Mediastinal tissue friability-An unreported complication from Mycobacterium chimaera infection post-cardiac surgery.

Mycobacterium chimaera can cause disseminated infection following cardiac surgery with cardiopulmonary bypass and contaminated heater-cooler devices. We discuss a 41-year-old man with a disseminated M. chimaera infection following surgery for a type A aortic dissection. His presentation included cachexia and dorsalgia with a work-up revealing vertebral osteomyelitis with an epidural abscess, bone marrow, and pulmonary infiltration, and fluid collection around his aortic graft. He received 1 month of antibiotics before the explantation of infected foreign material, mediastinal debridement, and aortic reconstruction. Complications included septic shock, respiratory and renal failure, mediastinitis, and four distal aortic anastomotic dehiscences from friable tissue and persistent infection.

Pulmonary Mycobacterium heckeshornense infection in a healthy woman.

Pulmonary infection due to Mycobacterium heckeshornense (M. heckeshornense) in healthy adults without underlying diseases is very rare and optimal treatments have not yet been established. A 39-year-old woman was admitted to our hospital for further examinations following the identification of a pulmonary cavitary nodule. Acid-fast bacilli were cultured from specimens obtained by bronchofiberscopy, and identified with M. heckeshornense using nucleotide sequencing. Antimycobacterial chemotherapy was effective temporarily, while the nodular lesion subsequently worsened. The patient underwent lobectomy and has not relapsed thus far. A lung specimen showed marked granulomatous inflammation with extensive caseous necrosis and the preservation of some parts of alveolar septa within caseous necrosis, indicating an exudative process and resistance to chemotherapy. M. heckeshornense is strongly pathogenic and switching to surgical intervention needs to be considered when chemotherapy is insufficient.

Ruptured Mycotic Aortic Aneurysm after Bacille Calmette-Guerin Therapy.

To report a case of a ruptured mycotic abdominal aortic aneurysm (MAA) after intravesical Bacille Calmette-Guerin (BCG) therapy because of bladder carcinoma. A 57-year-old male patient was admitted to our hospital for follow-up computed tomography 14 months after transurethral resection of a papillary carcinoma of the bladder and intravesical BCG therapy. The CT scan revealed a ruptured MAA aneurysm and the patient underwent an endovascular repair with an aorto-bi-iliac stent graft. A ruptured MAA is a rare but lethal complication after BCG instillation therapy. The standard therapy is the open reconstruction but according to the literature an endovascular therapy in combination with long-term antibiotics should be considered as a bridging or a definite solution.

Acute mycobacterial flexor tenosynovitis following accidental bacillus calmette-guérin inoculation in a health care worker: case report.

Solutions containing bacillus Calmette-Guérin (BCG), a live attenuated form of Mycobacterium bovis or Mycobacterium tuberculosis, commonly are injected intravesically to treat tumors of the urinary bladder. We report a case of acute mycobacterial flexor tenosynovitis in a health care worker who inadvertently inoculated her finger via needlestick while preparing BCG solution for intravesicular administration. She was treated successfully with immediate operative intervention followed by 6 months of antimycobacterial antibiotics. Of 3 previous reports of hand infections following self-inoculation with BCG solutions, this case is unique owing to rapid onset of acute mycobacterial flexor tenosynovitis and positive intraoperative mycobacterial cultures. Needlesticks with BCG-containing solutions, especially into the flexor tendon sheath, should be treated with timely surgical debridement and appropriate antimycobacterial management.

Feline cutaneous mycobacteriosis: a review of clinical, pathological and molecular characterization of one case of Mycobacterium microti skin infection and nine cases of feline leprosy syndrome from France and New Caledonia.

BACKGROUND: Ten cats with skin lesions characteristic of cutaneous mycobacteriosis were included in this retrospective clinical, pathological and molecular study. HYPOTHESIS/OBJECTIVES: The aim of this study was to identify the causative agent and to compare the clinicopathological features of these cases with those of previous studies. METHODS: Cats were from the south east of France (eight cases), central France (one case) and New Caledonia (South Pacific; one case). Criteria for inclusion were histological evidence of granulomatous dermatitis and/or panniculitis, with acid-fast bacilli within macrophages or extracellularly in regions of tissue necrosis. PCR targeting the 16S-23S internal transcribed spacer region and sequence analysis were performed using DNA extracted from formalin-fixed, paraffin-embedded tissues from all cases. RESULTS: All cats were presented with a history of alopecic to ulcerated nodules. Most cases had limited disease, with one to few nodules, while others (three cats) showed a more aggressive clinical course. Lesions from eight cats yielded a sequence consistent with Mycobacterium lepraemurium, while Mycobacterium microti was identified postmortem from the cutaneous lesion in the cat originating from central France and euthanized for its debilitating condition. No PCR product could be amplified from the remaining specimen. CONCLUSIONS AND CLINICAL IMPORTANCE: Based on this geographically restricted case series, feline leprosy in southern France is most likely to be caused by M. lepraemurium and presents as a generally self-limiting disease. Molecular testing is essential to assess zoonotic potential, because M. microti-induced cutaneous mycobacteriosis can resemble feline leprosy syndrome.

