mycobacterium chelonae abscessus lower extremity infection in the double transplant patient
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Cleveland Clinic/Kaiser Permanente Residency Program
M. chelonae abscessus Lower Extremity Infection in the Double Transplant Patient Jennifer Gerres DPM, PGY-2
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Objectives
✤ Mycobacterium chelonae abscessus is a rare cause of human infection
✤ Present an atypical manifestation in an immunosuppressed patient
✤ Review of the literature
✤ Proclivity for the renal transplant patient
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Case Study
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History of Present Illness
✤ December 2010, a 56yo male presents with pain to the right 4th MTPJ
✤ 2 months prior
✤ Clipping toenails and accidentally clipped right 4th toe
✤ Developed pain and edema
✤ Saw his local podiatrist in Michigan
✤ I&D performed, and per patient, purulent material was expressed, but no culture taken
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History of Present Illness
✤ 2 weeks after I&D
✤ Noticed increased pain and erythema at anesthetic injection site of the right 4th toe
✤ Returned to podiatrist, who prescribed empiric Augmentin x 10 days without improvement
✤ Epsom salt soaks twice daily
✤ Radiograph of right foot: calcified vessels
✤ ABI/PVR: small vessel disease
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History of Present Illness
✤ The patient describes the pain thusly:
✤ It begins at night, worsens until the morning, and resolves by midmorning
✤ Sharp, “tight-feeling” at the base of the right 4th toe
✤ Review of Systems
✤ Denies n/v/f/c/night sweats/weight change/loss of appetite
✤ Previous right foot surgery
✤ Distal chevron bunionectomy
✤ “It took 6 months for the incision to heal”
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Past Medical History
✤ DM Type I x 35 years
✤ Status-post cadaveric pancreas transplant 10 years prior
✤ Status-post living-donor kidney transplant 10 years prior
✤ Aortic Stenosis
✤ Glaucoma (legally blind)
✤ Hypothyroidism
✤ Irritable bowel syndrome
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✤ Past Surgical History
✤ Cadaveric pancreas transplant
✤ Living-donor kidney transplant
✤ Multiple eye surgeries
✤ Right HAV surgery 3 years prior
✤ Allergies
✤ No known drug allergies
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Medications
✤ Prednisone
✤ Tacrolimus anhydrous (Prograf)
✤ Mycophenolate mofetil (Cellcept)
✤ Bupropion
✤ Zetia
✤ Prilosec
✤ Synthroid
✤ Betimol 0.5% eye drops
✤ Lotemax 0.5% eye drops
✤ Aspirin 81mg
✤ Calcium carbonate/VitD3
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✤ Social History
✤ Lives by Lake Michigan
✤ Often spends his summers on the beaches
✤ Illicit drug use: denies
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Physical Exam: Right Foot
✤ Vascular: DP/PT pulses palpable. No edema. No dependent rubor
✤ Neurological: Light touch intact. SWMF 5.07 intact to all sites
✤ Musculoskeletal: Pain with ROM of the 4th MTPJ
✤ Pain on palpation at the 4th MTPJ and the 3rd interspace
✤ Negative Mulder’s click
✤ No pain to palpation of the 4th toe
✤ Dermatological: telangiectasias to dorsal forefoot
✤ No palpable mass
✤ Erythema to the distal pulp of the 4th toe as well as to the dorsal 4th MTPJ
✤ The erythema is blanchable
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Ancillary Studies✤ MRI without contrast
✤ Nonspecific soft tissue edema
✤ No focal soft tissue abnormality
✤ ABI/PVR
✤ Right: 1.16 TBI: 0.42 small vessel disease
✤ Left: 1.1 TBI: 0.63
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Plan
✤ ADMISSION
✤ Course of IV antibiotics
✤ IV Zosyn and Vancomycin
✤ During admission
✤ Patient remained afebrile
✤ Minimal resolution of erythema to the 4th MTPJ, but no resolution of pain
✤ Labs
✤ No leukocytosis
✤ ESR: 2
✤ CRP: 0.1
✤ Uric acid: wnl
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✤ Six-week course of IV antibiotics
✤ Despite the six-week course of IV antibiotics...
✤ The erythema failed to improve
✤ Patient continued to have pain at the right 4th MTPJ
After Discharge
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Six Weeks After Discharge
✤ Evaluated by Podiatry and Infectious Disease
✤ Plan
✤ Admission
✤ Underlying ischemia?
