eMedicine Specialties > Infectious Diseases > Mycobacterial Infections
Mycobacterium Chelonae
Updated: Aug 26, 2009
Introduction
Background
Mycobacterium chelonae and Mycobacterium abscessus are nontuberculous mycobacteria (NTM), a grouping that encompasses all mycobacteria outside of the Mycobacterium tuberculosis complex. They are classified in the Runyon group IV, rapidly growing mycobacteria. They have been found in natural and processed water sources, as well as in sewage, and are especially common in tap water. Distribution is probably worldwide.
M abscessus was previously classified as a subspecies of M chelonae. For this reason, determining which species is actually involved in an infection is often difficult, especially in older reports. Further identification of newer species such as Mycobacterium massiliense and Mycobacterium bolletii may further complicate future taxonomy.1 Prior reviews have dealt with both M abscessus and M chelonae infection; however, this review focuses solely on infections due to M chelonae.
These organisms are difficult to treat once true infection (versus colonization) is diagnosed and documented.
Of note, most information regarding diagnosis and treatment of M chelonae infection is derived from case reviews and expert opinion. Definitive statements regarding diagnosis and treatment are often lacking.2
Scanning electron micrograph of Mycobacterium chelonae. Courtesy of the CDC and Janice Haney Carr.
Scanning electron micrograph of Mycobacterium chelonae. Courtesy of the CDC and Janice Haney Carr.
Pathophysiology
M chelonae causes various clinical syndromes, including lung disease, local cutaneous disease, osteomyelitis, joint infections, and ocular disease (eg, keratitis or corneal ulcers). With the exception of lung disease, these syndromes commonly develop after trauma. M chelonae is a rare cause of isolated lymphadenitis. Endocarditis has also been documented. Disseminated disease, usually with disseminated skin and soft tissue lesions, occurs almost exclusively in the setting of immunosuppression, especially AIDS. Esophageal disorders may place patients at increased risk for pulmonary disease due to rapidly growing mycobacteria.3
Surgical-site infections due to M chelonae are well documented, especially in association with cardiothoracic surgery and augmentation mammoplasty. Alternative practices such as mesotherapy have been associated with skin infections.4 Frequently, the source is contamination of the wound, directly or indirectly, with colonized tap water; however, nosocomial infections have also been associated with contaminated gentian violet used for skin marking in plastic surgery.5 Other nosocomial M chelonae infections include infections of implanted devices (eg, catheters) and injection-site abscesses. A recent hospital outbreak in India was associated with the water used to rinse endoscopes for laparoscopic surgery, resulting in 145 infections in 35 patients. Pseudo-outbreaks have been associated with contaminated endoscopes.6 No human-to-human transmission has been documented.
In patients without HIV infection, cell-mediated immune defects may be responsible for dissemination of NTM, as many patients have concomitant reactive skin diseases.7
Frequency
United States
Reporting of NTM infections is not required; therefore, exact estimates of disease prevalence and incidence are impossible to determine. The most recent estimates come from voluntary reports tracked by the US Centers for Disease Control and Prevention (CDC). From 1993-1996, 0-0.27 cases of M abscessus infection per million population were reported to the CDC. For M chelonae infection, the rate was 0.93-2.64 cases per million population.8 Sputum was the most frequently reported site for both organisms, but this may represent a bias in the sites most likely to be cultured for mycobacteria.
One half of the reports of M abscessus infection came from mountainous regions of the western United States, including Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming. Almost all the cases of M chelonae infection were reported from the north-central United States, including Illinois, Indiana, Iowa, Michigan, Minnesota, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; the south-central United States, including Arkansas, Kansas, Louisiana, Missouri, Oklahoma, and Texas; and the southeast United States, including Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia.
Because all cases were likely not reported and some positive cultures may not represent disease, which is especially true of positive sputum cultures, these numbers may significantly overestimate or underestimate true disease incidence. However, they suggest the general order of magnitude of the situation. The increased recognition of M abscessus and M chelonae as true pathogens may be one reason why NTM infection rates are perceived to be increasing, even excluding Mycobacterium avium complex (MAC) infections in patients with AIDS.
International
The World Health Organization does not track NTM infections. Incidence and prevalence undoubtedly vary greatly by locale. For an extensive review of the international epidemiology of pulmonary nontuberculous mycobacteria, please see the review article by Marras and Daley.9 A recent study suggests that the incidence in Thailand may be increasing.7
Mortality/Morbidity
- Mortality from localized M chelonae infection is rare. Death may result from extensive pulmonary or disseminated disease.
- Morbidity largely depends on the site of infection. Localized skin lesions may eventually heal without therapy or surgical intervention. At other sites, chronic infection is common.
Race
M chelonae infection has no clear racial predilection.
Sex
M chelonae infection has no known sexual preference; approximately equal numbers of cases in men and in women were reported to the CDC from 1993-1996.8
Age
In general, M chelonae infection has no known age predilection. Lung disease in a younger patient (<50 y) strongly suggests a primary underlying lung disorder. Isolated lymphadenitis primarily occurs in children.
Clinical
History
- Patients with M chelonae skin disease may have a nonhealing but nonspreading wound or skin ulcer.
- Patients with M chelonae lung disease may have a chronic cough.
- Easy fatigability, occasional fever, night sweats, and weight loss occur with pulmonary or disseminated disease, although less commonly than with tuberculosis.
Physical
No physical examination findings are pathognomonic for M chelonae infection. Findings depend on infection site.
- Skin: Ulcerative lesions and/or subcutaneous nodules may be present. Deep infection may lead to draining fistulas. In contrast with Mycobacterium fortuitum infection, the skin lesions caused by M chelonae infection tend to be multiple and tend to occur in older patients and individuals receiving immunosuppressive drugs.10
Cutaneous lesions from Mycobacterium abscessus. Courtesy of K. Galil, US Centers for Disease Control and Prevention.
- Eye: Corneal ulcers or keratitis may be present.
- Lungs: Rales or rhonchi may be present.
- Heart: Valvular murmur with endocarditis may be present.
- Abdomen: Diffuse tenderness with peritonitis may be present, similar to that associated with peritoneal dialysis.
Causes
- Trauma or injection - Skin lesions, subcutaneous lesions, ocular lesions, and osteomyelitis
- Disseminated disease - Immunosuppression, especially AIDS or corticosteroid use
- Lung disease -Achalasia and bronchiectasis
More on Mycobacterium Chelonae |
 Overview: Mycobacterium Chelonae |
| Differential Diagnoses & Workup: Mycobacterium Chelonae |
| Treatment & Medication: Mycobacterium Chelonae |
| Follow-up: Mycobacterium Chelonae |
| Multimedia: Mycobacterium Chelonae |
| References |
| Further Reading |
| Next Page » |
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Further Reading
Clinical trials
Study of Mycobacterial Infections
Genetic Disorders of Mucociliary Clearance in Nontuberculous Mycobacterial Lung Disease
Keywords
Mycobacterium chelonei, M chelonei, M chelonae, Mycobacterium chelonae, Mycobacterium abscessus, M abscessus, nontuberculous mycobacterium, nontuberculous mycobacteria, mycobacterium other than tuberculosis, MOTT, Mycobacterium tuberculosis, mycobacterial cutaneous infection, NTM, NTM lung disease, AIDS, HIV, Runyon classification, Runyon's classification, Runyon classification group IV, Runyon group IV, rapidly growing mycobacteria, osteomyelitis, keratitis, corneal ulcers
