Disseminated Mycobacterium intracellulare infection

ARTICLE

ejd.2011.1387

Auteur(s) : Kyoko Tominaga, Masahisa Shindo shindo@med.tottori-u.ac.jp, Tessin Watanabe, Yuichi Yoshida, Osamu Yamamoto

Division of Dermatology, Faculty of Medicine Tottori University, 86 Nishi-cho Yonago, Tottori 683-8503, Japan

Mycobacterium intracellulare (M. intracellulare) is a low-pathogenic, non-tuberculous mycobacterium that is commonly present in the environment. It is known that M. intracellulare often affects patients with immunosuppressive conditions [1]. We report a rare case of disseminated M. intracellulare infection with diabetes mellitus.

An 82-year-old man with diabetes mellitus had a 6-month history of a skin lesion on his neck. He was treated with oral administration of voglibose (0.6 mg/day). The blood glucose level was less than 200 mg/dL and hemoglobin A1c was around 6.0%. The lesion had gradually evolved on his neck. There was no history of preceding trauma. Physical examination revealed a diffuse indurative plaque, 12×4 cm in size, with a purulent discharge in the mandibular area (figure 1A). In addition, there were neck, axillal, and inguinal lymphadenopathies. Results of laboratory investigation were as follows: white blood cell count, 14,800/μL with 93% neutrophils; red blood cell count, 2.91×10^6/μL; hemoglobin, 9.3 g/dL; platelet count, 24.8×10⁴/μ; interleukin-2 receptor, 3,964 IU/mL; glucose, 158 mg/dL; C-reactive protein level, 12.76 mg/dl; anti-human immunodeficiency virus (HIV) antibody, negative; hemoglobin A1c, 5.7%; CD4 count, 43.8% (normal: 28.3-58%); CD8 count, 36% (normal: 13-38.8%).

We suspected tuberculosis, non-tuberculous mycobacterial infection, phlegmone or malignant lymphoma. A skin biopsy revealed marked infiltration of neutrophils, lymphocytes, eosinophils, histiocytes and some multinucleated giant cells in the mid-dermis and adipose tissue (figures 1B, C). An acid-fast bacillus was not apparent with Ziehl-Neelsen's staining. Chest computed tomography showed only pulmonary emphysema. However, we detected M. intracellulare from sputum by polymerase chain reaction. In addition, magnetic resonance imaging revealed osteomyeritis in the spine (L2/3). Finally, M. intracellulare was identified from an abscess in the skin, the lymph node and the spine. Based on these findings, a diagnosis of disseminated M. intracellulare infection involving the skin, lymph nodes, lung, and bone was made. He was treated with combination chemotherapy (rifampicin, clarithromycin and ethambutol). However, the treatment was terminated temporarily because of drug eruption with rifampicin. Rifampicin was then replaced with streptomycin. The skin lesion had completely cleared at 9 weeks after treatment.

Mycobacterium species usually exist in nature in soil, water and house dust [1, 2]. M. intracellulare infection is most commonly seen in immunosuppressed individuals with conditions such as severe diabetes mellitus, HIV infection, and malignancy [3-6]. Primary cutaneous M. intracellulare infection is extremely rare and occurs after accidental traumatic inoculation [4]. On the other hand, there are some reports of widespread or disseminated lesions caused by M. intracellulare infection [5]. The usual route of disseminated M. intracellulare infection is thought to be through the respiratory tract. In the present case, it is not clear where the primary site was. Since there was no past history of preceding trauma, we suspected that M. intracellulare was disseminated from the lesion of the lung to other organs. Although our patient had well-controlled diabetes mellitus, disseminated lesions of the skin, lymph nodes, lung, and bone were seen. It is difficult to know if diabetes mellitus was related to the pathogenesis of M. intracellulare in our case. However, it is important for clinicians to pay attention to the possibility of other internal lesions when cutaneous M. intracellulare infection is seen.

Disclosure

Financial support: none. Conflict of interest: none.

References

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