Letter To The Editors e421

doi: 10.1111/ajd.13576 Twenty-five patients with positive NTM cultures were

Research Letter
Dear Editors,
Cutaneous non-tuberculous mycobacterial infection in
Singapore: The ‘cubital forearm’ sign- a complication of
topical corticosteroid use
Non-tuberculous mycobacteria (NTM) are ubiquitous in
the environment, with tap water being the main reservoir
for human pathogens.1 We highlight the unifying features
in seven cases of cutaneous NTM infection involving the
cubital forearm. Patients with positive NTM cultures were
identified based on filed records of mycobacterial cultures
ordered at the National Skin Centre, Singapore between
June 2014 and June 2016. The diagnosis of NTM infection
was based on consistent clinicopathological findings, aided
by positive cultures. Clinical and microbiological data were
collected based on review of electronic medical records.
identified. Twenty-eight per cent (n = 7) of patients who
had cutaneous NTM infection had the site of involvement
being the cubital forearm (Table 1). All patients were
elderly with a mean age of 81 years. The mean duration of
disease prior to presentation was 1.7 months. In contrast, of
the 18 patients with NTM infection not involving the cubital
fossa, the mean age of presentation was 58 years (P < 0.01).
All the patients with cubital forearm involvement did not
recall any penetrating trauma or exposures that could pre-
dispose to NTM infection. In comparison with the patients
with NTM involving other sites, 16 out of 18 patients
recalled previous trauma or exposures.
All the patients with cubital fossa NTM infection had sig-
nificant cutaneous atrophy. Six out of 7 had applied topical
corticosteroids to the affected areas for pre-existing skin
diseases such as psoriasis, eczema and immunobullous
diseases. In contrast, none of the patients who had NTM
infection at other sites applied topical corticosteroids.
A unilateral erythematous plaque mimicking cellulitis
was seen in 6 out of 7 patients who had cubital forearm

Table 1 Clinical characteristics of patients with NTM of the cubital forearm

Predisposing factors Duration

Case Age, of Mycobacteria
No. Sex Comorbidities Systemic Local disease Clinical presentation Histology isolated Antibiotic, duration Outcome

1 70, F Hypertension IFN-ɣ TCS 5 days Unilateral Suppurative M. abscessus Cefoxitin + amikacin + CR
Hyperlipidaemia antibodies application erythematous granulomas clarithromycin
Psoriasis Age Cutaneous plaque with with 4 months ? clarithromycin
Rheumatoid atrophy sparing of stellate inflammation + clofazimine 5 months
arthritis pseudoscars
2 90, F Hypertension, Age Cutaneous 2 weeks Unilateral Nodular M. abscessus Amikacin + cefoxitin + D
Osteoporosis atrophy erythematous granulomas clarithromycin 7 weeks
plaque with
sparing of stellate
pseudoscars
3 75, F Bullous Age TCS 5 months Unilateral ill defined Suppurative M. abscessus Azithromycin 3 months CR
pemphigoid Prednisolone application erythematous granulomas
9mg/day Cutaneous plaque with
atrophy inflammation
4 93, F Hypertension Age TCS 3 months Unilateral indurated Suppurative M. abscessus Progressed on clarithromycin CR
Hyperlipidaemia DM application plaque granulomas for 2 weeks ? Incision and
DM Cutaneous with drainage
Dermatitis atrophy inflammation
herpetiformis
5 72, Hypertension Age TCS 2 months Unilateral Non-necrotising M. haemophilum Minocycline 6 months with CR
M Hyperlipidaemia application erythematous granulomas relapse ? clarithromycin +
Psoriasis Cutaneous plaque with with ciprofloxacin for 9 months
atrophy papules at the rim inflammation
6 90, Hypertension Age TCS 2 weeks Unilateral scaly Suppurative M. marinum Minocycline 6 months CR
M Hyperlipidaemia DM application erythematous granulomas
IHD Cutaneous plaque with
DM atrophy inflammation
Eczema
7 77, Hypertension Age TCS 3 weeks Well-defined Non-necrotising M. haemophilum Cirprofloxacin + CR
M Hyperlipidaemia application erythematous granulomas clarithromycin
IHD Cutaneous plaque with with 5 months
Asthma atrophy pustules inflammation
Eczema

CR, complete resolution; D, death; DM, diabetes mellitus; IFN- ɣ, interferon-gamma; IHD, ischaemic heart disease; TCS, topical corticos-
teroids.

