Case of atypical cutaneousMycobacteriumchelonaeinfection in patient of systemic lupus erythematosus after cyclophosphamide therapy

Abstract

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.

Cutaneous lesions induced by Mycobacterium chelonae

“…Dermatology Review/Przegląd Dermatologiczny 2023/4 ment and disseminated disease, antibiotic therapy is recommended for 6-12 months [12][13][14]. The differential diagnosis of M. chelonae infections should take into account other atypical mycobacterial species such as M. fortuitum, M. abscessus, M. marinum and M. ulcerans.…”

“…A similar clinical picture may occur in other bacterial infections such as primary cutaneous nocardiosis, cutaneous ulcerative tularemia and fungal infections (Aspergillus spp., Cryptococcus spp., Scedosporium apiospermum, Pseudallescheria boydii and Sporothrix schenckii). In addition, the skin lesions in mycobacteriosis might imitate lupus vasculitis [6,13].…”

“…Początkowo zaleca się skojarzone stosowanie co najmniej dwóch antybiotyków z uwagi na możliwość wystąpienia oporności podczas leczenia, które często ma charakter długotrwały. W przypadku ciężkiego zakażenia skóry i tkanek miękkich, zajęcia kości i choroby rozsianej zaleca się prowadzenie antybiotykoterapii przez 6-12 miesięcy [12][13][14]. W diagnostyce różnicowej zakażeń M. chelonae należy także uwzględniać inne gatunki prątków atypowych, m.in.…”

“…Podobny obraz kliniczny może jednak wystąpić w przebiegu innych schorzeń o podłożu bakteryjnym, takich jak pierwotna nokardioza skórna, tularemia skórno-wrzodziejąca, oraz zakażeń grzybiczych (Aspergillus spp., Cryptococcus spp., Scedosporium apiospermum, Pseudallescheria boydii i Sporothrix schenckii). Zmiany skórne w przebiegu mykobakteriozy mogą także naśladować toczniowe zapalenie naczyń [6,13].…”

Nontuberculous mycobacteriosis (Mycobacterium chelonae): fatal outcome in a patient with severe systemic lupus erythematosus

“…Disseminated infection usually occurs in immunocompromised individuals, predominantly affecting the lower extremities. 7 , 8 …”