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INFECTIOUS DISEASE

Mucocutaneous Inflammatory Pseudotumours in

Simultaneous Mycobacterium avium subsp. avium
and Mycobacterium avium subsp. hominissuis
Infection in a Cat

cic†, M. Butorovic-Dujmovic‡, I. Ra
cic†, D. Huber*,
A. Beck*, S. Spi


Cvetnic†
A. Gudan Kurilj*, R. Beck† and Z.
* Department of Veterinary Pathology, Veterinary Faculty, University of Zagreb, Ulica Vjekoslava Heinzela 55, † Department
for Bacteriology and Parasitology, Croatian Veterinary Institute, Zagreb, Savska cesta 143, Zagreb and ‡ Veterinary Practice
Pharos, Stari Grad, Island of Hvar, Croatia

Summary
Mycobacterial spindle cell ‘pseudotumour’ has been described only once in cats. This unique proliferation of
spindle-shaped histiocytes containing Mycobacterium avium is associated with extensive subcutaneous lesions. We
report mycobacterial pseudotumour with invasion of muscular and subcutaneous tissues in a 1-year-old female
domestic longhair cat. Lesions involved the facial muscles and nasal cavity, making surgical excision impos-
sible. Necropsy examination revealed additional nodules in the subcutis and muscles of the trunk and subman-
dibular lymph nodes. Genotyping of organisms within these lesions revealed simultaneous infection with
Mycobacterium avium subsp. avium and Mycobacterium avium subsp. hominissuis. The microscopical appearance of
the granulomas was identical, regardless of the strain of bacterium or anatomical location.

Ó 2015 Elsevier Ltd. All rights reserved.

Keywords: cat; inflammatory pseudotumour; Mycobacterium avium subspecies avium; Mycobacterium avium subspecies hominissuis

