Odontogenic cutaneous sinus tracts due to infection with nontuberculous mycobacteria: a report of three cases.

BACKGROUND: Soft tissue or skin infections due to nontuberculous mycobacteria (NTM) have been reported frequently and are mostly associated with trauma or cosmetic interventions like plastic surgery. However, infection with NTM as a result of a dental procedure have rarely been described and the lack of clinical suspicion and a clear clinical manifestation makes diagnosis challenging. CASE PRESENTATION: We report on three patients with a facial cutaneous sinus tract of dental origin, due to an infection with respectively Mycobacterium fortuitum, M. abscessus and M. peregrinum. The infection source was the dental unit waterlines (DUWLs), which were colonized with NTM. CONCLUSIONS: Water of the DUWL can pose a health risk. This report emphasizes the need for quality control and certification of water flowing through DUWLs, including the absence of NTM. Our report also shows the need for a rapid recognition of NTM infections and accurate laboratory diagnosis in order to avoid long-term ineffective antibiotic treatment.

Pulmonary infection due to fluoroquinolone-resistant Mycolicibacterium fortuitum: a case report.

BACKGROUND: Mycolicibacterium fortuitum is a species of the rapidly growing mycobacteria that can cause pulmonary infection. It is susceptible to multiple antibiotics both in vitro and in clinical practice, so that any combination of susceptible drugs is effective. However, we encountered a case of infection due to fluoroquinolone-resistant M. fortuitum. In this study, we report the case and describe the mechanism of resistance. CASE PRESENTATION: A 65-year-old man with a history of total gastrectomy and immunosuppressant treatment for rheumatoid arthritis developed a recurrence of pulmonary infection caused by M. fortuitum. He was treated with clarithromycin and levofloxacin as a first-line treatment, based on the favorable susceptibility at that time. After recurrence, a high minimum inhibitory concentration to fluoroquinolones was detected. DNA sequencing of the pathogen showed the substitution of serine for tryptophan at residue 83 in the gyrA gene. He was successfully treated with a combination of other antibiotics. CONCLUSION: This is the first report on the treatment of fluoroquinolone-resistant M. fortuitum and investigation of the mechanism of resistance. We suggest that the susceptibility test remains effective for determining the next line of treatment after a pathogen has acquired resistance, and resistance to fluoroquinolones in M. fortuitum can be attributed to a single change of amino acid.

Mycobacterial Airsacculitis Caused by Mycobacterium fortuitum in a Southern Rockhopper Penguin (Eudyptes chrysocome).

A 21-year-old male southern rockhopper penguin (Eudyptes chrysocome) was presented with a chronic history of intermittently decreased appetite, lethargy, and regurgitation. On the external physical examination, the bird was determined to be in fair-to-thin body condition with the complete blood count and plasma chemistry panel being largely unremarkable. Full-body radiographic images were considered normal, and gastroscopy showed only mild gastritis and duodenitis. The penguin was euthanatized shortly thereafter due to acute onset of respiratory distress. During the gross necropsy examination, the bird had severe airsacculitis with thick, yellow-to-tan, moist granular plaques adhering to the surface of many air sacs, as well as regional contiguous pneumonia. Intralesional acid-fast bacilli were observed in histologic sections of air sac tissue, and polymerase chain reaction of the affected air sacs was positive for Mycobacterium fortuitum. This clinical case study describes mycobacteriosis in a sub-Antarctic penguin and to the best of the authors' knowledge, the first reported isolation of M fortuitum from a penguin.

Cardiac resynchronization therapy-defibrillator pocket infection caused by Mycobacterium fortuitum: a case report and review of the literature.

