Non tuberculosis

Mycobacteria causing Skin

and Soft tissue Infections
Dr. Joy Sarojini Michael
Professor
Department of Microbiology
Christian Medical College , Vellore
Mycobacterium
tuberculosis complex

Non tuberculosis Mycobacteria

Or
Atypical Mycobacteria
Spectrum of Disease
caused by
Non Tuberculosis
Mycobacteria
Table 1. More common nontuberculous mycobacteria causing skin and soft tissue infections in humans

Mycobacterium Common presentations

Rapid growers
M. fortuitum group Postsurgical infections, infections after cosmetic procedures, pedicure (folliculitis),
implant surgery
M. abscessus group (includes M. abscessus, Postsurgical infections, implant surgery, cosmetic and related procedures
M. massiliense and M. bolletii) (e.g. liposuction, tattooing, acupuncture, mesotherapy), spa cleaning
M. chelonae Localized lesions as per M. abscessus
Infection in organ transplantation
Other Cosmetic procedures, surgical procedures
M. mageritense
M. wolinskyi
M. mucogenicum
Slow growers
M. marinum Localized nodules (fish tank granuloma), nodular lymphadenitis, tenosynovitis
M. avium complex Cervicofacial lymphadenitis in children
(M. avium, M. intracellulare) Skin lesions uncommon. Disseminated infections in HIVþ patients
M. haemophilum Cervicofacial lymphadenitis in children
Skin and subcutaneous infections in SOT recipients and HIVþ patients
M. ulcerans Localized and extensively destructive, necrotizing ulcers in immunocompetent hosts.
(Buruli ulcer). More common in children in Africa
1. Post Operative wound Infection
• Rapidly Growing Mycobacteria –
M.fortuitum, M.chelonae and M.abscessus
are increasingly associated with SSTI-
cosmetic and implant surgeries
• Common contaminants of water and
cosmeceuticals
• Reported skin findings are diverse and
include subcutaneous nodules, abscesses,
cellulitis, ulcers, sporotrichoid nodules, sinus
tracts, drainage from chronic wounds,
erythema, papules, pustules, and folliculitis.
 2. Fish tank Granuloma
or Swimming pool
granuloma
• M. marinum occurs in fish,
amphibians and occasionally in
exposed humans.
• M. marinum infection typically
begins as an indolent nodule
around 2–3 weeks after inoculation,
and can frequently develop into
nodular lymphangitis in a
sporotrichoid pattern involving a
hand or an arm
• Spontaneous resolution can occur
after many months, but deeper
infections can lead to tenosynovitis
(called “fish tank finger” when
involving the digits), bursitis,
arthritis and osteitis
3. Buruli ulcer- Mycobacterium ulcerans
• Named after the Buruli district in Uganda where early cases were described
• Starts as a solitary, asymptomatic, firm nodule ( < 5cm) that presents after an
incubation period of 3–4.5 months à can develop into progressive necrotic ulcers
with scalloped edges that expand to 15 cm or larger
• Children are more commonly affected, and the extremities are frequently involved
• Buruli ulcers may heal spontaneously , but can result in extensive scarring and
deformities.
• If unhealed--> involve underlying tendons, joints and bones; osteomyelitis has
been reported in up to 14.5% of cases, and may lead to amputation
• A toxin produced by the organism called mycolactone is believed to be responsible
for necrosis and local immunosuppression, partly by inhibiting the production of
interleukins, TNFα and interferon-γ (IFN-γ)
Mycobacterium haemophilum- SSTI
• Mycobacterium haemophilum is a nontuberculous mycobacterium
that causes localized and disseminated infections in
immunocompromised patients and rarely in immunocompetent
patients
• It is a slow-growing, aerobic, fastidious mycobacterium that requires
heme-supplemented culture medium and low temperatures of 30°C–
32°C for optimal growth
• Because of the special conditions required for culture, it is frequently
not isolated because of use of inappropriate techniques, and thus is
rarely reported in the medical literature.
NON-TUBERCULOSIS MYCOBACTERIA / ATYPICAL MYCOBACTERIA
 AFB smear microscopy

Culture on MGIT / LJ Media

Clinical samples- Tissue,
pus, swabs
Identification using
biochemicals /MALDI-TOF
MS

Drug susceptibility testing-

Microbroth dilution method
Cutaneous Infections Due to Nontuberculosis Mycobacterium: Recognition and Management

Table 1 Common NTM-associated skin infections and treatment recommendations based on ATS/IDSA guidelines [16]
Agent Endemic region Clinical presentation Treatment recommendations

Mycobacterium Not endemic to the USA; found in Buruli ulcer Rifampin 10 mg/kg/day (maximum 600 mg
ulcerans tropical areas of Africa, South- QD) + clarithromycin 500 mg BID for 8 weeks [124]
east Asia, Australia, South and Surgery can be considered if no response after 4 weeks
Central America of antibiotic therapy
M. marinum Found in aquatic environments Fish-tank granuloma, swim- 2-drug regimen with clarithromycin 500 mg BID with
including fresh and saltwater, ming-pool granuloma either ethambutol 15 mg/kg QD or rifampin 600 mg
especially fish tanks and swim- QD for 1–2 months after symptom resolution
ming pools For mild disease, can consider monotherapy
with clarithromycin 500 mg BID, TMP-SMX
160 mg/800 mg BID, or minocycline/doxycycline
100 mg BID (minocycline > doxycycline)
M. fortuitum, USA and worldwide; M. fortuitum Often follows a surgical or Treatment with at least 2 susceptible agents (usually
M. chelonae, epidemics reported with pedi- cosmetic procedure; M. ciprofloxacin 750 mg BID or levofloxacin 500 mg
M. abscessus cures; M. chelonae epidemics fortuitum is more likely to BID, TMP-SMX 160 mg/800 mg BID, clarithromy-
(RGM) reported with tattoos and present as a single lesion cin 500 mg BID, or doxycycline 100 mg BID) for
LASIK procedures 4–6 months
Add amikacin, cefoxitin, imipenem or linezolid for
ocular or disseminated infections
Surgical excision if localized
M. haemophilum Worldwide; ecological niche not Cervical lymphadenitis in Surgical excision for lymphadenitis
well characterized due to fastidi- children; nodules, papules At least 2 agents: rifampin 600 mg QD or rifabutin
ous growth requirements and cysts in immunocom- 300 mg QD + clarithromycin 500 mg BID or azithro-
promised patients mycin 500 mg QD + moxifloxacin 400 mg QD or
levofloxacin 500 mg BID or ciprofloxacin 500 mg
BID
Treat until a few months past resolution of clinical
evidence of SSTI
Thank you
Any doubts