Journal of Infection (t99o) 20, 223-225
CASE REPORT Soft tissue abscess caused by
Mycobacterium fortuitum
D. Westmoreland,*~ R. T. W o o d w a r d s , t P. E. Holden~ and P. A. James*
*Joint Microbiology and Public Health Laboratory and the t Department of Orthopaedics, Royal United Hospital, Combe Park, Bath BA I 3NG and :~ The Health Centre, Park Road, Frome, Somerset BAI~ IEZ, U.K. Accepted for publication 19 December I989 Summary
Mycobacterium fortuitum is an environmental organism which rarely causes disease. We report the case of a young man in whom this organism caused a soft tissue abscess. The laboratory findings and subsequent management of the case are described. Introduction
Mycobacterium fortuitum is ubiquitous and has been isolated from water, soil and dust. 1 It is an opportunistic pathogen which can cause fatal disseminated disease in the i m m u n o c o m p r o m i s e d and severe infections associated with implanted prosthetic devices. 2-4 Soft tissue infections due to M. fortuitum, often following penetrating injury, have been reported from the U.S.A. 2'5'6 but the m a n a g e m e n t of these infections is not well established. We describe a subcutaneous abscess due to M. fortuitum and c o m m e n t on aspects of diagnosis and m a n a g e m e n t of this unusual infection.
Case report A 33-year-old m a n presented with a painful swelling above his right elbow. T h e swelling had appeared some 6 m o n t h s previously and, although tender, had not prevented h i m from continuing his e m p l o y m e n t as a manual worker in a y o g h u r t factory. T h e patient could not recall any specific injury to his elbow but a d m i t t e d that he often sustained blows to the arms in the course of his job. T h e r e was no relevant past medical history and the patient was otherwise well. On examination, a discrete fluctuant swelling about 3 cm in diameter was observed just above the elbow. T h e swelling was tender but w i t h o u t local inflammation. T h e r e was a full range of m o v e m e n t at the elbow joint. Radiography of the u p p e r arm did not reveal any b o n y abnormality. Ziehl-Neelsen staining of pus aspirated from the lesion revealed polym o r p h o n u c l e a r leucocytes together with scanty acid-fast bacilli. Culture of the pus on L 6 w e n s t e i n - J e n s e n m e d i u m led to growth of M. fortuitum within A u t h o r to w h o m correspondence should be addressed. oi63-4453/9o/o3o223 + 0 3 $o2,oo/o
© I99o T h e British Society for the Study of Infection 9-2
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3 days. T h e patient was referred for an orthopaedic opinion. This was followed by surgical exploration, drainage and curettage of the abscess which was found not to communicate with the elbow joint. T h e cleaned abscess cavity was closed and the contents sent for microbiological examination. T h e contents of the abscess were stained by the Ziehl-Neelsen technique but acid-fast bacilli were not observed. Mycobacterium fortuitum, however, was isolated on L6wenstein-Jensen medium. T h e patient was treated with cefoxitin 200 mg IV twice daily for 2 weeks together with ciprofloxacin 5oo mg orally twice daily for 4 weeks. He made an uneventful recovery. Throughout his illness the patient remained afebrile, his chest X-ray, biochemical and haematological tests being normal. Tests for antibody to the human immunodeficiency virus were negative. T h e only other feature was that, at the time the abscess was drained, the patient also underwent total dental clearance because of grossly neglected dentition and numerous chronic dental abscesses. Discussion