Surgical treatment for nontuberculous mycobacterial (NTM) cervicofacial lymphadenitis in children.

PURPOSE: To compare surgical excision with surgical curettage in the treatment of nontuberculous mycobacterial (NMT) cervicofacial lymphadenitis in children. PATIENTS AND METHODS: Fifty children, 22 boys and 28 girls, with a PCR- or cultured-confirmed diagnosis of cervicofacial NTM infection were included in the study. Twenty-five children were randomized to surgical excision of the involved lymph nodes, and 25 children to surgical curettage. RESULTS: The median age of the children was 36 months (range, 14-120 months). All children had a red, fluctuating lymphadenitis, and there were no marked differences between the treatment groups with respect to mean duration of lymph node swelling before presentation, location, and the size of the lymph node swelling. Most (84%) of the involved nodes were located in the submandibular region and 6% were located in the preauricular region. Multiple locations (both preauricular and submandibular) were observed in the remaining 10%. Mycobacterium avium (74%) and Mycobacterium haemophilum (22%) were the predominant NTM species. Mean wound healing time for the excision group was 3.6 ± 1.2 weeks versus 11.4 ± 5.1 weeks for the curettage group (P ≤ .05). Postoperative transient marginal mandibular nerve weakness of the facial nerve was seen in 4 patients (16%) of the excision group. In all these patients the function of the nerve returned to normal within 12 weeks. No facial nerve problems were observed in the curettage group. Postoperative infections were not observed. CONCLUSIONS: Surgical excision leads to a quick resolution of NTM cervicofacial lymphadenitis. Curettage leads to delayed healing but might be considered as an alternative if excision of the necrotized lymph nodes is technically difficult in cases of adherence of the facial nerve branche.

Clinical and microbiologic outcomes in patients receiving treatment for Mycobacterium abscessus pulmonary disease.

BACKGROUND: Mycobacterium abscessus can produce a chronic pulmonary infection for which little is known regarding optimal treatment and long-term outcomes. METHODS: We performed a retrospective observational study (2001-2008) including all patients who met American Thoracic Society criteria for M. abscessus pulmonary disease. Our aim was the evaluation of clinical and microbiologic outcomes in patients treated with combined antibiotic and surgical therapy, compared with antibiotic therapy alone. RESULTS: A total of 107 patients were included in the analysis. Patients were predominantly female (83%) and never-smokers (60%), with a mean age of 60 years. Fifty-nine (55%) of 107 patients had coexistent or previous history of Mycobacterium avium complex pulmonary infection. High-resolution chest CT showed bronchiectasis and nodular opacities in 98% of patients and cavities in 44%. Sixty-nine (46 medical, 23 surgical) patients were followed up for a mean duration of 34 months (standard deviation, 21.1 months, range, 2-82 months). Cough, sputum production, and fatigue remained stable, improved, or resolved in 80%, 69%, and 59% of patients, respectively. Twenty (29%) of 69 patients remained culture positive, 16 (23%) converted but experienced relapse, 33 (48%) converted to negative and did not experience relapse, and 17 (16%) died during the study period. There were significantly more surgical patients than medical patients whose culture converted and remained negative for at least 1 year (57% vs 28%; P = .022). CONCLUSIONS: Patients with M. abscessus pulmonary disease who are treated with multidrug antibiotic therapy and surgery or antibiotic therapy alone had similar clinical outcomes. However, surgical resection, in addition to antibiotics, may offer a prolonged microbiologic response.

Nerve dysfunction following surgical treatment of cervical non-tuberculous mycobacterial lymphadenitis in children.

