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Atypical Mycobacterial Diseases Clinical Presentation

  • Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: Dirk M Elston, MD  more...
Updated: Feb 16, 2016


Underlying diseases contribute to atypical mycobacteria infections, including pulmonary emphysema, diabetes mellitus, leukemia, collagen diseases, lung cancer, chronic kidney diseases, systemic lupus erythematosus (SLE),[3, 4] carcinomatous pleurisy, bronchiectasis, and previously treated tuberculosis. Drug abuse is a risk factor for atypical mycobacteria infections.[5] Anti–tumor necrosis factor therapy is another risk factor for atypical mycobacteria infections.[6] Immunosuppression[7] and tattoos[8] continue to be situations in which mycobacterial infections can occur. M haemophilum skin infection has been noted in a patient with multiple drug allergies and systemic lupus erythematosus.[9]

Most patients with M malmoense infections are older people with lung disease. Cutaneous M chelonae infection has occurred in a patient who underwent liver transplantation.

Some patients give a history of surgery. Surgery can provide a portal of entry of such infections. Procedures include cosmetic liposuction,[10] liposculpture,[10] breast augmentation mammaplasty, or median sternotomy.

In 2007, Sañudo et al[11] described nontuberculous mycobacterial infection after mesotherapy in 15 patients.

Breast implant infection with M fortuitum group was reported by Vinh et al[12] ; it required removal of the implant and a prolonged course of antibiotics. After the infection resolved, a new implant was successfully placed.

Infections with atypical mycobacteria following trauma have been reported.

In 2007, Murdoch and McDonald[13] reported M avium-intracellulare cellulitis occurring with septic arthritis after joint injection.

Nosocomial disease has become increasingly important; pseudoepidemics associated with contaminated, automated endoscopic washing machines are the most recently described manifestation. M chelonae has been found in the colonic mucous membranes, the respiratory tracts, and as a contaminant in the tap water used for diluting concentrated chlorhexidine. The organism happened to be isolated with the mucous membranes that were picked up while using the washed fiberscope in the colons of 6 patients. These findings suggest that M fortuitum and M chelonae groups, in spite of the fact that they rarely cause infection, have a significant risk of infecting older patients (those >60 y) in general hospitals with various underlying diseases attributable to infections.

Two patients were infected with M smegmatis after self-injection with a veterinary-grade anabolic steroid.

Most patients with M kansasii infection have some alteration of their immune status, but disseminated infection is relatively uncommon.

Patients can report systemic and constitutional symptoms that include productive cough/purulent sputum, hemoptysis, weight loss, weakness, fever, and night sweats.

Injection abscesses due to M chelonei var abscessus have been reported in a patient with diabetes. M chelonae wound infections after plastic surgery using contaminated gentian violet skin-marking solution has also been reported.[14] Infection with M abscessus associated with intramuscular injection of adrenal cortex extract has been reported.[15] Skin lesions due to M chelonae subsp abscessus associated with injections of lidocaine (lignocaine) given by a bioenergetic (a practitioner of alternative medicine) in Colombia have been reported. Megaesophagus and pulmonary infection with rapidly growing mycobacteria have been reported.[16] M chelonae often occurs after puncture wounds and is a community-acquired disease. Infection can occur from scratches; road traffic accidents; and other trauma, such nails or wire.

A patient with M gordonae infection reported a rat bite.

In 2003, Sungkanuparph et al[17] reported a retrospective study of a series of patients infected with rapidly growing mycobacteria in Ramathibodi Hospital (Bangkok, Thailand) from January 1993 to June 1999. The following was reported:

Eighteen patients had no underlying disease, and 2 were infected with HIV. Reported physical findings were lymphadenitis (7), skin and subcutaneous abscess (7), eye infection (4), pulmonary infection (1), and chronic otitis media (1). Sweet syndrome manifested in 4 of 7 patients with lymphadenitis. The organisms isolated included M chelonae/M abscessus group (17 cases) and M fortuitum group (3 cases).

The atypical mycobacteria were susceptible to amikacin, netilmicin, and imipenem. The M fortuitum group was susceptible to more antibiotics than the M chelonae/M abscessus group.

Histology findings demonstrated pathology that ranged from nonspecific to suppurative or caseous granulomas.

Antimicrobial susceptibility defined the clinical response, which was good. A combination of 2 or more drugs provided effective therapy. Surgical resection was performed in apposite cases to reduce the load of the organism. Surgery was almost always used in cases with infections involving pan-resistant atypical mycobacteria. Atypical microbacterial disease can affect the eyes and adnexal tissue.[18] It could be that malnourished person with anorexia nervosa are at greater risk than those who are well nourished, as a report of M avium-intracellulare infection in a female with anorexia nervosa has been noted.[19]

Redboard et al[20] noted 4 cases of M fortuitum complex furunculosis after pedicures (in Cincinnati, Ohio and northern Kentucky) that manifested as nonhealing furuncles on the lower leg.

