eMedicine Specialties > Dermatology > Mycobacterial Infections

Mycobacterium Avium-Intracellulare Infection: Differential Diagnoses & Workup

Author: Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Coauthor(s): Supriya Tomar, MD, Consulting Staff, Mohs College; Douglas W Kress, MD, Program Director, Medical Director of Clinical Services, Department of Dermatology, University of Pittsburgh Medical Center; Nicole Restauri, MD, Staff Physician, Radiology, University of Pittsburgh School of Medicine; Jessica M Allan, MD, Consulting Staff, Private Practice
Contributor Information and Disclosures

Updated: Jul 15, 2008

Differential Diagnoses

Acneiform Eruptions
Majocchi Granuloma
Actinomycosis
Mycetoma
Cellulitis
Mycobacterium Marinum Infection of the Skin
Chromoblastomycosis
Prurigo Nodularis
Coccidioidomycosis
Pseudomonas Folliculitis
Ecthyma
Pyoderma Vegetans
Ecthyma Gangrenosum
Rhinoscleroma
Halogenoderma
Rosacea
Impetigo
Sarcoidosis
Leishmaniasis
Yaws
Leprosy

Other Problems to Be Considered

In 2007, Perrin8 noted a patient with AIDS and a cutaneous MAI infection mimicking histoid leprosy.

Workup

Laboratory Studies

  • If MAI or DMAI infection is suspected, an HIV test should be performed. To evaluate the disease of MAI infection itself, a CBC count with differential should be performed. Disseminated disease can cause blood abnormalities. These abnormalities include anemia, leukocytosis, leukopenia, and hypogammaglobulinemia. Alkaline phosphatase levels can be elevated in persons with DMAI infection.
  • A urinalysis should be performed.
  • A liver function panel should be obtained.
  • Cultures should be obtained. MAI is classified as a nonchromogen. It is slow growing, and colonies may not appear for 2-4 weeks. Culture sites should include cutaneous lesions, blood, sputum, and urine if DMAI disease is suspected. Stool cultures can be collected if diarrhea is present.
  • Polymerase chain reaction studies of tissue may yield organism identification in 24 hours.

Imaging Studies

  • Chest radiography is indicated to assess pulmonary involvement if disseminated disease is suspected. One series found that 8 of 11 cases of DMAI infection with cutaneous involvement had positive results on chest radiographs.

Procedures

  • Biopsy should be performed. Tissue samples of cutaneous lesions may be obtained for histopathologic evidence of mycobacterial infection, and staining with Ziehl-Neelsen stain may reveal acid-fast bacilli.

Histologic Findings

A spectrum of histologic findings is present in skin infection with MAI. This is not surprising because tissue pathology varies with the stage of the disease and the host's immune status.

Granulomas are often present in tissue infected with MAI. Tuberculid, palisading, and sarcoidlike granulomas can be found in the context of a diffuse infiltrate of foamy histiocytic cells. Other nonspecific findings include panniculitis, chronic inflammation, cutaneous abscesses, necrotizing folliculitis, and suppurative granulomas.

Liou et al9 noted that spindle cell pseudotumors due to mycobacterial infection may occur in immunocompromised hosts. They reported a case of spindle cell pseudotumor in a 37-year-old man with AIDS. The tumor manifested as a firm nodule on the right arm. Histologically, the tumor was composed of spindle cells mixed with histiocytes and inflammatory cells. Ziehl-Neelsen stain revealed many acid-fast bacilli. The bacilli were identified as MAI. Culture and sequencing of the polymerase chain reaction product of the mycobacterial 65-kd heat-shock protein gene helped to establish the diagnosis. Immunohistochemically, the spindle cells stained with CD68, a marker found on active tissue macrophages.

In 2007, Shiomi et al10 reported a 58-year-old Japanese woman with systemic lupus erythematosus and interstitial pneumonia for 17 years. She had been treated with prednisolone and azathioprine, as well as insulin treatment for diabetes mellitus. She had a nodule in the deep dermis with extension into the subcutaneous fat tissue. The nodule was composed of spindle cells focally showing a vaguely storiform pattern, with focal foam cells, epithelioid histiocytes, and multinucleated giant cells. Ziehl-Neelsen staining showed numerous acid-fast bacilli within the spindle cells and epithelioid histiocytes, which were determined to be MAI after culture and polymerase chain reaction testing.

Staging

MAI is described as either localized or disseminated. A staging system is not applicable.

More on Mycobacterium Avium-Intracellulare Infection

Overview: Mycobacterium Avium-Intracellulare Infection
Differential Diagnoses & Workup: Mycobacterium Avium-Intracellulare Infection
Treatment & Medication: Mycobacterium Avium-Intracellulare Infection
Follow-up: Mycobacterium Avium-Intracellulare Infection
References
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References

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  2. Sanderson TL, Moskowitz L, Hensley GT, Cleary TJ, Penneys N. Disseminated Mycobacterium avium-intracellulare infection appearing as a panniculitis. Arch Pathol Lab Med. Mar 1982;106(3):112-4. [Medline].

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Further Reading

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Keywords

Mycobacterium avium complex, Mycobacterium avium-intracellulare, MAI, MAC, disseminated Mycobacterium avium-intracellulare, DMAI, cutaneous MAI, cervical adenitis, cervical lymphadenitis, atypical mycobacterial disease

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Contributor Information and Disclosures

Author

Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Optigenex Consulting fee Independent contractor

Coauthor(s)

Supriya Tomar, MD, Consulting Staff, Mohs College
Disclosure: Nothing to disclose.

Douglas W Kress, MD, Program Director, Medical Director of Clinical Services, Department of Dermatology, University of Pittsburgh Medical Center
Douglas W Kress, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Nicole Restauri, MD, Staff Physician, Radiology, University of Pittsburgh School of Medicine
Disclosure: Nothing to disclose.

Jessica M Allan, MD, Consulting Staff, Private Practice
Disclosure: Nothing to disclose.

Medical Editor

Takeji Nishikawa, MD, Emeritus Professor, Department of Dermatology, Keio University School of Medicine; Director, Samoncho Dermatology Clinic; Managing Director, The Waksman Foundation of Japan Inc
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine
Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology
Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Honoraria Consulting; Centocor Honoraria Consulting

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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