The Brief Case: Disseminated Mycobacterium haemophilum Infection in a Kidney Transplant Recipient

Abstract

A 65-year-old woman from Thailand was hospitalized in May 2016 with fevers and rash. The patient had end-stage renal disease and hypertension and received a deceased-donor kidney transplant in 2009. The induction immunosuppression agent was rabbit anti-thymocyte globulin, and she took tacrolimus and mycophenolate mofetil for maintenance immunosuppression. The patient was diagnosed with polymorphic, Epstein-Barr virus-positive posttransplant lymphoproliferative disorder (PTLD) of the central nervous system 5 weeks prior to admission. She completed two doses (375 mg/m 2 each) of rituximab with dexamethasone (10 to 24 mg/day in divided doses), and mycophenolate mofetil was discontinued after the PTLD diagnosis.On physical examination, the patient was ill appearing but alert and oriented. Her temperature was 38°C. The right eye conjunctiva was injected with nodular conjunctival lesions. On skin examination, there were erythematous papules, some with central pustules, on the forehead, face, neck, arms, anterior thighs, knees, and lower back (Fig. 1A). Human immunodeficiency virus antibody and tuberculosis gamma interferon release assays were performed, and both were negative. A computed tomography scan of the chest demonstrated several bilateral subcentimeter pulmonary nodules in the lower lobes and lingula.Skin biopsies were performed on the right arm, cheek, and thigh, and the samples were sent for histopathologic examination and bacterial, fungal, and mycobacterial cultures. Histopathology revealed a superficial and granulomatous reaction with a neutrophilic infiltrate involving the dermis and subcutaneous fat (Fig. 1C). Numerous acid-fast bacilli (AFB) were visualized after staining with Fite-Faraco stain (Fig. 1D). Rare AFB were observed by acid-fast fluorescent staining of tissue submitted to the clinical microbiology laboratory, and a portion of the specimen was inoculated onto chocolate agar and incubated at 30°C. Imipenem, azithromycin, levofloxacin, isoniazid, pyrazinamide, and ethambutol were administered as empirical therapy for rapidly growing mycobacterial species (Mycobacterium chelonae/Mycobacterium abscessus group and Mycobacterium fortuitum group), slowly growing mycobacterial species (Mycobacterium haemophilum and Mycobacterium marinum) that are often associated with skin lesions, and Mycobacterium tuberculosis. Aminoglycosides and rifamycins were initially avoided, given the potential for nephrotoxicity and drug interaction with tacrolimus, respectively.Two weeks after the skin biopsy, mycobacterial cultures demonstrated no growth. The skin lesions had progressed to extensive erythematous plaques and yellow/black crust covering the forehead, cheeks, both arms, and thighs. Painful ulcerations develCitation Jacobs SE, Zhong E, Hartono C, Satlin MJ, Magro CM, Jenkins SG, Westblade LF. 2018. The Brief Case: Disseminated Mycobacterium haemophilum infection in a kidney transplant recipient. J Clin Microbiol 56:e00561-17.

Mycobacterium haemophilum skin and soft tissue infection in a kidney transplant recipient: A case report and summary of the literature

“…Transplant recipients can also be affected and typically present with painless erythematous papules that subsequently ulcerate and form an abscess 3 . Rarely, M haemophilum can cause deep soft tissue infection leading to septic arthritis, pyomyositis, osteomyelitis, or metastatic infection at distant sites (eg, endophthalmitis, pulmonary nodules, or epididymal abscess) 4,5 . Herein, we present the case of a kidney transplant recipient with deep soft tissue infection caused by M haemophilum , confirmed by molecular testing, who presented with unilateral cellulitis‐like lesions complicated by tenosynovitis and abscess formation.…”

Cutaneous Mycobacterium haemophilum infection in an immunocompetent patient

“…Because our patient was a carpenter, he was subject to risks of occupational injury. This pathogen can present different clinical manifestations, including erythematous papules, violaceous subcutaneous nodules, deep ulcerations, abscesses, and focal panniculitis [2,5]. Shimizu et al reported a case of cutaneous disseminated M. haemophilum infection in a kidney transplant patient presenting with Sweet's syndrome-like features [6].…”

“…Because our patient was a carpenter, he was subject to risks of occupational injury. This pathogen can present different clinical manifestations, including erythematous papules, violaceous subcutaneous nodules, deep ulcerations, abscesses, and focal panniculitis [2,5] Mycobacterium haemophilum skin infections remain a diagnostic challenge. Diagnostic measures include histological work-up, culturing, and molecular microbiology examinations [8].…”

“…Because of challenges in its etiological diagnosis, infection caused by M. haemophilum is often misdiagnosed. This infection has been reported primarily in immunocompromised patients, such as transplant recipients with immunosuppressive therapy or in those affected with human immunodeficiency virus [2,3] and is rare in immunocompetent individuals.…”

Kutane Infektion mit Mycobacterium hämophilum bei einem immunkompetenten Patienten

“…Wegen der schwierigen ätiologischen Zuordnung wird eine Infektion durch M. haemophilum oft falsch diagnostiziert. Die Infektion tritt vor allem bei immungeschwächten Patienten auf, wie beispielsweise bei Transplantatempfängern mit immunsuppressiver Therapie oder bei Patienten mit humanem Immundefi zienz-Virus [ 2,3 ] . Bei immunkompetenten Personen ist sie selten.…”