In 2007, Hoetzenecker et al[21] described dissemination of a localized cutaneous infection with M chelonae in a patient undergoing immunosuppressive treatment.

A case of breast infection with combined Prevotella melaninogenica and M fortuitum infections following nipple piercing has been reported.[22]

Bilateral sporotrichoid lymphocutaneous dermatosis in a drug abuser caused by M fortuitum cured by clarithromycin and ciprofloxacin has been noted.[5]

M kansasii olecranon bursitis was reported in a woman treated with infliximab for Behçet disease.[6]

Toyoda et al report a case of a pediatric patient with squamous cell carcinoma who initially presented at age 1 year with an infection by atypical mycobacteria (ie, M fortuitum, Mycobacterium porcium).[23]

Duraipandian et al report a patient with asthma and diabetes who presented with an exacerbation of chronic obstructive pulmonary disease; physical examination findings included 2 soft nodules in an axillary location. Testing reveal co-infection with Aspergillus flavus and M fortuitum.[24]

In 2014, Mycobacterium arupense was noted to cause large-joint osteoarticular infection.[25]

In 2014, atypical mycobacterial infections were noted in Louisiana in the exit sites of peritoneal dialysis catheters.[26]

Breast prostheses can be the site of atypical mycobacterial infections.[27]



The lesions of atypical mycobacteria infection manifest in a variety of fashions. They can manifest with lymphadenitis, especially cervical lymphadenitis. Multiple or isolated skin nodules can present in a linear distribution. In this way, atypical mycobacteria infections can resemble sporotrichosis. This section reviews case reports related to specific types of atypical mycobacteria.

M genavense has caused disseminated disease in patients who are HIV positive.

In preschool-aged children who are immunocompetent, cervical lymphadenitis has been caused by M malmoense. It has caused cutaneous nodules on the hands.

Cutaneous infection has been caused by M szulgai in a boy who underwent a bone marrow transplantation with marrow from a matched unrelated donor.[28] M szulgai has caused cellulitis, draining nodules, and plaques. It has also been related to bursitis and pneumonia. Only a handful of case reports on M szulgai have been published. A patient with SLE developed a cutaneous nodule caused by M szulgai. Another patient was on long-term corticosteroid therapy for sarcoidosis and exhibited multicentric, purely cutaneous infection. Another patient had disseminated disease involving the skin, the bones, and the lungs and was shown to have a diminished proportion of T lymphocytes and a suppressed response to mitogens. Another patient had multiple inflammatory skin lesions and osteomyelitis and had been receiving prednisone therapy for desquamate interstitial pneumonitis. Finally, a patient aged 6 months with a carbuncle over the angle of the jaw has been reported.

M scrofulaceum is a slow-growing atypical mycobacteria that is found in environmental water sources, tap water, and the human respiratory tract. It causes scrofula, a granulomatous cervical adenitis in children and pulmonary disease in adults. It is usually unilateral. Few reports of it causing skin disease exist. It has caused an isolated red nodule on the finger. In 1987, Murray-Leisure et al[29] described a man with SLE who developed cutaneous abscesses due to M scrofulaceum. In 1982, Sowers[30] reported a case in which M scrofulaceum caused sporotrichoid infection of the hands of a woman who regularly cleaned fish aquariums.

A case series of disseminated M simiae infection with blood, pulmonary, and cutaneous localization has been reported. From the 11-year period from 1983-1993, 137 clinical isolates of M simiae were obtained from 75 patients at a university hospital in San Antonio, Texas. The sites of isolation of the 137 specimens varied. Of the isolates, 128 (93%) were from a pulmonary source, 4 (3%) were from a hematologic source, 1 (0.8%) was from a skin source, 1 (0.8%) was from urine, 1 (0.8%) was from a lymph node, 1 (0.8%) was from bone marrow, and 1 (0.8%) was from the brain. Of 62 patients in this series, 6 (10%) had definite infection, 9 (14%) had probable disease, and 48 (76%) were thought to be colonized. During the last 2 years of the study, 1992-1993, M simiae became the second most frequently isolated NTMB at this university hospital in San Antonio, Texas. The only atypical mycobacteria that infected more patients were of the M avium complex species.

M smegmatis has been linked to cutaneous disease.