Mycobacterium fortuitum is a rapidly growing species which is divided into three serotypes. 1'8 Lipid analysis at the Public Health Laboratory Service Mycobacterium Reference Unit in Cardiff showed that the strain isolated from our patient belonged to subtype 'peregrinum'. Results of sensitivity tests reported by the Mycobacterium Reference Unit included resistance to traditional antituberculous drugs as well as to penicillin, amoxycillin, piperacillin, cephradine, cefuroxime, erythromycin, chloramphenicol, tetracycline, clindamycin, sulphamethoxazole and fusidic acid. T h e organism was slightly sensitive to gentamicin and fully sensitive to ciprofloxacin, amikacin and cefoxitin. Primary cutaneous disease due to M. fortuitum has been described as presenting with cellulitis, draining abscesses or, as in the case described here, as a single slightly tender lump. Most patients give a history of penetrating injury, the time interval between injury and clinical onset ranging from 3 weeks-I2 months. L5-70steomyelitis may complicate cutaneous disease. Postinoculation abscesses following immunisation have also been described. 1'5 Approximately IO-2O % of cutaneous infections due to M. fortuitum are said to resolve spontaneously over a period of several months. Fatal progressive infections, however, have been described. Treatment is therefore needed. 1'2' 9 Although only a few patients with abscesses have been reported, it is recommended that abscesses should be incised and drained as well as chemotherapy given. ''7 Recommended therapy in the U.S.A. for serious infections is based on parenteral amikacin plus cefoxitin for several weeks followed by prolonged 0ral therapy selected in accordance with the results of susceptibility testsfl Ciprofloxacin and other fluorinated quinolones have been shown to be active against Mycobacterium fortuitum in vitro. 1° This agent has been used to treat one patient with peritonitis caused by M. fortuitum. 4 Our patient's illness was not considered severe enough to warrant therapy with amikacin but combined therapy with oral ciprofloxacin and parenteral cefoxitin had a good effect. Long-term follow-up is planned since relapse of the disease
Abscess due to M y c o b a c t e r i u m f o r t u i t u m
225
has b e e n n o t e d , a l t h o u g h u s u a l l y f o l l o w i n g d i s s e m i n a t e d r a t h e r t h a n localised infection. 2 C o l d abscess d u e to M . fortuitum was first d e s c r i b e d in 193 811 b u t t h e i n f r e q u e n c y o f this c o n d i t i o n has led to its diagnosis b e i n g r a r e l y c o n s i d e r e d . P r o l o n g e d d e l a y in diagnosis m a y b e f o l l o w e d b y s e v e r e d e e p - s e a t e d i n f e c t i o n s a n d o s t e o m y e l i t i s w h i c h m a y b e difficult to treat. 2 O u r p a t i e n t ' s s y m p t o m s h a d been treated unsuccessfully with antibiotics and non-steroidal anti-inflamm a t o r y a g e n t s b e f o r e a c o r r e c t diagnosis was m a d e . M i c r o b i o l o g i c a l l a b o r a t o r y r o u t i n e p r a c t i c e does n o t always i n c l u d e e x a m i n a t i o n o f skin a n d m a t e r i a l f r o m abscesses for m y c o b a c t e r i a . E x a m i n a t i o n for m y c o b a c t e r i a was p e r f o r m e d in t h e case o f o u r p a t i e n t b e c a u s e his g e n e r a l p r a c t i t i o n e r t h o u g h t t h a t t h e lesion r e s e m b l e d t u b e r c u l o u s ' c o l d ' abscesses m o r e o f t e n seen n o w a d a y s o u t s i d e t h e U . K . I n f e c t i o n w i t h an atypical m y c o b a c t e r i u m s h o u l d be c o n s i d e r e d in t h e differential diagnosis o f a n y cold abscess, p a r t i c u l a r l y if a s s o c i a t e d w i t h local trauma. (We thank M r A. C. Ross, Consultant Orthopaedic Surgeon, Royal United Hospital, Bath for permission to report this case as well as D r P. A. Jenkins and staff of the Mycobacterium Reference Unit, Cardiff for help in identification and sensitivity testing of the organism.)
