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CID 1998;26 (June)
Brief Reports
the avoidance of unnecessary endoscopic retrograde cholangiography and may be used in cases in which endoscopic retrograde
cholangiography is not possible.
Andrea Laghi, Antonella Teggi, Paolo Pavone,
Cristiana Franchi, Franco De Rosa, and Roberto Passariello
Departments of Radiology and Infectious and Tropical Diseases,
University of Rome, Rome, Italy
References
1. Kattan YB. Intrabiliary rupture of hydatid cyst of the liver. Br J Surg 1975;
62:885 – 7.
Nontuberculous Mycobacterial Tenosynovitis: Report of
Two Cases
Tenosynovitis due to nontuberculous mycobacteria is rare. We
describe two cases of tenosynovitis, one due to Mycobacterium
abscessus, and one due to Mycobacterium malmoense.
Case 1. A 44-year-old woman with a long history of anorexia
nervosa presented for evaluation of right-index finger swelling of
5 months’ duration. Laboratory examination results were normal
with the exception of neutropenia (WBCs, 650/mL) and CD4/
lymphocytopenia (406 cells/mL). The patient did not recall a history of traumatic incident. She had been treated previously with
local cortisone injections. A biopsy specimen was obtained, and
histological evaluation revealed subacute nonspecific inflammation. A culture of the specimen was sterile. Staining for fungi was
negative, and microscopic examination did not reveal acid-fast
bacilli (AFB). After 6 weeks, a mycobacterial culture yielded nontuberculous mycobacteria, probably Mycobacterium chelonae
complex. Clarithromycin therapy was instituted.
Two months later, scar tenderness of the incisional was noted
in association with a sinus that was draining clear fluid. At that
time, a tenosynovectomy was performed. Histological examination
revealed an epithelioid granuloma. Ziehl-Neelsen staining revealed
AFB. The patient received oral clarithromycin and ciprofloxacin
together with iv imipenem. In vitro testing of the mycobacterial
strain revealed susceptibility to tobramycin, kanamycin, and erythromycin and resistance to amikacin, imipenem, and ciprofloxacin.
Therapy with imipenem and ciprofloxacin was replaced by that
with tobramycin, and the patient’s condition improved.
Three months later, the isolate was identified as M. abscessus
at the National Mycobacterium Reference Laboratory (NMRL). In
vitro testing of the M. abscessus strain at the NMRL revealed
susceptibility to clarithromycin, imipenem, ciprofloxacin, ethion-
Reprints or correspondence: Dr. André Boibieux, Service des Maladies Infectieuses et Tropicales, Hôpital de la Croix-Rousse, 93 Grande Rue de la
Croix-Rousse, 69317 Lyon cedex 04, France.
Clinical Infectious Diseases 1998;26:1467–8
q 1998 by the Infectious Diseases Society of America. All rights reserved.
1058–4838/98/2606–0042$03.00
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1467
2. Lewall DB, McCorkell SJ. Rupture of echinococcal cysts: diagnosis, classification and clinical implications. AJR Am J Roentgenol 1986; 146:
391 – 4.
3. Subramanyam BR, Balthazar EJ, Naidich DP. Ruptured hydatid cyst with
biliary obstruction: diagnosis by sonography and computed tomography.
Gastrointest Radiol 1983; 8:341 – 3.
4. Marti-Bonmati L, Menor Serrano F. Complications of hepatic hydatid cysts:
ultrasound, computed tomography and magnetic resonance diagnosis.
Gastrointest Radiol 1990; 15:119 – 25.
5. Moreira VF, Merono E, Simon MA. Endoscopic retrograde cholangiography
(ERCP) and complicated hepatic hydatid cyst in the biliary tract. Endoscopy 1984; 16:124 – 6.
6. Morimoto K, Shimoi M, Shirakawa T, et al. Biliary obstruction: evaluation with
three-dimensional MR cholangiography. Radiology 1992;183:578–80.
7. Guibaud L, Bret PM, Reinhold C, et al. Bile duct obstruction and choledocholithiasis: diagnosis with MR cholangiography. Radiology 1995;197:109–15.
amide, clofazimine, and kanamycin and resistance to rifampin,
isoniazid, streptomycin, amikacin, rifabutin, and ofloxacin. The
patient was treated with clarithromycin and ciprofloxacin. Treatment with this antibiotic regimen was discontinued after 12
months, as she was well without focal symptoms. One year later,
the patient continued to do well without recurrence of symptoms.