M kansasii presents clinically in a manner most resembling tuberculosis. Most patients who present with localized primary cutaneous M kansasii infection are immunocompetent, whereas most patients with disseminated or pulmonary infection are immunocompromised. It may resemble cellulitis or sporotrichosis. M kansasii flexor tenosynovitis caused the development of carpal tunnel syndrome.[31] The diagnosis was made from synovial tissue specimens. It has also caused granulomatous synovitis and bursitis. M kansasii infection has been limited to the skin in a patient with AIDS with intracutaneous abscess formation and regional lymph node enlargement. M kansasii infection has presented as cellulitis in a patient with SLE.

Cutaneous and mediastinal lymphadenitis due to M kansasii is reported. M kansasii can cause septic arthritis.[32] About 50 cases have been published. Risk factors include local trauma; local or systemic corticosteroid therapy; chronic skin psoriasis; and immunodepression, especially that due to HIV infection. A clinical presentation similar to that expected in lupus profundus has been reported. Cutaneous M kansasii infection associated with a papulonecrotic tuberculid reaction[33] and ulcerative perineal lesions[34] due to M kansasii have been reported.

Cutaneous M chelonae infection has occurred with a bilateral linear distribution that resembled sporotrichosis.[35]

M gordonae has caused granulomatous synovitis and bursitis. It is sometimes called tap water scotochromogen. It has also caused granulomatous nodules on the back of the hand.

M haemophilum can cause multiple, tender, cutaneous nodules. They can be purple and develop into ulcers or abscesses. They are often situated over the joints of the limbs. Wasting, tenosynovitis, and joint effusions can occur.

M fortuitum, M chelonae, and M abscessus can present as painful papular lesions, epitrochlear adenopathies, and erythematous nodular and ulcerating skin nodules. In people with end-stage renal disease who are on hemodialysis, atypical mycobacteria infection manifests as multiple abscesses on the lower legs. A dermatosis with a linear distribution, which resembles the dermatitis caused by sporotrichosis, and is caused by M abscessus has been reported. Disseminated nodules are rare. An infection due to atypical mycobacteria, acquired from a public bath, has been reported.[36] Cold abscesses can be present. Erythema at the site of a puncture wound can also occur as an initial manifestation of an atypical mycobacteria infection. Other findings present in patients infected with atypical mycobacteria can include osteomyelitis, lymphadenitis, and endocarditis. Atypical mycobacteria infections can result is keratitis and corneal ulcerations.

A case of concomitant M avium-intracellulare infection with leukocytoclastic vasculitis of the skin in a female with anorexia nervosa who had pulmonary M avium-intracellulare infection has been noted.[19]



Exposure to contaminated water, injections, surgical procedures, and trauma has been linked to infection with atypical mycobacteria. Immunosuppression predisposes patients to infections with atypical mycobacteria. This would include exposure to tumor necrosis factor-alpha–blockings drugs and interleukin (IL)-12/23–blocking drugs. This is also the case in genetic defects that involve immune impairment.

An interesting report in 2012[37] noted a child suffering from complete interferon (IFN)–γ receptor-1 deficiency who was afflicted with recurrent M bovis, M avium intracellulare, M tuberculosis, and M fortuitum infections. These infections manifested with granulomatous skin plaques involving severe lower limb and scrotal edema. The child died after stem cell transplantation. This might be the first case of a IL-12/IFN-γ pathway defect characterized by severe lymphedema.

In a hospital in Taiwan,[38] 12 cockroaches (Periplaneta americana) were found to be infected with the following organisms:

  • Four with M kansasii
  • Three with M xenopi
  • Two with M gordonae
  • One with M haemophilum
  • One with M fortuitum
  • One with M avium

Because cockroach infestation commonly occurs in the hospital environment, cockroaches might be implicated as a cause of hospital-acquired infections due to atypical mycobacteria.

Contributor Information and Disclosures

Noah S Scheinfeld, JD, MD, FAAD Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice

Noah S Scheinfeld, JD, MD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Abbvie<br/>Received income in an amount equal to or greater than $250 from: Optigenex<br/>Received salary from Optigenex for employment.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey P Callen, MD Professor of Medicine (Dermatology), 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, American College of Rheumatology

Disclosure: Received income in an amount equal to or greater than $250 from: XOMA; Biogen/IDEC; Novartis; Janssen Biotech, Abbvie, CSL pharma<br/>Received honoraria from UpToDate for author/editor; Received honoraria from JAMA Dermatology for associate editor and intermittent author; Received royalty from Elsevier for book author/editor; Received dividends from trust accounts, but I do not control these accounts, and have directed our managers to divest pharmaceutical stocks as is fiscally prudent from Stock holdings in various trust accounts include some pharmaceutical companies and device makers for i inherited these trust accounts; for: Celgene; Pfizer; 3M; Johnson and Johnson; Merck; Abbott Laboratories; AbbVie; Procter and Gamble; Amgen.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

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.

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Mycobacterium marinum is an atypical mycobacteria found in water with a wide range of temperatures and salinities
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