause of soft tissue infection, which is resistant to all anti-tuberculous drugs. It is susceptible to a wider range of antimicrobial agents including tobramycin, imipenem, clarithromycin, linezolid, co-trimoxazole. A high index of suspicion is necessary for diagnosis, particularly in immunocompromised patients. The incidence may be increasing, possibly due to enhanced detection. Infection can mimic MSK presentations including capsulitis, tendonitis and tenosynovitis. Close monitoring is required as anti-microbial therapy complications are common including prolongation of QTc on tobramycin. Vigilance for disseminated multiorgan involvement is essential due to high mortality, particularly with CNS and lung involvement. Atypical infections should always be considered in the immunocompromised, particularly mycobacteria, nocardia & fungi. Disclosures S. Rasool None. A. Afifi None. D. De Lord None.
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