Conflicts of Interest: The authors have no conflicts of interest

to declare.
Sources of Funding: This article has no funding source.

© 2021 The Australasian College of Dermatologists

e422 Letter To The Editors

(a) (a)

(b)

Figure 1 Cutaneous NTM infection mimicking bacterial cellulitis.

(a) In Case 1, there was a well-demarcated erythematous plaque (b)
extending from right mid upper arm to metacarpophalangeal
joints, with sparing of the stellate pseudoscars. (b) Erythematous
scaly plaque over the left forearm extending to the cubital fossa,
occurring on a background of cutaneous atrophy and senile pur-
pura in Case 6. For Cases 1 and 2, the plaques were warm on pal-
pation with sparing of the stellate pseudoscars of the forearms

involvement (Fig. 1). Unlike in cellulitis, the plaques were

minimally tender. Case 4 was the only case that presented
with an abscess. Five of the six patients were initially trea-
ted for bacterial cellulitis or abscess.
All patients had positive NTM cultures and a granuloma-
tous infiltrate on histological examination (Fig. 2).
Mycobacterium abscessus (n = 4), Mycobacterium haemo-
philum (n = 2) and Mycobacterium marinum (n = 1) were
isolated. In Cases 1, 2 and 3, polymerase chain reaction
(PCR) for NTM was positive from skin tissue and further
16s RNA sequencing identified Mycobacterium abscessus.
Chest radiographs for Cases 1, 2 and 4 were normal.
Five out of 7 patients completed their antibiotics and
remained in complete remission. One patient (Case 4)
failed clarithromycin treatment and underwent incision
and drainage with complete resolution. Another patient
(Case 2) succumbed to severe acute gallstone pancreatitis,
an unrelated event that was complicated by multi-organ
failure, while receiving treatment for her NTM infection.
In total, 3 patients received inpatient treatment (Cases 1, 2,
4), while the rest were treated on an outpatient basis.
In conclusion, we highlight a quarter of cutaneous NTM
infection occurred at the cubital forearm, often in the pres-
ence of cutaneous atrophy, prolonged topical corticosteroid
use and advanced age. None of the patients recalled a his-
tory of relevant exposure.
Perhaps, a clue to the diagnosis was that all but 1 of the
patients reported the use of topical corticosteroids over the
affected area(s). The use of topical corticosteroids could
account for localised immunosuppression and a defective
skin barrier due to atrophogenic side effects which predis-
posed to NTM infection.2,3 The high incidence of cubital
forearm involvement could be explained by this site being
more susceptible to corticosteroid-induced cutaneous
Figure 2 Histological findings in Case 2. (a) Nodular granulomas
in the superficial dermis consist of aggregates of neutrophils sur-
rounded by dense infiltrate of plasma cells, lymphocyte, histiocytes
and multinucleated giant cells. (Haematoxylin and Eosin, 9100).
(b) Numerous acid-fast bacilli are seen within the granulomas.
(Ziehl-Neelson stain, 9100) Ziehl-Neelson stain was positive in 2
out of 7 cases (b)
atrophy and also trauma (including minor ones which
patients themselves cannot remember). There has been a
similar report of NTM infection of the cubital fossa in an
elderly patient with history of topical corticosteroid appli-
cation.4
Finally, we emphasise the emergence of Mycobacterium
abscessus, with its multi-drug resistance pattern5 and
potential need for intravenous therapy or surgical inter-
vention. Although Mycobacterium abscessus is a fast grow-
ing mycobacterium, cultures had a turnaround time of 4–
6 weeks in our cases, longer than the traditionally under-
stood timing of 2 weeks. This is often longer owing to the
need for further subcultures to identify the mycobacterium
species.
In our cases, initial antibiotics were guided by speciation
of Mycobacterium abscessus from NTM PCRs, which had a

