Multiple skin lesions caused by Mycobacterium scrofulaceum infection

ARTICLE

ejd.2011.1534

Auteur(s) : Ayako Ito¹ ayama813@grape.med.tottori-u.ac.jp, Yuichi Yoshida¹, Hiromi Higaki-Mori¹, Tessin Watanabe¹, Kazue Nakanaga², Norihisa Ishii², Osamu Yamamoto¹

¹ Division of Dermatology, Faculty of Medicine, Tottori University, 86 Nishi-cho, Yonago 683-8503, Japan

² Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan

Mycobacterium (M.) scrofulaceum is a slow-growing, non-tuberculous mycobacterium that is widely distributed in nature and is isolated from soil and water [1]. It is known that M. scrofulaceum usually causes subacute and chronic cervicofacial lymphadenitis in children [1]. However, cutaneous involvement caused by this organism is not common and it has rarely been reported in the literature [2-6]. Most of the reported cases showed disseminated lesions, involving multiple organs including the skin, lung and the other organs in immunocompromised hosts. We report a case of cutaneous M. scrofulaceum infection with idiopathic thrombocytopenic purpura.

A 77-year-old Japanese woman presented with a 2-month history of painless nodules on her wrist and legs. She had been treated with oral administration of predonisolone (5 mg/day) for idiopathic thrombocytopenic purpura (ITP). Physical examination revealed reddish nodules, 0.5 to 1.5 cm in diameter, some with pustules and ulceration, on the left wrist and the legs (figure 1A, B). Histopathological examination on the leg showed caseating granuloma composed of histiocytes, giant cells, neutrophils and lymphcytes, from the dermis to subcutaneous tissue (figure 1C). Neither bacilli nor fungi were found by Periodic acid-Schiff, Grocott's or Ziehl-Neelsen's staining. Bacteria, mycobacterium and fungi were negative in the culture of the lesion. Chest X-ray, computed tomography and routine laboratory examination showed no abnormalities. Although the results of an intradermal purified-protein derivative test and QuantiFERON^®-TB Gold assay were negative, we suspected mycobacterial infection from histopathological findings. Minocycline (100 mg/day) therapy was initiated. The sizes of the lesions decreased, but the patient stopped the therapy.

Six months later, she visited our hospital again. She presented with newly developed nodules and abscesses on her legs, wrist and face. A smear from abscesses on the face confirmed the presence of acid-fast bacilli by Ziehl-Neelsen's stain. After 4 weeks, M. scrofulaceum was identified by the DNA-DNA hybridization method. She was treated with clarithromycin (CAM, 80 mg/day) in addition to minocycline (MINO, 200 mg/day). Although the response was remarkable, the treatment was terminated because of liver dysfunction. MINO was then replaced with rifampicin (RFP, 450 mg/day). The multiple skin lesions had almost cleared at 4 months after the start of treatment.

Cutaneous involvement caused by M. scrofulacrum is rare. There have so far only been five reports of M. scrofulaceum infection limited to skin [2-6]. The skin lesions included nodules, abscess, plaque, or ulceration in either solitary [2-4] or multiple fashions [5, 6]. Most of the skin lesions developed on the arms, hands or face [2-4, 6]. Among the reported cases, 2 patients had preceding trauma in relation to the infection [2, 6]. Two cases were associated with immunosuppresive conditions [2, 5].

In our case, the skin lesions spread in both proximal and distal directions and were limited to exposure sites such as the face, hands and feet. This suggests that M. scrofulaceum infection in our patient probably spread by autoinoculation. In addition, long-term corticosteroid therapy of ITP may have increased her susceptibility to cutaneous autoinoculation.

There is no consensus on the most appropriate therapeutic regimen for M. scrofulaceum infection. Recently, it has been reported that CAM [3], combinations of azithromycin and RFP [2], sparfloxacin and MINO [4], and isoniazid and RFP [5] were effective for treatment of M. scrofulaceum infection. In our case, we started MINO therapy because the mycobacterium was not identified at this point. However new lesions developed six months later. The skin lesions disappeared with combination therapy (MINO, CAM and RFP) for 4 months. Therefore, we recommend combination chemotherapy against M.scrofulaceum infection.

In conclusion, it is important for clinicians to pay attention to the possibility of rare non-tuberculosis infection and give appropriate chemotherapy.

Disclosure

Financial support: none. Conflicts of interest: none.

References

1. Hautman G, Lotti T. Disease caused by Mycobacterium scrofulaceum. Clin Dermatol 1995 ; 13 : 277-280.

2. Kandyil R, Maloney D, Tarrand J, Duvic M. Red nodule on the finger of an immunosuppressed woman. Arch Dermatol 2002 ; 138 : 689-694.

3. Jang HS, Jo JH, Oh CK, et al. Successful treatment of localized cutaneous infection caused by Mycobacterium scrofulaceum with clarithromycin. Pediatr Dermatol 2005 ; 22 : 476-479.

4. Ishii N, Sugita Y, Sato I, Nakajima H. A case of mycobacterial skin disease caused by Mycobacterium peregrinum and M. scrofulaceum. Acta Derm Venereol 1998 ; 78 : 76-77.

5. Murray-Leisure KA, Egan N, Weitekamp M.R. Skin lesions caused by Mycobacterium scrofulaceum. Arch Dermatol 1987 ; 123 : 369-370.

6. Sowers W.F. Swimming pool granuloma due to Mycobacterium scrofulaceum. Arch Dermatol 1972 ; 105 : 760-761.