Mycobacterium Chelonae Clinical Presentation

Updated: Jun 07, 2022
  • Author: Mary B Ford, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Presentation

History

Patients with infections secondary to M chelonae can present with a variety of clinical syndromes at sites including skin and soft tissue, bone and joint, and less commonly, pulmonary, ocular, bacteremia, and infection of prosthetic materials. [21]

Skin and soft tissue infections (SSTI) can be localized or disseminated. A case series examining M chelonae isolates from 100 skin, soft tissue, and bone cultures identified the associated clinical disease as disseminated cutaneous infection in 53% of isolates. Thirty-five percent of the isolates were characterized as localized cellulitis, abscess, or osteomyelitis. The final 12% of isolates evaluated in this study were catheter infections. [21]  SSTI typically will present as a chronic, non-healing, ulcer or cellulitis. Patients frequently will have had courses of antimicrobials traditionally used for bacterial SSTIs and will have demonstrated either initial mild improvement with relapse of infection after cessation of treatment, or no response to therapy at all. In patients with non-resolving or relapsing SSTI, M chelonae is an important pathogen to consider. Patients with localized SSTI may report a history of superficial cosmetic procedures including recent tattoos, pedicures, or mesotherapy. Those with disseminated cutaneous disease are likely to have a history of chronic immunosuppression, either from long-term corticosteroid use, underlying organ transplantation, or rheumatoid arthritis. [21]

As mentioned, pulmonary disease secondary to M chelonae is much less common. A paper examining chronic lung disease due to RGM found only 1 of 146 isolates identified as M chelonae. [18]  Symptoms with M chelonae pulmonary disease are similar to symptoms caused by disease with other NTM: patients often present with chronic cough with or without sputum production, and progressive dyspnea. Systemic symptoms including fever, night sweats, fatigue, and weight loss also can occur with these infections. Patients often have a history of underlying pulmonary disease including chronic obstructive pulmonary disease (COPD), cystic fibrosis, and bronchiectasis. [35]

A variety of other rare clinical syndromes secondary to M chelonae are reported in the literature. [5, 6]  Although less common than infections with M abscessus and M fortuitum, it is important to consider M chelonae as a pathogen in patients presenting with wound infections after medical or surgical procedures. In addition to wound infections, instrumentation including placement of intravenous or peritoneal dialysis catheters also can lead to infection with M chelonae. [36]

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Physical

No physical examination findings are pathognomonic for M chelonae infection, and the presentation of these infections varies widely by clinical syndrome. An abnormal pulmonary exam – diminished breath sounds, rhonchi, or rales – would be expected for NTM pulmonary disease depending on the severity and the extent of the disease, but this is not unique to M chelonae infections. The focus here is on the skin and soft tissue features of M chelonae infection, as this is the most likely clinical scenario where it will be encountered. 

NTM SSTI can be fairly nonspecific as these infections may present with cellulitis, abscess, ulcers, nodules, sporotrichoid lesions, and draining sinus tracts, among other presentations. [37]  These infections can present as single or multiple lesions, depending on the route of infection and the immune status of the host. M chelonae has been documented to cause multiple lesions more frequently than the single lesions of M fortuitum. [12, 38]

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Causes

Community-acquired disease

Community acquired SSTI and/or bone disease often isdue to traumatic inoculation of M chelonae from the environment. Classic evidence supporting this includes documentation of outbreaks of M chelonae infections associated with tattoo parlors and with contaminated footbaths at nail salons. [20, 19]  What about risk factors or causes of pulmonary disease? A study evaluating the clinical relevance of M chelonae-abscessus infections found that pre-existing pulmonary disease, including COPD, smoking, CF, and non-CF bronchiectasis, was the most common pre-disposing condition for NTM pulmonary disease caused by these organisms. [33] However, a systematic review performed by Lange et al failed to identify risk factors for M chelonae pulmonary disease in the 57 patients evaluated. [39]  Immune compromise, especially long-term steroid use, hematologic malignancy, solid organ transplant, and rheumatoid arthritis with its associated immunomodulatory medications place patients at increased risk for development of disseminated disease. [21, 5]

Healthcare-associated disease

A multitude of clinical syndromes secondary to M chelonae have been described following medical or surgical procedures. These infections can result from contaminated surgical equipment or implants, or from environmental sources, most commonly tap water. M chelonae infections have been described after cosmetic procedures including liposuction, botox injections, breast augmentation, and cosmetic facial procedures. [40]  Surgical implants including ocular implants and porcine heart valves that were contaminated with M chelonae, with resultant infection, have also been reported. [5, 25]  Although uncommon, M chelonae intravenous catheter-related infections have occurred, as has M chelonae peritonitis secondary to peritoneal dialysis catheters. [5]  

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Complications

Although untreated infections can lead to significant morbidity, complications of M chelonae infection typically stem from sequalae of the difficult to eradicate disease process and toxicity from therapy. If extensive or disseminated, SSTI or bone infection with M chelonae can require highly morbid surgical debridement. Pulmonary disease can lead to permanent parenchymal damage. If the infection was found to be associated with implanted foreign material, it nearly always is necessary to removal the foreign body to achieve cure. Rarely, severe lung or disseminated disease can lead to death.

Appropriate antimicrobial therapy for M chelonae infections typically requires at least 2 to 3 antimicrobials, 1 or more of which are typically administered intravenously for at least the first 2 to 6 weeks. Depending on the extent and location of disease, length of therapy can be anywhere from a few months to longer than a year. These prolonged courses of multiple antimicrobials place the patient at risk for developing a multitude of antimicrobial-associated complications including drug reactions, antibiotic associated diarrhea, and development of drug resistant organisms.

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