Case
A 66-year-old man presented with a 1 month history of reddish-brown, circumscribed, infiltrative papules on the extremities (Figure 1A). The lesions developed central necroses and transformed into painful abscesses (Figure 1B; posterior thigh).
(A) Reddish-brown, circumscribed papule on the extremity. (B) Development of an abscess on the posterior thigh. (C) Skin biopsy showing acute panniculitis with abscess formation (asterisk) in the mid-dermis (haematoxylin and eosin stain; magnification: × 2) and (inset) Langhans-type giant cells (haematoxylin and eosin stain; magnification: × 400). (D) Skin biopsy showing rapid-growing acid-fast bacilli (Ziehl–Neelsen stain; magnification: × 600).
The patient had a history of anti-neutrophil cytoplasm antibodies-associated systemic vasculitis, presenting with severe renal disease. Combination therapy with cyclophosphamide and prednisolone had been terminated after 5 weeks due to treatment-related toxicity and development of end-stage renal disease. Subsequently, the patient had been on haemodialysis treatment for 18 months. Then, 3 months before presentation he had been transplanted with a cadaveric kidney. The immunosuppressive regimen consisted of prednisolone, cyclosporin A and mycophenolate mofetil.
The biopsy specimen obtained from the lesions showed acute panniculitis with abscess formation in the mid-dermis and few Langhans-type giant cells (Figure 1C). Numerous acid-fast bacilli could be demonstrated (Figure 1D). Culturing of a wound smear showed Mycobacterium abscessus. Drug sensitivity was tested. The patient received clarithromycin 250 mg twice daily and pyrazinamide 2 g daily. Treatment was continued for 8 months, during which the lesions showed regression and healing with scar formation.
Mycobacterium abscessus belongs to the family of rapid-growing atypical (non-tuberculous) mycobacteria. They can be isolated from water, soil and dust and have been identified in cutaneous and joint abscesses [1,2]. Infections caused by rapid-growing atypical mycobacteria have been described in immunocompromised patients and in patients with end-stage renal failure [1–3]. It is often misdiagnosed and treated as a fungal or common bacterial infection. Infections due to M. abscessus are currently managed by using the macrolide clarithromycin for several weeks, possibly in combination with amikacin or cefoxitin [1,4].
Conflict of interest statement. None declared.
(Section Editor: G. H. Neild)
References
Brown-Elliott BA, Wallace RJ, Jr. Clinical and taxonomic status of pathogenic nonpigmented or late-pigmenting rapidly growing mycobacteria.
Bartralot R, Pujol RM, Garcia-Patos V et al. Cutaneous infections due to nontuberculous mycobacteria: histopathological review of 28 cases. Comparative study between lesions observed in immunosuppressed patients and normal hosts.
Lowry PW, Beck-Sague CM, Bland LA et al. Mycobacterium chelonae infection among patients receiving high-flux dialysis in a hemodialysis clinic in California.
Author notes
1Nephrologie and 2Pathologie, Charité Campus Benjamin Franklin, Berlin, Germany
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