© 2021 The Australasian College of Dermatologists

 Letter To The Editors e423

shorter turnaround time. Hence, skin biopsies for NTM Table 1 Demographic features of patients
PCRs should be performed early if Mycobacterium absces- Female/male (n) 28 / 35
sus is a possibility or if there is failure of response to oral Age (mean  SD) 46.7  13.3 (20–80)
antibiotics. (min–max)
In conclusion, we highlight that 28% of cutaneous NTM Age at onset (mean  SD) 28.4  16.3 (0–76)
infection occurs at the cubital forearm. The involvement of (min–max)
Disease duration (mean  SD) 18.6  9.4 (2–45)
the cubital forearm should be recognised and raise the
(min–max) (years)
index of suspicion for NTM infections. We emphasise the Body mass index (mean  SD) 28.3  5.7 (15–41)†
emergence and importance of Mycobacterium abscessus as (min–max)
a pathogen and recommend aids to its early identification Previous treatments (n)
via NTM PCRs. Methotrexate 53
Cyclosporine 33
Yuxin Evelyn Tay1 | Shiyao Sam Yang2 | Acitretin 32
Adalimumab 29
Sern Ting Eugene Tan | Tien Guan Steven Thng3 |
3
Phototherapy 27
See Ket Ng3 | Wei-Sheng Chong3 Infliximab 17
1
Department of Dermatology, Changi General Hospital, Ustekinumab 15
2
Department of Dermatology, National University Hospital Etanercept 14
and 3National Skin Centre, Singapore, Singapore Certolizumab 4
Golimumab 2
Efalizumab 1
REFERENCES Current or ex-smokers (%) 46 %
Hypertension 30.2 %
1. Lamb RC, Dawn G. Cutaneous non-tuberculous mycobacterial Hyperlipidaemia 19 %
infections. Int. J. Dermatol. 2014; 53: 1197–204. Comorbidities (%)
2. Dirac MA, Horan KL, Doody DR et al. Environment or host?: a Diabetes 15.9%
case-control study of risk factors for Mycobacterium avium Chronic obstructive 4.8 %
complex lung disease. Am. J. Respir. Crit. Care Med. 2012; 186: pulmonary disease
684–91. Arthritis (%) 42.8 %
3. Brode SK, Jamieson FB, Ng R et al. Increased risk of mycobacte- Duration of treatment with 11.8  6.7 (1–28)
rial infections associated with anti-rheumatic medications. Tho- secukinumab (mean  SD)
rax 2015; 70: 677–82. (min-max) (months)
4. Chan WSA, Tee SI, Chandra NSY et al. Two episodes of cuta-
†
neous non-tuberculous mycobacterial infection in a patient with 55.6% of patients were overweight or obese (BMI ≥ 25).
psoriasis. Dermatol. Rep. 2015; 7: 25–7.
5. Nessar R, Cambau E, Reyrat JM et al. Mycobacterium abscessus:
a new antibiotic nightmare. J. Antimicrob. Chemother. 2012; 67:
810–8. National Psoriasis Foundation (NPF) guidelines and treated
with secukinumab between September 2018 and March
2020 in the psoriasis outpatient clinic of Marmara Univer-
doi: 10.1111/ajd.13588 sity School of Medicine, Department of Dermatology, Istan-
bul, Turkey.
Research Letter Patient characteristics, treatment duration, number of
patients achieving absolute Psoriasis Area and Severity
Secukinumab has established high efficacy and favourable Index (aPASI) score of ≤ 2, reasons for discontinuation
safety profile in clinical studies. Considering the pivotal were determined. All infections, including hepatitis B, hep-
role of IL-17 for immunosurveillance against fungi, intra- atitis C and tuberculosis (Tb), reactivation and possible
cellular and extracellular bacteria, infectious complica- risk factors were evaluated. Tb status was determined by
tions related to anti-IL-17 agents may be underestimated history, physical examination, chest X-ray and Quanti-
in clinical practice.1–4 FERON-TB tests.
The aim of this study was to investigate, prospectively, Statistical analyses were performed using the PASW
the infectious complications of secukinumab in a psoriasis Statistics for Windows. Chi-square and independent-sam-
cohort in real-life setting and define the risk groups. ples t-tests were used in two group comparisons for cate-
gorical and numerical variables, respectively.

METHODS
This is a prospective observational study of 63 psoriasis
patients being screened and vaccinated according to the
Funding source: None.
Conflict of Interest: None relevant to the manuscript.
RESULTS
Demographic data on 63 patients included in the study are
shown in Table 1. Duration of treatment with secuk-
inumab ranged from 1 to 28 months (mean + SD:
11.8 + 6.7). 63.5% of patients achieved aPASI score ≤ 2
(78.3% vs 51.4% of biologic naive and exposed patients,
respectively, P = 0.022).

© 2021 The Australasian College of Dermatologists