AIM: To present our experience of nerve dysfunction following surgical treatment among 126 children with microbiologically verified non-tuberculous mycobacterial (NTM) lymphadenitis. METHODS: We retrieved data from medical records, and a questionnaire with an invitation to a clinical follow-up was returned by 88 families. RESULTS: The time from onset of symptoms to diagnosis was more than 3 months in 24% of subjects. Mycobacterium avium complex was isolated from 105, Mycobacterium malmoense from 12 and Mycobacterium scrofulaceum from one cervical lymph node. A total of 89% of the children underwent surgery and were examined in particular with regard to cranial motor nerve functions. Major persisting nerve dysfunction occurred in 3/51 (6%) children who underwent radical surgery, and minor dysfunction in seven (14%). In nine children, the marginal mandibular branch of the facial nerve was affected, and the accessory nerve was affected in one child. There were no neurological signs in 25 children treated with incision and drainage alone or in 12 followed with observation alone. Healing took >6 months in 2/76 (3%) surgically treated and 3/12 (25%) non-surgically treated children. CONCLUSION: Considering the risk of nerve dysfunction following extirpation, incision with drainage and observation alone should both be included among the management options for cervical NTM lymphadenitis in children.

[Lymphadenitis caused by nontuberculous mycobacteriae]. / Lasten atyyppiset mykobakteeri-infektiot lisääntyvät.

Lymphadenitis caused by nontuberculous mycobacteriae has been increasingly seen in Finland since the cessation of universal BCG vaccination in 2006. An otherwise healthy child develops a slowly growing unilateral mass in the cervicofacial region. Without treatment, the lymphadenitis suppurates and forms a draining sinus, which dries after some weeks or months, leaving a scar. Surgical excision is curative treatment but cannot always be performed because of risk to the facial nerve or need of extensive surgery. In these cases, observation without antimicrobial treatment is usually recommended. The parents need professional information and support.

[Nontuberculous mycobacterial lymphadenitis]. / Niet-tuberculeuze mycobacteriële lymfadenitis.

A 4-year-old girl was referred with a chronically enlarged left cervical lymphadenitis of the neck. This swelling appeared to be caused by a Mycobacterium avium infection. Mycobacterium avium belongs to the group of nontuberculous mycobacteria. These micro-organisms can cause a cervicofacial lymphadenitis in children in the head and neck region. The children are healthy, and are seen to have a submandibular or preauricular swelling. Early recognition of the disease is important because it gives the best chance that treatment will result in a successful outcome.

Femoropopliteal prosthetic bypass graft infection due to Mycobacterium abscessus localized by FDG-PET/CT scan.

A patient with postvascular graft placement presented with bacteremia but no localizing symptoms. Our standard infected graft workup of computed tomography (CT) scan, ultrasound scan, magnetic resonance imaging (MRI) scan, and additional laboratory tests did not localize the infection source. Nuclear medicine had three options including white blood cell (WBC) scan, gallium scan, and the fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET)/CT scan. FDG-PET/CT imaging alone demonstrated the location. We present an unusual case of Mycobacterium abscessus in a vascular graft not localized with CT scan, ultrasound scan, or MRI scan and could only be localized with FDG-PET/CT scan.

[Severe course of a rare non-tuberculous Mycobacteriosis (M. haemophilum) of the hand - case report and strategic comments]. / Schwerer Verlauf einer seltenen atypischen Mykobakteriose (M. haemophilum) an der Hand - Fallbericht und strategische Anmerkungen.

INTRODUCTION: Mycobacterium haemophilum belongs to the group of atypical mycobacteria and is rarely reported as a cause of upper extremity and hand infections. It is of low virulence. The bacterium seems to be ubiquitous. Sources and mechanism of infection are poorly defined. CASE REPORT: A 48-year-old female patient was admitted with chronic flexor tendon synovitis of the left palm and distal forearm site. Three debridements were carried out and wound swabs were taken. No proof of bacterial colonisation was found. Histologically a granulomatous infection with Langerhans cells was revealed. Effectively calculated monotherapy with ciprofloxacin was begun. Six weeks postoperatively Mycobacterium haemophilum was cultivated in a colaboration with the National Reference Centre for Mycobacteria in Borstel. Medication was changed to triple therapy with clarithromycin, ethambutol and rifabutin. The patient could carry out her daytime job three months postoperatively. One year after first admission functional impairment needed to be treated by scar excision and radical flexor tendon tendolysis. The palmar defect was resurfaced by using a transmetacarpal DMCA 2 flap at the same time. An almost full range of motion was achieved with intensive hand and physiotherapy after a total treatment period of 15 months. DISCUSSION: Patients with upper extremity infections caused by atypical Mycobacteria need qualified hand-surgical care. The decision about need and kind of medicamentous treatment is based on germ differentiation and should be made in cooperation with the National Reference Centre for Mycobacteria in Borstel. To shorten the diagnostic gap between first admission and detection of Mycobacteria in hand infections with a non-typical course of disease we suggest a standardised approach.

Medical Tourism and Postoperative Infections: A Systematic Literature Review of Causative Organisms and Empiric Treatment.