✤ Multidisciplinary approach
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During Admission✤ Vitals: afebrile
✤ Physical exam remained unchanged
✤ Labs
✤ No leukocytosis
✤ ESR: 1
✤ CRP: 0.1
✤ Procalcitonin: <0.05
✤ MRI with contrast
✤ Mild, nonspecific subcutaneous and muscular edema
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✤ After a multidisciplinary discussion, it was determined to halt the current administration of antibiotics
✤ Evaluate the patient in the outpatient setting
✤ Weekly photographs and phone calls
✤ The patient provided weekly updates until February 2011
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Two Months from Initial Presentation
✤ Increased pain to the right 4th MTPJ
✤ New complaint of a “lump” to the area
✤ Denied n/v/f/c/night sweats
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PLAN
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Plan
✤ Aspiration
✤ Anaerobe/aerobe
✤ AFB stain and culture
✤ Fungal culture and smear
✤ Nocardia
✤ Mycoplasma
✤ Admission
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During Admission
✤ Patient remained afebrile
✤ Labs
✤ No leukocytosis
✤ ESR and CRP remained unchanged
✤ Microbiology
✤ Rapid-growing, acid fast bacilli
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At Discharge
✤ Final cultures demonstrated
✤ Mycobacterium chelonae abscessus
✤ S: clarithromycin/azithromycin, linezolid, tigecycline
✤ Antibiotic regimen
✤ Tigecycline 50mg IV q12h
✤ Azithromycin 500mg PO
✤ Linezolid 600mg PO q12h
✤ Local wound care for ulceration
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At Six Months
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Discussion
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Mycobacterium chelonae abscessus
✤ Multi-drug resistant, rapid-growing acid fast bacilli
✤ Chopra et al. J Antimicrob Chemother, 2011:
✤ Systematic review, screening 1040 approved drugs, antimicrobial and non-antimicrobial
✤ Discovered 32 compounds with significant antimicrobial activity
✤ Illustrated the resilience of this group
✤ Biofilm
✤ Ubiquitous and fastidious
✤ Found: water
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Mycobacterium chelonae abscessus
✤ Cause of nosocomial, post-surgical wound, and post-injection abscesses
✤ Clustered cases of infection
✤ Foot baths, contaminated water supply or injected material
✤ Infrequently, a cause of infection
✤ Immunocompromised
✤ Solid organ transplants
✤ Cutaneous lesions of the extremities
✤ Arthritis and tenosynovitis; meningitis; and disseminated infection
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Mycobacterium chelonae abscessus
✤ Several reported cases among solid organ transplant patients
✤ Cooper et al. Am J Med, 1989:
✤ Identified 7 renal transplant patients
✤ Distinct pattern emerged:
✤ Indolent, tender nodules isolated to the lower extremities
✤ Absence of systemic symptoms and no leukocytosis
✤ Garrison et al. Transpl Infect Dis, 2009:
✤ Found 25 cases involving solid organ transplant recipients
✤ 4 received renal transplants
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Mycobacterium chelonae abscessus
✤ Diagnosis and treatment are complex
✤ Lesion biopsy and wound culture with susceptibility
✤ Resistance patterns unpredictable
✤ Naturally resistant to conventional anti-TB drugs
✤ No guidelines as to duration of therapy
✤ IDSA
✤ 4 months for skin and soft tissue infections
✤ 6 months for bone infections
✤ Chernenko et al. J Hear Lung Transplant, 2006:
✤ 12 to 18 months of combination therapy in the immunocompromised
✤ Surgical intervention
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Conclusion
✤ Multi-drug resistant acid-fast bacilli with proclivity for the immunocompromised
✤ Treatment of these infections are complex
✤ Culture and sensitivity are imperative
✤ Aspiration and/or debridement necessary to improve outcome
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References
✤ Morales P, Gil A, Santos M. Mycobacterium abscessus infection in transplant recipients. Transplantation Proceedings. 2010;42:3058-306
✤ Morris-Jones R, Fletcher C, Morris-Jones S, et al. Mycobacterium abscessus : a cutaneous infection in a patient on renal replacement therapy. Clin Exp Dermatol. 2001;26:415-418
✤ Garrison, AP, Morris MI, Lewis SD, et al. Mycobacterium abscessus infection in solid organ trasnplant recipients : report of three cases and review of the literature. Transpl Infect Dis. 2009;11:541-548
✤ Moore M, Frerichs JB. An unusual acid-fast infection of the knee with subcutaneous, abscess-like lésions of the gluteal région ; report of a case with a study of the organism, Mycobacterium abscessus, n. sp. J Invest Dermatol. 1953 ;20 :133-169
✤ Chopra S, Matsuyama K, Hutson C, Madrid P. Identification of antimicrobial activity among FDA-approved drugs for combating Mycobacterium abscessus and Mycobacterium chelonae. J Antimicrob Chemother. 2011;66:1533-1436
✤ Kwon YH, Lee GY, Kim WS, Kim JK. A case of skin and soft tissue infection caused by mycobacterium abscessus. Ann Dermatol (Seoul). 2009;21(1) :84-87
✤ Doucette K, Fishman JA. Nontuberculous mycobacterial infection in hematopoietic stem cell and solid organ transplant recipients. Clin Infect Dis. 2004;38(10):1428-1439
✤ Galil K, Miller LA, Yakrus MA, et al. Abscesses due to Mycobacterium abscessus linked to injection of unapproved alternative medication. Emerg Infect Dis. 1999;5:681-687
✤ Cooper JF, Lichtenstein MJ, Graham BS, Schaffner W. Mycobacterium chelonae: A cause of nodular skin lesions with a proclivity for renal transplant recipients. Am J Med. 1989;86(2):173-177
✤ Prinz BM, Michaelis S, Kettelhack N, et al. Subcutaneous infection with Mycobacterium abscessus in a rental transplant recipient. Dermatology. 2004;208(3)259-261
✤ Scholze A, Loddenkemper C, Grumbaum M, et al. Cutaneous Mycobacterium abscessus infection after kidney transplantation. Nephrol Dial Transplant. 2005;20(8):1764-1765
✤ Chernenko SM, Humar A, Hutcheon M, et al. Mycobacterium abscessus infections in lung transplant recipients : the international experience. J Hear Lung Transplant. 2006;25(12):1447-1455
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Thank You