BACKGROUND: With the rising utilization of cardiovascular implantable electronic devices (CIEDs), infections secondary to device implantation are increasingly encountered. Staphylococcus aureus and coagulase-negative staphylococci are usually the predominant causative organisms. A CIED infection due to non-tuberculous mycobacteria (NTM) is extremely rare. CASE PRESENTATION: A 68-year-old man was admitted to our hospital with a history of pain and swelling at his cardiac resynchronization therapy-defibrillator (CRT-D) pocket site, for 4 days. The CRT-D had been implanted 2 weeks prior. The exudate smear was positive for acid-fast bacilli and culture results revealed rapidly growing nontuberculous mycobacteria (RGM). After an urgent removal of the device followed by 1 year of antibiotic treatment, the patient was completely cured. A new device was finally implanted, 3 years later. CONCLUSIONS: Infections caused by nontuberculous mycobacteria following the implantation of cardiac devices are very rare. The typical manifestations of post-implantation CIED infections caused by RGMs include an early onset, with local redness, swelling, and spontaneous drainage. Systemic symptoms such as fever, chills, and fatigue are absent. Mycobacterium fortuitum is the most common species of RGM implicated in CIED infections, the manifestations of which usually appear within several weeks of the implantation procedure. An urgent removal of the device and appropriate antibiotic therapy are essential therapeutic measures. This is the first such reported case, in which the patient has been re-implanted with another device at the same site, after achieving a complete cure. We followed-up the patient for an additional 3 years and observed that the patient remained free of infection. Our case report shows that though an RGM infection is rare and difficult to treat, it can be completely cured. In addition, we demonstrated that it is subsequently possible to safely re-implant a CIED for the patient, at the same site.

Efficacy of copper and silver as residual disinfectants in drinking water.

Contamination events and biofilms can decrease the amount of free chlorine available in drinking water systems. The efficacy of 100 µg/L silver and 400 µg/L copper, individually and combined, were evaluated as secondary, longer-lasting residual disinfectants against Salmonella enterica serovar Typhimurium, Escherichia coli, Listeria monocytogenes, and Mycobacterium fortuitum at 24 °C and 4 °C. A >5.0-log10 reduction was observed in E. coli and L. monocytogenes after three hours and S. Typhimurium following seven hours of exposure to silver. M. fortuitum was the most resistant species to silver (1.11-log10 after seven hours). Copper did not significantly reduce S. Typhimurium and E. coli at 24 °C; ≥2.80-log10 reductions were observed in the Gram-positive L. monocytogenes and M. fortuitum. Longer exposure times were required at 4 °C to achieve significant reductions in all species. A synergistic effect was observed when silver and copper were combined at 24 °C. In addition, silver was not affected by the presence of organic matter at concentrations that completely inhibited 0.2 mg/L chlorine. The results of this study suggest that combinations of silver and copper show promise as secondary residual disinfectants. They may also be used in conjunction with low chlorine levels or other disinfectants to provide additional, long-lasting residuals in distribution systems.

Characterization of non-tuberculous mycobacterium from humans and water in an Agropastoral area in Zambia.

BACKGROUND: The non-tuberculous mycobacteria include those mycobacterium species that are not members of the Mycobacterium tuberculosis complex, the causative agent of pulmonary tuberculosis and Mycobacterium leprae. In Zambia, Non-tuberculous Mycobacteria are gaining recognition as pathogens of public health significance. However, there is scanty information on the isolation and speciation of these organisms for better patient management, consequently reducing the burden of these infections. Given the above information, the thrust of this study was to isolate and characterize NTM from humans and water in Namwala district of Zambia. METHOD: This was a cross-sectional study were 153 individuals with suspected TB were sampled from four health facilities in Namwala district, sputum samples were also collected. Additionally, 149 water samples were collected from different water drinking sources such as Tap water, Borehole water, rivers, wells and streams. Standard TB culture methods were employed to isolate Non-tuberculous Mycobacteria and later 16S-23S internal transcribed spacer region Sequencing was employed to characterize NTM. RESULTS: Seven (7, 4.6%) NTM species were identified from humans with M. arupense (3, 42.9%) being the most common organism, while twenty three (23, 15.4%) NTM were identified from water with the common species being Mycobacterium gordonae (5, 21.7%). Mycobacterium avium and Mycobacterium fortuitum were both identified from human and water samples. CONCLUSION: This study has shown the isolation of NTM species from humans and water. The isolation of NTM from drinking water sources could signify a public health risk to humans.

Cutaneous mycobacteriosis in a captive Amazonian manatee Trichechus inunguis.