Case 2. A 63-year-old man presented for evaluation of right
carpal tunnel syndrome. He was treated with local cortisone injections. Nine months later he developed swelling of the anterior
wrist. The CD4/ lymphocyte count was 300/mL. Surgical decompression was performed, and histological examination of the biopsy specimen obtained perioperatively showed an epithelioid
granuloma. Microscopic examination did not reveal AFB. Chronic
tuberculoid flexor tenosynovitis was suspected. The patient received therapy with rifampin, isoniazid, and ethambutol.
Four months later his condition was unchanged, and a second
open biopsy was performed. Ziehl-Neelsen staining of the specimen was negative for AFB. A mycobacterial culture yielded nontuberculous mycobacteria (with negative hybridization techniques
identifying Mycobacterium tuberculosis). There was no evidence
of penetrating trauma, and because of exposure to a water tank
and farm activity, treatment with clarithromycin, ciprofloxacin,
and ethambutol was begun for suspected infection due to Mycobacterium marinum or Mycobacterium avium complex (MAC).
Despite this treatment, the anterior wrist swelling became tender
and fluctuant. M. malmoense was identified (confirmed at the
NMRL by use of 16sRNA sequence analysis). Treatment with
rifampin, ethambutol, isoniazid, and ciprofloxacin was instituted.
In vitro tests showed susceptibility to rifabutin and clarithromycin
and resistance to isoniazid and ethambutol. The treatment regimen
was changed to that with rifabutin and clarithromycin; rifampin,
ethambutol, and isoniazid were discontinued. The patient’s condition improved. However, therapy with ciprofloxacin was discontinued because arthralgia developed; rifabutin therapy was discontinued because of neuropathy. Ethambutol therapy was instituted
in place of rifabutin. The clinical response was good; and antimicrobial treatment was discontinued after 9 months. The patient
was well 6 months later without relapse.
Nine of the nontuberculous mycobacteria have been reported in
association with infections of the hand. The most common is
M. marinum, and the next most frequent is Mycobacterium kansasii
[1]. Other less frequent organisms associated with hand infections
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Brief Reports
CID 1998;26 (June)
include MAC, Mycobacterium terrae, Mycobacterium szulgai, Mycobacterium fortuitum, and M. chelonae. The first case of wrist
tenosynovitis due to Mycobacterium xenopi was reported recently
[2]. We describe the first case of M. abscessus tenosynovitis (case
1). Four cases of M. malmoense tenosynovitis have been reported
in the literature [3–6].
In the cases we describe, the sites of mycobacterial infections
corresponded to the anatomic areas previously injected with corticosteroids. Given that there was no other history of trauma or
penetrating injury to these areas, it is possible that the infections
were the consequence of these injections. Lau [7] described four
patients with hand infections due to M. chelonae after receiving
steroid injections. The organism was probably inoculated via contaminated needles, and steroids were probably an important factor
in the perpetuation of the infections by suppression on of the local
inflammatory response [7].
The two patients we describe had mild CD4/ lymphocytopenia
without HIV infection. To our knowledge, there are no other reports of nontuberculous mycobacterial tenosynovitis associated
with CD4/ lymphocytopenia in the literature. Disseminated mycobacterial infection can induce CD4/ lymphocytopenia, probably
as a result of lymphocyte sequestration in the granulomas. This
mechanism is unlikely in cases of localized tenosynovitis. It is
possible that CD4/ lymphocytopenia contributed to the acquisition
of nontuberculous mycobacterial infection in our patients. In case
1, neutropenia associated with malnutrition was a possible additional risk factor.
Rapid identification of the causative organism and appropriate
in vitro susceptibility studies are imperative for adequate therapy.
Because of clarithromycin’s extensive activity against many nontuberculous mycobacteria, in most cases the empirical addition of
this agent to a multidrug regimen would probably be appropriate
treatment for tenosynovitis due to nontuberculous mycobacteria.
There is some question as to whether surgery or antimicrobial
agents alone is as effective as the combination of the two for this
condition [1]. Some synovial infections, particularly those due to
M. marinum and M. kansasii, have been eradicated by use of
antimicrobial therapy alone [8]. There are also reports of successful
treatment with synovectomy alone [8, 9]. However, most reports
indicate that the combination seems to be the most efficacious [8].