References I. Woods, GL, Washington JA. Mycobacteria other than Mycobacterium tuberculosis : review of microbiologic and clinical aspects. Rev Infect Dis 1987; 9: 275-294. 2. Wallace RJ, Swenson JM, Silcox VA, Bullen MG. Treatment of nonpulmonary infections due to Mycobacterium fortuitum and Mycobacterium chelonei on the basis of in-vitro susceptibilities. J Infect Dis 1985; 152: 5oo-514. 3. Hoy JF, Rolston KVI, Hopfer RL, Bodey GP. Mycobacterium fortuitum bacteremia in patients with cancer and long-term venous catheters. Am J Med 1987; 83: 213-217. 4. Woods, GL, Hall GS, Schreiber MJ. Mycobacterium fortuitum peritonitis associated with continuous ambulatory peritoneal dialysis. J Clin Microbiol 1986; 23: 786-788. 5. Clapper WE, Whitcomb J. Mycobacterium fortuitum abscess at an injection site. J A M A 1967; 2o2: 550. 6. Canilang B, Armstrong D. Subcutaneous abscess due to Mycobacterium fortuitum. Report of a case. Am Rev Respir Dis 1968; 97: 451-454. 7. Hendrick SJ, Jorizzo JL, Newton RC. Giant Mycobacterium fortuitum abscess associated with systemic Lupus Erythematosus. Arch Dermatol I986; 122: 695-697. 8. Silcox VA, Good R, Floyd MM. Identification of clinically significant Mycobacterium fortuitum complex isolates. J Clin Microbiol 198I ; 14: 686-691. 9. Varghese G, Shepherd R, Watt P, Bruce JH. Fatal infection with Mycobacterium fortuitum associated with oesophageal achalasia. Thorax 1988 ; 43 : 15 I-152. IO. Young LS, Berlin OGW, Inderlied CB. Activity of Ciprofloxacin and other fluorinated Quinolones against mycobacteria. Am J Med 1987; 82 (4A): 23-26. i i. Cruz, J da Costa. Mycobacterium fortuitum: un novo bacilo acido-resistente pathog6nico para o homen. Acta iVied Rio DeJaneiro I938; I: 297.
CASE REPORT Soft tissue abscess caused by
Mycobacterium fortuitum
D. Westmoreland,*~ R. T. W o o d w a r d s , t P. E. Holden~ and P. A. James*
*Joint Microbiology and Public Health Laboratory and the t Department of Orthopaedics, Royal United Hospital, Combe Park, Bath BA I 3NG and :~ The Health Centre, Park Road, Frome, Somerset BAI~ IEZ, U.K. Accepted for publication 19 December I989 Summary
Mycobacterium fortuitum is an environmental organism which rarely causes disease. We report the case of a young man in whom this organism caused a soft tissue abscess. The laboratory findings and subsequent management of the case are described. Introduction
Mycobacterium fortuitum is ubiquitous and has been isolated from water, soil and dust. 1 It is an opportunistic pathogen which can cause fatal disseminated disease in the i m m u n o c o m p r o m i s e d and severe infections associated with implanted prosthetic devices. 2-4 Soft tissue infections due to M. fortuitum, often following penetrating injury, have been reported from the U.S.A. 2'5'6 but the m a n a g e m e n t of these infections is not well established. We describe a subcutaneous abscess due to M. fortuitum and c o m m e n t on aspects of diagnosis and m a n a g e m e n t of this unusual infection.
Case report A 33-year-old m a n presented with a painful swelling above his right elbow. T h e swelling had appeared some 6 m o n t h s previously and, although tender, had not prevented h i m from continuing his e m p l o y m e n t as a manual worker in a y o g h u r t factory. T h e patient could not recall any specific injury to his elbow but a d m i t t e d that he often sustained blows to the arms in the course of his job. T h e r e was no relevant past medical history and the patient was otherwise well. On examination, a discrete fluctuant swelling about 3 cm in diameter was observed just above the elbow. T h e swelling was tender but w i t h o u t local inflammation. T h e r e was a full range of m o v e m e n t at the elbow joint. Radiography of the u p p e r arm did not reveal any b o n y abnormality. Ziehl-Neelsen staining of pus aspirated from the lesion revealed polym o r p h o n u c l e a r leucocytes together with scanty acid-fast bacilli. Culture of the pus on L 6 w e n s t e i n - J e n s e n m e d i u m led to growth of M. fortuitum within A u t h o r to w h o m correspondence should be addressed. oi63-4453/9o/o3o223 + 0 3 $o2,oo/o
© I99o T h e British Society for the Study of Infection 9-2
224
D. W E S T M O R E L A N D
ET AL.