An adult male Amazonian manatee Trichechus inunguis under human care presented with 3 circular cutaneous lesions on the dorsal aspect of the rostrum and between the nostrils (plenum). Initially these lesions were superficial, hypopigmented, without warmth and non-painful. Microbiological cultures of skin swabs isolated Candida sp. and Pseudomonas aeruginosa, and topical treatment with antiseptic, antifungal, anti-inflammatory and antibiotic medication was instituted. This treatment strategy did not lead to any clinical improvement, and after 6 mo, the lesions progressed to a confluent abscess (5.0 × 3.0 cm) with increased temperature and obvious discomfort on palpation. An impression smear of a cutaneous biopsy was submitted for Ziehl-Neelsen staining and after detection of acid-fast bacilli, the cutaneous biopsy and a swab from the lesion were sent for histopathology, culture and sensitivity testing. After 5 d of incubation and through PCR-restriction analysis of the isolates, Mycobacterium fortuitum and M. abscessus were identified. Sensitivity testing indicated that the isolates were susceptible to ciprofloxacin and clarithromycin, and after draining of the lesion and administration of systemic antibiotic treatment, there was rapid clinical improvement. This report describes non-healing lesions in an aquatic animal and illustrates the importance of evaluating the presence of non-tuberculous mycobacteria, opportunistic pathogens which are ubiquitous in the aquatic environment, in protracted, non-responsive cases. We also highlight the importance of a correct diagnosis and treatment approach, and we review concerns that these bacteria are zoonotic agents and are frequently resistant to conventional antibiotics.

Mycobacterium fortuitum infection associated with achalasia.

The association achalasia and non tuberculous Mycobacteria lung infection is described in the literature. Most of the time Mycobacterium Fortuitum is responsible of aspiration pneumonia that didn't respond to usual antibiotic therapy. We report a new case about a 15 year-old woman with Allgrove's syndrome history. The chest imaging showed a right pulmonary condensation and the diagnosis was bacteriological. Mycobacterium Fortuitum resistant to Rifampicin, isoniazid, Pyrazinamide and ethamabutol was isolated. She was treated by cotrimoxazole, ciprofloxacin and clarithromycin for 12 months, with a good clinical, radiological and bacteriological evolution. With the purpose to prevent the relapse the patient was treated by cardiomyotomy.

Mycobacterium Fortuitum infection associated with achalasia.

The association between achalasia and no tuberculosis mycobacterial   lung infection is well described in the literature. MycobactériumFortuitum is often responsible, and the clinical's presentation   is an aspiration pneumonia resistant to usual antibiotic therapy. We report the case of a 15 year-old patient with the history of Allgrove syndrome. The chest imaging showed right lung congestion; the diagnosis was bacteriological and MycobactériumFortuitum resistant to rifampicin, isoniazid, pyrazinamide and ethambutol was isolated. The patient was treated by the association cotrimoxazole, ciprofloxacin and clarithromycin for 12 months and the clinical, radiological and bacteriological outcomes were favorable. To prevent the recurrence the patient benefited from a cardiomyotomy.

Mycobacterium fortuitum empyema associated with an indwelling pleural catheter: Case report and review of the literature.

Mycobacterium fortuitum is a rapidly growing mycobacterium (RGM) that is an uncommon cause of healthcare-associated infections. The most common infections caused by M. fortuitum include skin, soft tissue, and catheter-related infections. Although occasionally cultured from sputum samples, M. fortuitum is a rare cause of pulmonary disease. We report a case of M. fortuitum empyema associated with an infected pleural catheter and review M. fortuitum pulmonary infections.

Mycobacterium fortuitum infection after acupuncture treatment.

Actinic keratoses are cutaneous lesions that appear as the result of the proliferation of atypical keratinocytes. These lesions are considered pre-malignant and they can progress to squamous cell carcinoma. Ingenol mebutate has been approved as an effective treatment for AK on the face and trunk. We studied the local skin reactions to this therapy. Data about local skin reactions were collected in a series of 5 patients with photographic documentation, a visual analog scale, and a ranking of satisfaction of the patient. Moderate to severe reactions were reported in most of patients, but only one stopped treatment early. The short duration of treatment contributes to high adherence to the therapy.

Utility of the MALDI-TOF MS method to identify nontuberculous mycobacteria.

In comparison to the conventional real-time polymerase chain reaction method (PCR method) or the DNA-DNA hybridization method (DDH method), the utility of NTM identification by the matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) method has seldom been reported. In this study, 75 clinical NTM isolates from our hospital between April 2013 and July 2014 were identified and analyzed using PCR, DDH, and MALDI-TOF MS methods, and the results for the MALDI-TOF MS method were compared with the others. Identification at the species level was in agreement for 71 (94.5%) of the 75 isolates. For further details, identification was possible for 23 (95.8%) of 24 Mycobacterium avium, 11 (100%) of 11 Mycobacterium intracellulare, and 1 (50%) of 2 isolates mixed with M. avium and M. intracellulare. Mycobacterium ksansasii, Mycobacterium abscessus, Mycobacterium fortuitum, Mycobacterium gordonae, and Mycobacterium chelonae identified by DDH method were same result by MALDI-TOF MS. Additionally, Mycobacterium mucogenicum, which could not be identified by the DDH method, was identified by the MALDI-TOF MS method. However, two isolates identified as Mycobacterium terrae by DDH method could not be identified by the MALDI-TOF MS method and were determined to be Mycobacterium arupense by 16S ribosomal RNA (rRNA) sequence analysis. The present findings show that, for rare bacterial species, identification is sometimes not possible, but, in most cases, the results of identification by the MALDI-TOF MS method have a high concordance rate with the results of the PCR and DDH methods.

