Cleveland Clinic/Kaiser Permanente Residency Program

M. chelonae abscessus Lower Extremity Infection in the Double Transplant Patient Jennifer Gerres DPM, PGY-2

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

Case Study

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

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

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”

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

✤ Past Surgical History

✤ Cadaveric pancreas transplant

✤ Living-donor kidney transplant

✤ Multiple eye surgeries

✤ Right HAV surgery 3 years prior

✤ Allergies

✤ No known drug allergies

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

✤ Social History

✤ Lives by Lake Michigan

✤ Often spends his summers on the beaches

✤ Illicit drug use: denies

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

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

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

✤ 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

Six Weeks After Discharge

✤ Evaluated by Podiatry and Infectious Disease

✤ Plan

✤ Admission

✤ Underlying ischemia?

✤ Multidisciplinary approach

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

✤ 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

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

PLAN

Plan

✤ Aspiration

✤ Anaerobe/aerobe

✤ AFB stain and culture

✤ Fungal culture and smear

✤ Nocardia

✤ Mycoplasma

✤ Admission

During Admission

✤ Patient remained afebrile

✤ Labs

✤ No leukocytosis

✤ ESR and CRP remained unchanged

✤ Microbiology

✤ Rapid-growing, acid fast bacilli

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

At Six Months

Discussion

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

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

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

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

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

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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