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Cutaneous Mycobacterium chelonae infection distal to the arteriovenous fistula

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ABSTRACT

A few single cases of Mycobacterium chelonae skin infection have been reported in haemodialysis patients. We report three additional cases that share peculiar clinical characteristics, pointing to diagnostic clues. All three cases presented as erythematous nodules developing distally to a proximal arteriovenous fistula (AVF). This presentation was identical to that of two published cases. A survey of all Belgian haemodialysis units during the period 2007–11 yields an estimated incidence of ∼0.9/10 000 patient-years. Although the source of M. chelonae remains unclear, this specific clinical presentation should be added to the listing of potential complications of an AVF and should be recognized, as it is fully treatable if diagnosed by culture and tissue biopsy.

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(A) Erythematous, nodular lesion on the back of the right hand, distal to the AVF. (B) Transverse (a) T1-, (b) T2- and (c) short tau inversion recovery (STIR)-weighted magnetic resonance imaging. Images at the level of metacarpal bones show severe infiltration of the dorsal soft tissues and extensor tendon sheaths (arrows), with areas of confluence corresponding to abscesses (arrowheads) and extension within the interosseous spaces (star) and volar tendon sheaths (curved arrows).
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SFW073F1: (A) Erythematous, nodular lesion on the back of the right hand, distal to the AVF. (B) Transverse (a) T1-, (b) T2- and (c) short tau inversion recovery (STIR)-weighted magnetic resonance imaging. Images at the level of metacarpal bones show severe infiltration of the dorsal soft tissues and extensor tendon sheaths (arrows), with areas of confluence corresponding to abscesses (arrowheads) and extension within the interosseous spaces (star) and volar tendon sheaths (curved arrows).

Mentions: This patient, a Caucasian man born in 1929, was on HD in our unit (Brussels) since June 2010 through a right humero-cephalic AVF. His medical history included type 2 diabetes, ischaemic heart disease treated by coronary artery bypass grafting and chronic atrial fibrillation. In July 2011, a red-purple skin lesion developed on the back of the third metacarpo-phalangeal joint of the right hand (FigureĀ 1). Antibiotics were given without improvement (cefazolin, azithromycin). A biopsy showed lichenified epidermis and a reactive dermal inflammatory infiltrate, rich in neutrophils. A polymerase chain reaction test for atypical mycobacteria was negative. Corticosteroids were injected locally in November 2011, with subsequent further growth of the lesion. Magnetic resonance imaging showed an abscess with infiltration of the tendons. The abscess fistulized to the skin with exposure of the tendons. Light microscopy of aspiration fluid showed the presence of acid-fast bacilli. Rifampicin, ethambutol, pyrazinamide and isoniazid were started. Culture grew M. chelonae; the isolate was sensitive to clarithromycin and tobramycin, so treatment was changed to rifampicin, clarithromycin and moxifloxacin. Several surgeries were required. The antibiotics were continued for 10 months, with a slowly favourable evolution. The patient died in July 2013 from an unrelated cause.Fig. 1.


Cutaneous Mycobacterium chelonae infection distal to the arteriovenous fistula
(A) Erythematous, nodular lesion on the back of the right hand, distal to the AVF. (B) Transverse (a) T1-, (b) T2- and (c) short tau inversion recovery (STIR)-weighted magnetic resonance imaging. Images at the level of metacarpal bones show severe infiltration of the dorsal soft tissues and extensor tendon sheaths (arrows), with areas of confluence corresponding to abscesses (arrowheads) and extension within the interosseous spaces (star) and volar tendon sheaths (curved arrows).
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5036905&req=5

SFW073F1: (A) Erythematous, nodular lesion on the back of the right hand, distal to the AVF. (B) Transverse (a) T1-, (b) T2- and (c) short tau inversion recovery (STIR)-weighted magnetic resonance imaging. Images at the level of metacarpal bones show severe infiltration of the dorsal soft tissues and extensor tendon sheaths (arrows), with areas of confluence corresponding to abscesses (arrowheads) and extension within the interosseous spaces (star) and volar tendon sheaths (curved arrows).
Mentions: This patient, a Caucasian man born in 1929, was on HD in our unit (Brussels) since June 2010 through a right humero-cephalic AVF. His medical history included type 2 diabetes, ischaemic heart disease treated by coronary artery bypass grafting and chronic atrial fibrillation. In July 2011, a red-purple skin lesion developed on the back of the third metacarpo-phalangeal joint of the right hand (FigureĀ 1). Antibiotics were given without improvement (cefazolin, azithromycin). A biopsy showed lichenified epidermis and a reactive dermal inflammatory infiltrate, rich in neutrophils. A polymerase chain reaction test for atypical mycobacteria was negative. Corticosteroids were injected locally in November 2011, with subsequent further growth of the lesion. Magnetic resonance imaging showed an abscess with infiltration of the tendons. The abscess fistulized to the skin with exposure of the tendons. Light microscopy of aspiration fluid showed the presence of acid-fast bacilli. Rifampicin, ethambutol, pyrazinamide and isoniazid were started. Culture grew M. chelonae; the isolate was sensitive to clarithromycin and tobramycin, so treatment was changed to rifampicin, clarithromycin and moxifloxacin. Several surgeries were required. The antibiotics were continued for 10 months, with a slowly favourable evolution. The patient died in July 2013 from an unrelated cause.Fig. 1.

View Article: PubMed Central - PubMed

ABSTRACT

A few single cases of Mycobacterium chelonae skin infection have been reported in haemodialysis patients. We report three additional cases that share peculiar clinical characteristics, pointing to diagnostic clues. All three cases presented as erythematous nodules developing distally to a proximal arteriovenous fistula (AVF). This presentation was identical to that of two published cases. A survey of all Belgian haemodialysis units during the period 2007–11 yields an estimated incidence of ∼0.9/10 000 patient-years. Although the source of M. chelonae remains unclear, this specific clinical presentation should be added to the listing of potential complications of an AVF and should be recognized, as it is fully treatable if diagnosed by culture and tissue biopsy.

No MeSH data available.


Related in: MedlinePlus