3 days. T h e patient was referred for an orthopaedic opinion. This was followed by surgical exploration, drainage and curettage of the abscess which was found not to communicate with the elbow joint. T h e cleaned abscess cavity was closed and the contents sent for microbiological examination. T h e contents of the abscess were stained by the Ziehl-Neelsen technique but acid-fast bacilli were not observed. Mycobacterium fortuitum, however, was isolated on L6wenstein-Jensen medium. T h e patient was treated with cefoxitin 200 mg IV twice daily for 2 weeks together with ciprofloxacin 5oo mg orally twice daily for 4 weeks. He made an uneventful recovery. Throughout his illness the patient remained afebrile, his chest X-ray, biochemical and haematological tests being normal. Tests for antibody to the human immunodeficiency virus were negative. T h e only other feature was that, at the time the abscess was drained, the patient also underwent total dental clearance because of grossly neglected dentition and numerous chronic dental abscesses. Discussion
Mycobacterium fortuitum is a rapidly growing species which is divided into three serotypes. 1'8 Lipid analysis at the Public Health Laboratory Service Mycobacterium Reference Unit in Cardiff showed that the strain isolated from our patient belonged to subtype 'peregrinum'. Results of sensitivity tests reported by the Mycobacterium Reference Unit included resistance to traditional antituberculous drugs as well as to penicillin, amoxycillin, piperacillin, cephradine, cefuroxime, erythromycin, chloramphenicol, tetracycline, clindamycin, sulphamethoxazole and fusidic acid. T h e organism was slightly sensitive to gentamicin and fully sensitive to ciprofloxacin, amikacin and cefoxitin. Primary cutaneous disease due to M. fortuitum has been described as presenting with cellulitis, draining abscesses or, as in the case described here, as a single slightly tender lump. Most patients give a history of penetrating injury, the time interval between injury and clinical onset ranging from 3 weeks-I2 months. L5-70steomyelitis may complicate cutaneous disease. Postinoculation abscesses following immunisation have also been described. 1'5 Approximately IO-2O % of cutaneous infections due to M. fortuitum are said to resolve spontaneously over a period of several months. Fatal progressive infections, however, have been described. Treatment is therefore needed. 1'2' 9 Although only a few patients with abscesses have been reported, it is recommended that abscesses should be incised and drained as well as chemotherapy given. ''7 Recommended therapy in the U.S.A. for serious infections is based on parenteral amikacin plus cefoxitin for several weeks followed by prolonged 0ral therapy selected in accordance with the results of susceptibility testsfl Ciprofloxacin and other fluorinated quinolones have been shown to be active against Mycobacterium fortuitum in vitro. 1° This agent has been used to treat one patient with peritonitis caused by M. fortuitum. 4 Our patient's illness was not considered severe enough to warrant therapy with amikacin but combined therapy with oral ciprofloxacin and parenteral cefoxitin had a good effect. Long-term follow-up is planned since relapse of the disease
Abscess due to M y c o b a c t e r i u m f o r t u i t u m
225
