Atypical Mycobacterial Infection Clinical Presentation

  • Author: Arry Dieudonne, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Apr 16, 2012
 

History

Suppurative cervical or submandibular lymphadenopathy that produces or does not produce systemic symptoms is the most common presentation of atypical mycobacterial infection caused by M avium-intracellulare and M scrofulaceum in the immunocompetent pediatric host. In a cohort of children infected with HIV prospectively monitored by Hoyt et al in 1992, recurrent and persistent fever and chronic anemia were the most common signs and symptoms, followed by chronic diarrhea and a history of recurrent abdominal pain with disseminated M avium complex (MAC) disease[38, 40, 41]

Weight loss, failure to gain weight, and wasting syndrome are part of the long-term presentations of disseminated MAC disease in immunocompromised children. Other signs and symptoms include leukopenia, hepatosplenomegaly, and persistent generalized lymphadenopathies. Ulcerative lesions of the colon and mesenteric disease with abscess formation have been reported.[41, 42, 43] Primary cutaneous infections with MAC are rare; most cases are caused by dissemination, with manifestations including scaling plaques, crusted ulcers, ecthymalike lesions, verrucous ulcers, inflammatory nodules, panniculitis, pustular lesions, and draining sinuses.[44]

Buruli ulcer is a chronic ulcerative skin disease, caused by M ulcerans, that mostly affects the limbs. The lack of acute inflammatory response is typical and is likely due to an immunosuppressive toxin called mycolactone, which is produced by mycobacteria.[26, 25] Buruli ulcer mainly affects children living in humid areas of the tropical rain forest. Following a microinjury, the organism penetrates the skin. A subcutaneous nodule develops a few weeks later, followed by necrosis of the subcutaneous fat and finally by a large dermal ulceration. Constitutional symptoms are normally absent.

Atypical mycobacteria may cause skeletal infections. A large outbreak of spinal infections after discovertebral surgery was reported in 2001.[45] Tenosynovitis, multifocal osteomyelitis, septic arthritis, protracted carpal tunnel syndrome, and spondylitis implicating M chelonae, Mycobacterium kansasii, MAC, or Mycobacterium xenopi have been described in the literature.[46, 47, 48, 49, 50] Keratitis and endophthalmitis after intravitreous injection of steroids or other ophthalmoscopic procedures secondary to M chelonae invasion have been reported. Although most of those infections secondary to atypical mycobacteria have been described in the adult population, cases of cutaneous mycobacteriosis manifesting as cellulitis, skin abscess, or sporotrichoid lesions secondary to M chelonae abscessus and M kansasii have been reported. M kansaii and M marinum have been reported in aquariumworkers.[51, 52] M avium– associated typhlitis mimicking appendicitis has been described in an immunocompetent host.[53]

Catheter-related infections are the most common nosocomial nontuberculous mycobacterial infections encountered. The fast-growing atypical mycobacteria, such as M fortuitum, cause most catheter-related infections. Patients with long-term central intravenous catheters are most susceptible. However, infections have occurred in patients with peritoneal and shunt catheters. Local catheter site drainage; tunnel infections; and mycobacteremia, with or without fever, are the usual manifestations, but granulomatous hepatitis and, sometimes, pulmonary infiltrates have been observed. Case reports of atypical mycobacterial infection in transplant patients due to M chelonae and M xenopi have been described in the medical literature.[54, 55]

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Physical

Immunocompetent children with adenitis secondary to MAC present with suppurative adenitis that may or may not produce constitutional symptoms such as fever. Fistula may be present with coalescence of involved cervical or mandibular nodes. In immunocompromised children with HIV/AIDS, no pathognomonic signs are present. Physical examination may reveal that a debilitated patient has a history of failure to gain weight, chronic fatigue, chronic diarrhea, and recurrent abdominal pain. Hepatosplenomegaly may be present. Early during disseminated MAC disease, some patients may not have fever and may not appear acutely or chronically ill.[56]

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Causes

Numerous atypical mycobacterial infections are known. The most common forms of diseases are chronic pulmonary disease resembling tuberculosis (occurring mainly in adults), cervical adenopathy in children, skin and soft tissue infections, and disseminated disease in immunocompromised persons.[7, 16] Lymphadenitis is the most common manifestation in children.[7, 23] However, progressive immunodeficiency due to infection with HIV appears to be the most significant factor for disseminated MAC disease.[57, 16, 58]

A unique MAC syndrome that develops in patients with AIDS in the first 1-2 months following the initiation of HAART has been described by 3 groups of investigators.[59, 60, 61, 62] The symptom consists of fever and focal MAC lymphadenitis, with a blood culture negative for mycobacteria in most cases. The symptom is also known as immune reconstitution syndrome. It may occur in patients who already had subclinical MAC disease that becomes unmasked by HAART. The atypical mycobacteria observed in children are M avium-intracellulare complex, M scrofulaceum, and, rarely observed in children with AIDS, M kansasii.

Mycobacterium marinum is the causative agent of swimming pool granuloma. However, both rapidly growing and slow-growing species of NTM have been implicated in chronic granulomatous infections. Those infections mostly involve tendon sheaths, bursae, bones, and joints after direct inoculation through accidental trauma, surgical incisions, or puncture wounds.[3, 63] Tenosynovitis of the hand secondary to MAC and M marinum has been described. Osteomyelitis of the sternum caused by M abscessus has been found in clustered and sporadic outbreaks. M fortuitum and M chelonae strains, also known as the rapidly growing organisms, have occasionally been implicated in wound, soft tissue, pulmonary, and middle ear infections.[64, 7]

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Contributor Information and Disclosures
Author

Arry Dieudonne, MD  Associate Professor of Pediatrics, Division of Pulmonology, Allergy, Immunology and Infectious Diseases, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Clinical Director, Francois-Xavier Bagnold Center for Children, University Hospital

Arry Dieudonne, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

James M Oleske  MD, MPH, François-Xavier Bagnoud Professor of Pediatrics, Director, Division of Pulmonary Allergy Immunology and Infectious Diseases, Department of Pediatrics, New Jersey Medical School; Professor, Department of Quantitative Methods, University of Medicine and Dentistry of New Jersey

James M Oleske is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Allergy Asthma and Immunology, American Academy of HIV Medicine, American Academy of Hospice and Palliative Medicine, American Academy of Pain Management, American Academy of Pediatrics, American Association of Pediatrics, American Association of Public Health Physicians, American College of Preventive Medicine, American Pain Society, American Public Health Association, American Society for Microbiology, American Thoracic Society, Arab Board of Family Medicine, Association of Clinical Researchers and Educators (ACRE), Infectious Diseases Society of America, Infectious Diseases Society of America, Infectious Diseases Society of New Jersey, Medical Society of New Jersey, National Association of Pediatric Nurse Practitioners, Pediatric Infectious Diseases Society, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Itzhak Brook, MD, MSc  Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mark R Schleiss, MD  American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

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