Use of this combination seems to be particularly important for
treatment of immunocompromised patients [10].
Asymptomatic Mycobacterium avium Complex Pneumonia
Complicated by Infectious Arthritis/Osteomyelitis
who had no identifiable predisposing factors. Reports of osteomyelitis due to MAC are rare and include both patients with a single
site and those with multiple sites of osteomyelitis [2]. Cases of
localized MAC arthritis and/or osteomyelitis contiguous with a
joint were frequently preceded by intraarticular corticosteroid injections [3]. MAC infections, however, can become disseminated
and cause multifocal osteomyelitis. Concomitant pulmonary infiltrates are sometimes noted in cases of multifocal MAC osteomyelitis [1, 2]. Among patients with disseminated MAC infections who
are symptomatic, symptoms include malaise, fever, weight loss,
cough, lymphadenopathy, bone pain, and draining sinuses [1, 2].
I describe an immunocompetent individual with no known pulmonary disease who presented with asymptomatic MAC pneumonia complicated by sternoclavicular arthritis/osteomyelitis. This
case clearly establishes the potential for occurrence of mycobacteremia in immunocompetent individuals with asymptomatic MAC
pneumonia and raises questions about appropriate management.
Before the AIDS era, infections due to Mycobacterium avium
complex (MAC) were generally recognized as chronic, indolent,
sometimes progressive pneumonias that occurred in individuals
with preexisting lung disease or gastrectomy, although osteomyelitis with and without pulmonary disease had been reported [1].
Prince [1] recently reported 21 patients with pulmonary disease
Reprints or correspondence: Dr. Roger Bitar, Kaiser Permanente Medical
Center, 4647 Zion Avenue, San Diego, California 92120.
Clinical Infectious Diseases 1998;26:1468–70
q 1998 by the Infectious Diseases Society of America. All rights reserved.
1058–4838/98/2606–0043$03.00
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Thierry Zenone, André Boibieux, Sylvestre Tigaud,
Jean-François Fredenucci, Véronique Vincent,
and Dominique Peyramond
Department of Infectious and Tropical Diseases, Microbiology
Laboratory, Hôpital de la Croix-Rousse, and Department of
Orthopaedic Surgery, Clinique Charcot, Ste Foy Les Lyon, Lyon; and
National Mycobacterium Reference Laboratory, Institut Pasteur,
Paris, France
References
1. Neviaser RJ. Tenosynovitis. Hand Clin 1989; 5:525 – 31.
2. Coombes GM, Teh LS, Denton J, Johnson AS, Jones AK. Mycobacterium
xenopi an unusual presentation as tenosynovitis of the wrist in an immunocompetent patient. Br J Rheumatol 1996; 35:1008 – 10.
3. Prince H, Ispahani P, Baker M. A Mycobacterium malmoense infection
of the hand presenting as carpal tunnel syndrome. J Hand Surg 1988;
13B:328 – 30.
4. Elston RA. Missed diagnosis of mycobacterial infection. Lancet 1989; ii:
1144.
5. Osterwalder VC, Salfinger M, Sulser H. Mycobacterium malmoense infektion der beugesehnenscheiden. Handchir Mikrochir Plast Chir 1992; 24:
210 – 4.
6. Gabl M, Pechlaner S, Hansdorfer H, Kreczy A, Went P. Flexor tenosynovitis of the hand caused by Mycobacterium malmoense: a case report. J
Hand Surg 1997; 22:338 – 40.
7. Lau JHK. Hand infection with Mycobacterium chelonei. BMJ 1986; 292:
444 – 5.
8. Gunther SF, Levy CS. Mycobacterial infections. Hand Clin 1989; 5:
591 – 8.
9. Kozin SH, Bishop AT. Atypical Mycobacterium infections of the upper
extremity. J Hand Surg 1994; 19A:480 – 7.
10. Hellinger WC, Smilack JD, Greider JL Jr, et al. Localized soft-tissue
infections with Mycobacterium avium/Mycobacterium intracellulare
complex in immunocompetent patients: granulomatous tenosynovitis of
the hand and wrist. Clin Infect Dis 1995; 21:65 – 9.
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