Atypical Mycobacterial Infection Following Upper Eyelid Blepharoplasty.

Atypical mycobacterial infection is a rare complication following periocular surgery. The majority of previously reported cases are following dacryocystorhinostomy or lower eyelid blepharoplasty. To the authors' knowledge, there is only 1 reported culture-proven case of atypical mycobacterial infection following upper eyelid blepharoplasty. The authors describe the first known case of Mycobacterium fortuitum infection after upper eyelid blepharoplasty successfully treated with oral doxycycline.

[Frequency and clinical relevance of rapidly growing mycobacterium isolated from respiratory samples].

OBJECTIVE: To assess the frequency and clinical relevance of rapidly growing mycobacterium (RGM) isolates in a tuberculosis referral center in Beijing, China. METHODS: All isolates were identified by using targeted gene sequencing. RESULTS of species identification for 228 nontuberculous Mycobacterium (NTM) isolates from respiratory samples were analyzed, and available medical files of patients from whom NTM were isolated were reviewed retrospectively. Diagnostic criteria for RGM pulmonary disease issued by the American Thoracic Society (ATS) were used to determine clinical relevance. RESULTS: Isolates of Mycobacterium abscessus (M.abscessus) and Mycobacterium fortuitum (M.fortuitum) accounted for 28.9% (66 isolates) and 8.8% (20 isolates)of NTM isolates, respectively. Sixty-six M. abscessus isolates from 32 patients had evaluable medical files, including 28 cases diagnosed as definite M. abscessus lung disease, and 4 as probable M. abscessus lung disease. Eight M. fortuitum isolates from 8 cases had evaluable medical files, and all of them were diagnosed as unlikely lung disease. Mycobacteria Growth Indicator Tube (MGIT) was more effective to diagnose M. abscessus lung disease, as compared with Lowestein-Jensen medium (23/24 vs 18/28). CONCLUSIONS: RGM is a common NTM in our institute. M. abscessus is mostly associated with RGM lung disease, but M. fortuitum is not.

Mycobacterium fortuitum lipoid pneumonia in a dog.

A 1-year old female spayed German Shepherd dog was evaluated for acute onset of dyspnea. Pyogranulomatous inflammation and green globoid structures were present on aspirates of the affected lung. Impression smears and histopathology confirmed pyogranulomatous pneumonia, with large amounts of lipid corresponding to the green structures noted cytologically, and identified poorly staining bacterial rods within lipid vacuoles. Special stains confirmed the presence of acid-fast bacterial rods, and polymerase chain reaction and DNA sequencing identified the organism as Mycobacterium fortuitum. M. fortuitum pneumonia is well described in humans and has previously been reported in 4 dogs and 1 cat. Lipid was a prominent cytologic and histologic feature, as is often described in humans and in the single feline case report. Additionally, this case highlights the variable cytologic appearance of lipid, as well as Mycobacterium spp, which are classically nonstaining with Wright-Giemsa.

Heterogeneity of clinical and environmental isolates of Mycobacterium fortuitum using repetitive element sequence-based PCR: municipal water an unlikely source of community-acquired infections.

M. fortuitum is a rapidly growing mycobacterium associated with community-acquired and nosocomial wound, soft tissue, and pulmonary infections. It has been postulated that water has been the source of infection especially in the hospital setting. The aim of this study was to determine if municipal water may be the source of community-acquired or nosocomial infections in the Brisbane area. Between 2007 and 2009, 20 strains of M. fortuitum were recovered from municipal water and 53 patients' isolates were submitted to the reference laboratory. A wide variation in strain types was identified using repetitive element sequence-based PCR, with 13 clusters of ⩾2 indistinguishable isolates, and 28 patterns consisting of individual isolates. The clusters could be grouped into seven similar groups (>95% similarity). Municipal water and clinical isolates collected during the same time period and from the same geographical area consisted of different strain types, making municipal water an unlikely source of sporadic human infection.