BACKGROUND: Medical tourism has become increasingly globalized as individuals travel abroad to receive medical care. Cosmetic patients in particular are more likely to seek surgery abroad to defray costs. Unfortunately, not all procedures performed abroad adhere to strict hygienic regulations, and bacterial flora vary. As a result, it is not uncommon for consumers to return home with difficult-to-treat postoperative infections. METHODS: A systematic literature review of PubMed, Ovid, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases was performed to assess the microbiology patterns and medical management of patients with postoperative infections after undergoing elective surgery abroad. RESULTS: Forty-two cases of postoperative infections were reported among patients who underwent elective surgery abroad. Most cases were reported from the Dominican Republic, and the most common elective procedures were abdominoplasty, mastopexy, and liposuction. Rapidly growing mycobacteria such as Mycobacterium abscessus, Mycobacterium fortuitum, and Mycobacterium chelonae were among the most common causes of postoperative infection, with M. abscessus involving 74 percent of cases. Most cases were treated with surgical débridement and a combination of antibiotics. Clarithromycin, amikacin, and moxifloxacin were the most common drugs used for long-term treatment. CONCLUSIONS: When encountering a patient with a history of medical tourism and treatment-refractory infection, rapidly growing mycobacteria must be considered. To increase the likelihood of yielding a diagnostic organism, multiple acid-fast bacilli cultures from fluid and débridement content should be performed. There has been reported success in treating rapidly growing mycobacterial infections with a combination of antibiotics including clarithromycin, amikacin, and moxifloxacin.

Infections Caused by Rapidly Growing Mycobacteria spp in Children and Adolescents With Cancer.

BACKGROUND: Rapidly growing mycobacteria (RGM) infections in pediatric oncology patients have not been completely characterized. METHODS: We reviewed medical records of oncology patients at St. Jude Children's Research Hospital (St. Jude) from 1990 to 2010 with RGM infections and summarized the results of previously published cases. RESULTS: Twenty-five St. Jude patients had 27 episodes of infection. Approximately half of the cases occurred in patients with hematological malignancies and in males; infections were more common in white patients. Most patients were not neutropenic or lymphopenic. The most common causative species were Mycobacterium chelonae, Mycobacterium abscessus, and Mycobacterium fortuitum. Most isolates were susceptible to amikacin and clarithromycin; all were susceptible to at least 1 of these. Treatment regimens varied considerably, particularly with respect to the duration of antimicrobial chemotherapy. Two St. Jude patients died; both had pulmonary infections. The literature search identified an additional 58 cases of infection. Localized catheter-associated infections were more common than bloodstream infections in the current series than in previous reports, and outbreaks were not recognized. Otherwise, the demographic and clinical characteristics of patients were similar. CONCLUSIONS: Localized catheter-associated infections were most common in this largest reported single center experience reported to date. Pulmonary infection is uncommon in children but, as in adults, has a high mortality rate. Relatively short-term antimicrobial treatment and surgical debridement of infected tissue, if present, may be as effective for catheter-associated infections as prolonged antimicrobial use and may reduce adverse drug effects in these patients, who are vulnerable to drug-drug interactions and toxicity.

Cervical lymphadenitis caused by Mycobacterium lentiflavum.

We report a case of human infection caused by Mycobacterium lentiflavum and review the literature for infections caused by this bacterium. The patient was a 19-month-old boy with involvement of a cervical lymph node. Surgical removal of the lymphadenopathy was both diagnostic and curative.

The surgical management of atypical mycobacterial soft-tissue infections.

Group IV atypical mycobacterial infections, especially Mycobacterium fortuitum and M. chelonei, are being reported with increased frequency. We report our experience with five cases of soft-tissue infection with these acid-fast bacilli. Often these infections are chronic, with formation of abscesses and multiple fistulas. Optimal surgical treatment often requires wide excision of all diseased tissue followed by delayed closure. Presentation, optimal surgical management, and antibiotic therapy are discussed.

Penile mass caused by the newly described organism Mycobacterium celatum.

We report a penile infection in a man with the acquired immunodeficiency syndrome caused by a newly described infectious organism, Mycobacterium celatum. Mycobacterium tuberculosis is the only mycobacterial species previously reported to cause infection in the penis. This is only the third documented human infection with M celatum, and the first to involve the genitourinary system.

Mycobacterium chelonei and orbital granuloma after tear duct probing.

A 75-year-old woman developed an orbital mass after lacrimal duct probing. Acid-fast bacteria were observed on special stains and Mycobacterium chelonei, subspecies abscessus was isolated. The patient had been taking systemic corticosteroids.