Opportunistic bacteria from the Mycobacterium avium
complex (MAC) are a rare cause of feline systemic
and cutaneous inflammation (Miller et al., 1999; Lee
Gross et al., 2010; Klang et al., 2014). As a cause of
focal or multifocal cutaneous and/or subcutaneous
infection, MAC members can initiate three
morphological forms of inflammatory response in
infected cats: granulomatous, pyogranulomatous or
spindle cell granulomas (Lee Gross et al., 2010). In hu-
man medicine, proliferation of spindle-shaped histio-
cytes containing acid-fast mycobacteria occurs as an
inflammatory response to both tuberculous and non-
tuberculous mycobacteria (Ilyas et al., 2011). These
benign lesions are referred to as mycobacterial-
Correspondence to: A. Beck (e-mail: abeck@vef.hr).
0021-9975/$ - see front matter
http://dx.doi.org/10.1016/j.jcpa.2015.07.001
induced inflammatory ‘pseudotumour’ (IPT) and
are described rarely. Human cases of mycobacterial
induced IPT are reported to involve the skin, lymph
nodes, nasal cavity, lungs, spleen and brain of immu-
nocompromised and immunocompetent patients
(Ilyas et al., 2011; Philip et al., 2012).
In veterinary medicine, only one case of MAC-
associated IPT has been described. This was an
immunocompetent cat with locally invasive prolifera-
tion of spindle-shaped histiocytic cells within the cuta-
neous and subcutaneous tissue and regional lymph
node of the left hind foot (Miller et al., 1999).
Spindle-shaped histiocyte proliferation associated
with acid-fast mycobacteria is challenging to diagnose
because, if the lesions are not subjected to acid fast
staining, they can be misdiagnosed as malignant
spindle-cell neoplasia with mild cytological and
Ó 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Beck A, et al., Mucocutaneous Inflammatory Pseudotumours in Simultaneous Mycobacterium avium subsp. avium
and Mycobacterium avium subsp. hominissuis..., Journal of Comparative Pathology (2015), http://dx.doi.org/10.1016/j.jcpa.2015.07.001
2 A. Beck et al.
nuclear atypia (Miller et al., 1999; Lee Gross et al.,
2010; Ilyas et al., 2011; Philip et al., 2012). In this
report we describe the second case of feline MAC-
associated IPT.
A 1-year-old female domestic longhair cat from a
stray cat colony at the seaport Hvar, Island of
Hvar, Croatia, was presented to a veterinary practice.
The cat had ulcerated plaques on the skin and mucosa
of the upper lip, excessive salivation and respiratory
distress. Examination established the presence of
bilateral subcutaneous masses over the facial region
and also occupying the maxillary and paranasal si-
nuses. There was marked bilateral enlargement of
the submandibular lymph nodes. The cat had two
additional well-demarcated, ulcerated skin nodules
on the paw of the left forelimb and on the left shoul-
der. All the masses and plaques were firm and non-
painful. The cat was afebrile and obese. Serological
tests for feline immunodeficiency virus and feline
leukaemia virus were negative. Giemsa-stained im-
prints of lip ulcers revealed numerous clear rod-
shaped structures (2.42e3.25 mm) in the cytoplasm
of occasional multinucleated giant cells and spindle-
shaped macrophages and free within a protein-rich
background. The clinical and cytological findings
suggested mucocutaneous granulomatous mycobac-
teriosis. The cat was humanely destroyed because sur-
gical excision of the facial lesions was not feasible.
Necropsy examination revealed bilaterally sym-
metrical, pink, firm, raised subcutaneous facial nod-
ules (Fig. 1), with aggressive infiltration of the
superficial maxillary and facial muscles and the nasal
cavity and maxillary sinuses up to the lachrymal fossa.
Enlarged submandibular lymph nodes had intact
capsules, but had a multilobulated appearance due
Fig. 1. Bilateral facial inflammatory pseudotumours. Head with
removed skin and mandible, transverse section through
the nasal cavity. Maxillary muscles are replaced with coa-
lescing pink to light-brown nodules.
Please cite this article in press as: Beck A, et al., Mucocutaneous Inflammatory Pseudotumours in Simultaneous Mycobacterium avium subsp. avium
and Mycobacterium avium subsp. hominissuis..., Journal of Comparative Pathology (2015), http://dx.doi.org/10.1016/j.jcpa.2015.07.001
to coalescing, firm, pink granulomas affecting 80%
of the parenchyma. Additional well-demarcated nod-
ules were also found within the panniculus at the tail
base, gluteal muscles and associated fascia. Other or-
gan or tissue involvement was not detected.
Haematoxylin and eosin (HE) and ZiehleNeelsen
(ZN) staining of sections of fixed tissue from all of le-
sions was performed. Microscopically, all of lesions
were composed of spindle-shaped or stellate histio-
cytes arranged in parallel streams, whorls or interlac-
ing bundles. These cells had moderate to high
anisokaryosis and anisocytosis with variably distinct
cell borders. They had elongated vesicular nuclei con-
taining one or two nucleoli and set in scant
eosinophilic or occasionally vacuolated, cytoplasm.
Collagenous stroma was sparse or absent. Mitotic fig-
ures were scant (0e1 mitosis per 10
400 fields). Oral
and facial lesions revealed locally infiltrative
sarcomatous-like growth affecting skeletal muscles
(Fig. 2), fasciae, connective and adipose tissues. Pe-
ripheral nerve tissue, cartilage, bones and nasal respi-
ratory epithelia were unaffected. Lesions from the
trunk and legs were well demarcated with a distinct
fibrous capsule. Small numbers of multinucleated gi-
ant cells were found, mostly within facial lesions and
lymph node granulomas. Low to moderate numbers
of neutrophils and sparse lymphocytes and plasma
cells were scattered between the spindle and stellate
histiocytes. Central necrosis was present within small
early lesions as well as within advanced and coa-
lescing proliferations. ZN staining revealed low to
moderate numbers of acid-fast bacilli, mostly free
within necrotic tissue and within spindle cells, at the
outer rim of the necrotic foci or within multinucleated
giant cells and occasionally in spindle-shaped histio-
cytes (Fig. 3).
Fig. 2. Streams of spindle-shaped histiocytic cells with facial mus-
cle cell remnants. Spindle cells are admixed with neutro-
phils, lymphocytes and plasma cells. HE.
 Mycobacterial Infection in a Cat
Fig. 3. Numerous acid-fast rods in the cytoplasm of spindle-shaped
histiocytes and a single giant cell. ZN.
For cultural and molecular identification of the
Mycobacteria, approximately 1 g of tissue from the up-
per lip, shoulder, tail base and submandibular lymph
node were frozen at 20 C. Prior to culture, confir-
mation of the presence of acid-fast bacilli was per-
formed by ZN staining of smears of the tissue
homogenate. Culture was performed by the National
Veterinary Services Laboratory on standard nutrient
media. Cultures were negative at 12 weeks. DNA was