Mycobacterium fortuitum infection arising in a new tattoo.

We report an uncommon case of a cutaneous infection with Mycobacterium fortuitum arising in a new tattoo. A 29-year-old man presented with a several month history of a non-pruritic papular eruption within a tattoo; the papules developed 1-to-2 weeks after the tattoo procedure. He denied similar symptoms with previous tattoos. He had been treated unsuccessfully with cephalexin. Histopathologic examination revealed perifollicular chronic and granulomatous inflammation, consistent with chronic folliculitis. Acid-fast bacilli culture identified Mycobacterium fortuitum complex. The patient was treated with a 2-month course of oral trimethoprim-sulfamethoxazole (160mg/800mg twice daily) and ciprofloxacin (250 mg twice daily), with clinical improvement at follow up after three weeks of the antibiotic regimen. Rapidly growing mycobacteria have emerged as a cause of tattoo-associated cutaneous infection in recent years. Diagnosis and treatment can be difficult without clinical suspicion. M. fortuitum and other rapidly growing mycobacteria should be considered in the differential diagnosis of tattoo-associated dermatologic complications.

Nontuberculous mycobacteria in freshwater fish and fish products intended for human consumption.

Nontuberculous mycobacteria (NTM) are potentially pathogenic agents commonly found in natural ecosystems, while food is considered to be another source of NTM for humans. We investigated a total of 92 tissue samples of freshwater fish and fish products: fish directly obtained from ponds (n=25), retail fresh (n=23) and frozen fish (n=23) and smoked fish products (n=21). Culture examination for the presence of mycobacteria was positive in 11 (11.9%) from all the examined samples. The 15 obtained isolates were identified as Mycobacterium fortuitum (n=5), M. immunogenum (n=2), M. phocaicum/ mucogenicum (n=1), M. neoaurum (n=2), M. peregrinum (n=2), M. porcinum (n=1) and M. senegalense/houstonense/conceptionense (n=2). NTM DNA was found in one (4.0%) sample of fresh fish from ponds and in 60.9% and 91.3% of retail fresh and frozen fish, respectively. None of the smoked fish products contained NTM DNA. The results of our study suggest that freshwater fish and fish products, especially retail frozen fish, might be a reservoir of NTM for humans, and proper handling and treatment before consumption of such products is recommended.

[Comparative evaluation of acid-fast staining for the detection of Mycobacterium fortuitum--clinical performance of fluorescent and Ziehl-Neelsen staining].

OBJECTIVE: Fluorescent staining is of paramount importance, not only for confirming the presence of mycobacteria in a given specimen but also for providing an estimated growth quantification. In this study, for rapidly growing Mycobacterium fortuitum, we evaluated the effectiveness of a rapid fluorescent staining method employing auramine-rhodamine (AR) fluorescent stain and acridine-orange (AO) fluorescent stain compared to that of the standard Ziehl-Neelsen (ZN) stain currently in use in our laboratory. METHOD: We evaluated the acid-fast nature of M. fortuitum strain ATCC6841 and 42 clinical isolates from each patient diagnosed at NHO Kinki-chuo Chest Medical Center. These isolates were preliminarily identified as M. fortuitum using DNA-DNA hybridization (DDH Mycobacteria; Kyokuto Pharmaceutical, Tokyo, Japan). These isolates were further identified by comparative sequence analysis of the ITS regions and the partial 16S rRNA gene. RESULTS: A total of 26 M. fortuitum strains (61.9%) demonstrated the lack of an acid-fast nature by AR staining, and slightly fewer demonstrated the same by AO staining. Sequence analysis of these 42 clinical isolates led to the identification of 35 M. fortuitum subsp. acetamidolyticum isolates (83.3%) and 7 closely M. fortuitum isolates. DISCUSSION: This work reported the loss of the acid-fast nature of specific M. fortuitum strains. It is likely that both the specific cell envelope of M. fortuitum and the staining mechanics could have been responsible for the loss of the acid-fast nature since the 2 different fluorescent stains yielded the same results. M. fortuitum is a mycobacterium species that does not stain with the commonly used fluorescence microscopy technique. Therefore, we suggested the use of an identification scheme for these organisms that employs ZN staining and the study of cultural characteristics (growth rate, temperature, and pigment production).