Extensive Infection of Face by Mycobacterium chelonae: An Unusual Presentation.

Mycobacterium chelonae is a rapidly growing mycobacteria, causes cutaneous, soft tissue, and rarely lung infections. Here we present a rare case of extensive infection of face at multiple sites by Mycobacterium chelonae, with an unusual presentation, diagnosed by using conventional methods.

What was known?

Mycobacterium cheolonae is rapid growing (Group IV) atypical mycobacteria (growth in 1-7 days) and can cause infections in Immunocompromised as well as immunocompetent people. Infections caused are Cutaneous infections (cervical skin, hand and leg), post operative infections and injection abscesses. (Face is very unusual site of infection).

Introduction

Cutaneous infections by rapid growing atypical mycobacteria are being reported increasingly nowadays, especially in immunocompromised patients or patients with underlying diseases. Among rapid growing mycobacteria Mycobacterium fortuitum, Mycobacterium chelonae and Mycobacterium abscessus are reported commonly. These organisms are probably transmitted by water, dust, aerosol or unsterile injections. Postoperative infections and injection abscesses are commonly reported. In cutaneous infections, cervical skin, hand and leg are the common sites. Face is a very unusual site of infection. Here, high clinical suspicion of atypical mycobacterial infection is important because these bacteria do not respond to the first-line antikoch's treatment, and even may not respond well to the second-line antimycobacterial treatment.[1]

Case Report

A 48-year female presented with complaints of generalized edema, generalized weakness, mild to moderate fever without chills since 2-3 weeks.

The patient had history of trauma by unsterile blade over her face and neck 1 year back. The injuries were in the form of abrasions and were all over neck, cheek as well as forehead [Figure 1a–c]. These injuries never healed completely. She was subscribed treatment orally, topically. But there was no improvement and things got worsened after her intralesional treatment. She lost appetite and weight, and due to facial lesions her face was also disfigured. Her lesions were from 1×1 to 3×3 cm, tender, inflamed, indurated, and discharging seropurulent fluid. Gram staining of aspirate from lesions revealed no organism; Ziehl-Neelsen staining showed abundant acid fast bacteria. Blood agar [Figure 2] and Lowenstein Jensen media showed growth of cream-white-colored colonies in 3-4 days. MacConkey agar also showed growth of acid fast bacilli. The rapidly growing bacteria was identified by nitrate reduction and aryl sulfatase test. It was differentiated from Mycobacterium fortuitum by sensitivity to polymixin B 300 unit disc on blood agar [Figure 3].[1] There was no zone of inhibition around the polymixin B disc. Mycobacterium chelonae was differentiated from Mycobacterium abscesses by a positive citrate test and inability to grow in 5% NaCl.[2]

Figure 1a

Extensive lesions on face and neck, few in the stage of healing

Figure 1c

Abscess like lesions on forehead

Figure 2

Growth on blood agar in 3 days

Figure 3

Identification by using a polymixin B disk

Lesion on cheek

Sensitivity was carried out as per CLSI (M24)[3] guidelines for rapidly growing mycobacteria by MIC break point testing. Drugs used were cotrimoxazole, ciprofloxacin, moxifloxacin, cefoxitin, amikacin, doxycycline, clarithromycin, linezolid, imipenem, cefepime, amoxicillin/clavulanic acid, ceftriaxone, minocycline, and tobramycin.

M. chelonae was sensitive to ciprofloxacin, moxifloxacin, cefoxitin, amikacin, doxycycline, linezolid, imipenem, and tobramycin while it was resistant to cotrimoxazole,, clarithromycin, cefepime, amoxicillin/clavulanic acid, ceftriaxone, and minocycline.

The patient was started with levofloxacin, linezolid, and amikacin. The patient showed considerable improvement after 3 weeks, treatment being continued.

Discussion

Various cases of cutaneous atypical mycobacterium infection have been reported of Mycobacterium chelonae and Mycobacterium fortuitum, in both immunocompromised and immunocompetent individuals.[34] Mycobacterium fortuitum is reported from injection abscess, postoperative infections.[45] While cases of Mycobacterium chelonae infection are reported from postoperative wound infections and a case from open fracture,[67] M. chelonae has been associated with prosthetic valve endocarditis and central line infections. It can cause keratitis in contact lens wearers and wound infection after ocular surgery, including LASIK surgery or postcataract lens replacement surgery.[89]

M. chelonae is associated with skin, bone, and soft tissue infections. It is not transmitted from person to person but is acquired from the environment. The route of infection for atypical mycobacteria is inoculation in the cutaneous infections and inhalation in the pulmonary infections.

In our case, the route of infection could be either primary trauma by unsterile blade or intralesional injections. Such extensive infection in the form of multiple sites over face and neck is rarely reported. Diagnosis of atypical mycobacterial infection and sensitivity is of utmost importance to prevent long-term morbidity in patients.

What is new?

Face is very unusual site of infection in this case. Similar cases have not been found in reviewed case reports. The patient had a history of lesions since years and possibility of not getting appropriate treatment cannot be ruled out. Thus, diagnosis of atypical mycobacteria is important now days, otherwise the infection could result in adverse prognosis.