has b e e n n o t e d , a l t h o u g h u s u a l l y f o l l o w i n g d i s s e m i n a t e d r a t h e r t h a n localised infection. 2 C o l d abscess d u e to M . fortuitum was first d e s c r i b e d in 193 811 b u t t h e i n f r e q u e n c y o f this c o n d i t i o n has led to its diagnosis b e i n g r a r e l y c o n s i d e r e d . P r o l o n g e d d e l a y in diagnosis m a y b e f o l l o w e d b y s e v e r e d e e p - s e a t e d i n f e c t i o n s a n d o s t e o m y e l i t i s w h i c h m a y b e difficult to treat. 2 O u r p a t i e n t ' s s y m p t o m s h a d been treated unsuccessfully with antibiotics and non-steroidal anti-inflamm a t o r y a g e n t s b e f o r e a c o r r e c t diagnosis was m a d e . M i c r o b i o l o g i c a l l a b o r a t o r y r o u t i n e p r a c t i c e does n o t always i n c l u d e e x a m i n a t i o n o f skin a n d m a t e r i a l f r o m abscesses for m y c o b a c t e r i a . E x a m i n a t i o n for m y c o b a c t e r i a was p e r f o r m e d in t h e case o f o u r p a t i e n t b e c a u s e his g e n e r a l p r a c t i t i o n e r t h o u g h t t h a t t h e lesion r e s e m b l e d t u b e r c u l o u s ' c o l d ' abscesses m o r e o f t e n seen n o w a d a y s o u t s i d e t h e U . K . I n f e c t i o n w i t h an atypical m y c o b a c t e r i u m s h o u l d be c o n s i d e r e d in t h e differential diagnosis o f a n y cold abscess, p a r t i c u l a r l y if a s s o c i a t e d w i t h local trauma. (We thank M r A. C. Ross, Consultant Orthopaedic Surgeon, Royal United Hospital, Bath for permission to report this case as well as D r P. A. Jenkins and staff of the Mycobacterium Reference Unit, Cardiff for help in identification and sensitivity testing of the organism.)
References I. Woods, GL, Washington JA. Mycobacteria other than Mycobacterium tuberculosis : review of microbiologic and clinical aspects. Rev Infect Dis 1987; 9: 275-294. 2. Wallace RJ, Swenson JM, Silcox VA, Bullen MG. Treatment of nonpulmonary infections due to Mycobacterium fortuitum and Mycobacterium chelonei on the basis of in-vitro susceptibilities. J Infect Dis 1985; 152: 5oo-514. 3. Hoy JF, Rolston KVI, Hopfer RL, Bodey GP. Mycobacterium fortuitum bacteremia in patients with cancer and long-term venous catheters. Am J Med 1987; 83: 213-217. 4. Woods, GL, Hall GS, Schreiber MJ. Mycobacterium fortuitum peritonitis associated with continuous ambulatory peritoneal dialysis. J Clin Microbiol 1986; 23: 786-788. 5. Clapper WE, Whitcomb J. Mycobacterium fortuitum abscess at an injection site. J A M A 1967; 2o2: 550. 6. Canilang B, Armstrong D. Subcutaneous abscess due to Mycobacterium fortuitum. Report of a case. Am Rev Respir Dis 1968; 97: 451-454. 7. Hendrick SJ, Jorizzo JL, Newton RC. Giant Mycobacterium fortuitum abscess associated with systemic Lupus Erythematosus. Arch Dermatol I986; 122: 695-697. 8. Silcox VA, Good R, Floyd MM. Identification of clinically significant Mycobacterium fortuitum complex isolates. J Clin Microbiol 198I ; 14: 686-691. 9. Varghese G, Shepherd R, Watt P, Bruce JH. Fatal infection with Mycobacterium fortuitum associated with oesophageal achalasia. Thorax 1988 ; 43 : 15 I-152. IO. Young LS, Berlin OGW, Inderlied CB. Activity of Ciprofloxacin and other fluorinated Quinolones against mycobacteria. Am J Med 1987; 82 (4A): 23-26. i i. Cruz, J da Costa. Mycobacterium fortuitum: un novo bacilo acido-resistente pathog6nico para o homen. Acta iVied Rio DeJaneiro I938; I: 297.