isolated from the upper lip, shoulder, tail base and
submandibular lymph node granulomas using the
QIAcube system (Qiagen, Valencia, California,
USA). Polymerase chain reaction (PCR) for detec-
tion of the 16S rRNA gene of Mycobacterium was per-
formed (Johansen et al., 2007; Kaevska et al., 2011).
A partial fragment of 16S rDNA from all samples
was amplified and subsequently sequenced and
compared with sequences in GenBank. All four
sequences were 100% identical to sequences of
MAC members isolated from human clinical cases
and environmental sources. For identification of the
Mycobacterium strain within MAC members, a
second round of PCR was performed using primers
for detection of the insertion sequence IS1245 and
IS901(Johansen et al., 2007; Kaevska et al., 2011).
Although M. avium subsp. hominissuis and M. avium
subsp. avium are closely related, they differ in the pres-
ence of the insertion sequence IS1245 and IS901. Mul-
tiple copies of IS1245 and the absence of IS901 is
characteristic of M. avium subsp. hominissuis, while
M. avium subsp. avium typically possesses multiple
copies of IS901 and a single copy of IS1245
(Johansen et al., 2007; Kaevska et al., 2011). The
presence of M. avium subsp. avium was confirmed in
tissue samples from the upper lip and shoulder as
well as from the submandibular lymph nodes.
Please cite this article in press as: Beck A, et al., Mucocutaneous Inflammatory Pseudotumours in Simultaneous Mycobacterium avium subsp. avium
and Mycobacterium avium subsp. hominissuis..., Journal of Comparative Pathology (2015), http://dx.doi.org/10.1016/j.jcpa.2015.07.001
3
M. avium subsp. hominissuis was detected in the
sample from the tail base. Granulomatous tissue
from the submandibular lymph node harboured
both strains.
Free-ranging domestic cats have a strong hunting in-
stinct, which exposes them to different environmental
niches (Loss et al., 2013). Close contact with different
prey species, including snails, grasshoppers, lizards,
snakes, birds and rodents, increases the opportunity
for ubiquitous MAC members to enter dermal, subcu-
taneous or mucosal hunting wounds (Kaevska et al.,
2011). Wound contamination in cats increases due to
other specific behavioural patterns such as territorial
and mating fighting or the grooming urge (Lee Gross
et al., 2010; Medina et al., 2011). In the current study,
we have shown that one cat can be infected
simultaneously with two MAC strains at different
anatomical locations. These infections probably
resulted from deep cutaneous scratches and bite
wounds being repeatedly exposed to mycobacteria
from different environmental sources. Concurrent
infection with M. avium subsp. hominissuis and
M. avium subsp. avium within the same tissue was
detected only in the submandibular lymph node. The
presence of both strains in the regional lymph node is
likely a result of dendritic cells and macrophages
trafficking from superficial primary exposure sites or
following afferent vessel drainage from advanced
facial and/or oral lesions.
Recent developments in genotyping protocols have
facilitated detection of concurrent mycobacterial
infection in man and animals. Genotyping also rules
out the possibility that one strain overgrows the other
in standard culture media, as well as false-negative
culture results, as occurred in this case (Johansen
et al., 2007; Kaevska et al., 2011). Members of the
MAC are well known causes of human and animal
local and systemic mycobacteriosis (Miller et al.,
1999; Johansen et al., 2007; Lee Gross et al., 2010;
Kaevska et al., 2011; Philip et al., 2012; Klang et al.,
2014) and some have been reported to cause
granulomas dominated by spindle-shaped histiocytes
(Miller et al., 1999; Ilyas et al., 2011; Philip et al.,
2012).
M. avium subsp. hominissuis has also been recognized
as a cause of systemic and localized granulomatous
inflammation in immunocompetent and immunocom-
promised people and animals, but reported lesions
were of typical granulomatous or pyogranulomatous
type (Johansen et al., 2007; Lee Gross et al., 2010;
Kaevska et al., 2011; Klang et al., 2014). In this
study, we showed that genotyping of organisms from
single granulomas, where there are multiple lesions,
is needed to detect multiple mycobacterial strains.
This information would likely drive decisions about
4 A. Beck et al.
antimicrobial therapy of such patients. The
morphology of the granulomas was identical
regardless of strain differences or anatomical location.
The relative severity of tissue destruction in different
sites was probably connected with chronicity of the
lesion. The largest and most coalescing lesions were
detected on the face, so we presumed that these
developed first. Mycobacterial granulomatous
cheilitis and stomatitis are common findings in feline
mycobacteriosis due to higher exposure of the face to
hunting and fighting wounds (Lee Gross et al., 2010).
To our knowledge, this is the first report of facial
muscle and nasal cavity involvement by an infiltrative
spindle cell growth of mycobacterial-induced IPT in
a cat. The morphology and distribution of the spindle
cell granulomas in the present case were similar to
those in previously reported cases in a cat (Miller
et al., 1999) and in man (Ilyas et al., 2011; Philip
et al., 2012). The only differences were the low
number of multinucleated giant cells and the lack of
collagenous stroma (Miller et al., 1999; Ilyas et al.,
2011; Philip et al., 2012).
Human IPTs are described as sessile with minimal
mass effect or, alternatively, as infiltrative of sur-
rounding tissue, even causing bone destruction.
Both patterns of growth occur in cats (Miller et al.,
1999; Ilyas et al., 2011; Philip et al., 2012). In
human pathology, immunodeficiency is not crucial
for the development of IPT (Philip et al., 2012). The
occurrence of IPTs can be connected with trauma,
surgery, chronic irritation and multiple infectious
agents (Philip et al., 2012). Both cats with
mycobacterium-induced IPT were immunocompe-
tent; however, we presume that repeated trauma
and exposure of wounds to multiple infectious agents
associated with the normal lifestyle of cats are suffi-
cient for this phenomenon to develop. Both reported
cats were humanely destroyed due to the progression
of disease, so if not recognized and treated early,
mycobacterial-induced IPTs will progress to become
fatal lesions.
Acknowledgments
We thank E. Gjur
cevic for technical support and A.
Polkinghorne for proof reading the manuscript.
Please cite this article in press as: Beck A, et al., Mucocutaneous Inflammatory Pseudotumours in Simultaneous Mycobacterium avium subsp. avium
and Mycobacterium avium subsp. hominissuis..., Journal of Comparative Pathology (2015), http://dx.doi.org/10.1016/j.jcpa.2015.07.001
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½ Received,
Accepted, July 2nd, 2015 
June 1st, 2015