Download Fadok, Valerie_Atypical_mycobacteriosis

Atypical Mycobacteriosis
Valerie Fadok, DVM, PhD, DACVD
North Houston Veterinary Specialists
Bellaire, TX
The rapidly growing mycobacteria consist of a large group of bacteria that are normally present in the environment (soil, vegetation,
standing bodies of water). They are introduced into the tissue when there is a break in the skin, most often secondary to a penetrating
wound or bite. These infections have also been associated with surgical procedures and even injections. Cats often develop lesions in
the inguinal fat pad, and the lesions tend to spread into surrounding tissues. Initially the infection may present as an abscess which
progresses to thickening of the tissue, the development of characteristic draining tracts with a serosanguinous discharge, and the
development of small purple-colored depressions in the skin. These areas are ideal for collecting exudate for culture as well as
cytology for acid-fast stain. Most cats with rapidly growing mycobacterial infections have no systemic signs, but a few will develop
fevers, maialse, and loss of appetite, especially when the disease flares up. Dogs can be infected with these organisms as well.
The key historical feature is a lack of response to conventional antibiotic therapy. Biopsies for histopathology and culture should
be taken. If exudate can be aspirated from the small purple depressions, chances of isolating the organism are excellent. It is critical
that material for culture be submitted to a laboratory with experience in isolating these organisms. If the organism can be isolated, it
should be identified as to species and sensitivities done. Often identification and sensitivity testing is done by mycobacterial reference
laboratories.
For most of these cats, immediate surgical excision is not recommended because the surgical sites often dehisce, particularly if the
cat is not given the correct antibiotics. We have had some good success with treating with antibiotic therapy for one to two months
first, then using wide surgical excision to remove the lesions when they have shrunk into smaller firm nodules. Antibiotics are usually
continued for at least 1-2 months after the surgery.
Although these are rapidly growing mycobacteria, it still can take 7 days for them to grow, and then additional time will be needed
in order to get the sensitivity testing done. As we wait for our data, we can pick some combinations of antibiotics that will cover most
of the mycobacteria we are likely to isolate. There are several species, but they can be divided into groups which share sensitivity
patterns. These include the M. fortuitum group, the M. chelonae and M. abscessus group, and the M. smegmatis group. Those in the
M. fortuitum group have variable sensitivities but are often sensitive to fluoroquinolones and doxycycline. Those in the M.
chelonae/M. abscessus group tend to be resistant to most oral options except for clarithromycin. Those in the M. smegmatis group are
often sensitive to a number of agents EXCEPT for clarithromycin. Empirical therapy could therefore be started with a
fluoroquinolone combined with clarithromycin. My first choice now is pradofloxacin (Veraflox, Bayer). It is most like the human
drug moxifloxacin used in the sensitivity testing, and it attacks bacteria at two different points, making the development of resistance
less likely. Pradofloxacin in the USA is labeled for 7 days, but it can be used off-label for long periods of time safely in adult cats,
based on the European literature and experiences. Doxycycline could be added in as well for triple antibiotic therapy until the
sensitivity results are back. The empirical choice of antibiotics will be determined by where in the world one practices, but the
combination of a fluoroquinolone, clarithromycin and doxycycline should cover most of these species. For many species of rapidly
growing mycobacteria, amikacin can be very effective. Although an aminoglycoside, it is less likely to cause renal problems than
gentamicin, and with monitoring, it can be used for several months if needed.
Antibiotic
Dose (mg/kg)
Route
Interval
doxycycline
5-10 mg/kg
PO
12 hrs
minocycline
5-10 mg/kg
PO
12 hrs
clarithromycin
10-15 mg/kg
PO
12 hrs
marbofloxacin
5.5 mg/kg
PO
24 hrs
pradofloxacin
7.5 mg/kg
PO
24 hrs
Moxifloxacin (human)*
10 mg/kg?
PO
24 hrs
amikacin
15 mg/kg
SQ
24 hrs
*long term safety studies in cats are lacking
The prognosis for cats with atypical mycobacteriosis is always guarded, because the disease tends to relapse.
References
Malik R, Martin M, Wigney D, Foster S. 2006. Infections caused by rapidly growing mycobacteria. In Greene’s Infectious Diseases of the Dog and
Cat, Ed 3. 2006. Pp. 482-488.
1
Adékambi, Toïdi, and Michel Drancourt. "Dissection of Phylogenetic Relationships Among 19 Rapidly Growing Mycobacterium Species by 16S
RRNA, Hsp65, SodA, RecA and RpoB Gene Sequencing." International journal of systematic and evolutionary microbiology 54, no. Pt 6 (2004):
doi:10.1099/ijs.0.63094-0.
Alander-Damsten, Y K, E E Brander, and L G Paulin. "Panniculitis, Due to Mycobacterium Smegmatis, in Two Finnish Cats." Journal of feline
medicine and surgery 5, no. 1 (2003): doi:12547619.
Appleyard, Greg D, and Edward G Clark. "Histologic and Genotypic Characterization of a Novel Mycobacterium Species Found in Three Cats."
Journal of clinical microbiology 40, no. 7 (2002): doi:12089257.
Bercovier, H, and V Vincent. "Mycobacterial Infections in Domestic and Wild Animals Due to Mycobacterium Marinum, M. Fortuitum, M. Chelonae,
M. Porcinum, M. Farcinogenes, M. Smegmatis, M. Scrofulaceum, M. Xenopi, M. Kansasii, M. Simiae and M. Genavense." Revue scientifique et
technique (International Office of Epizootics) 20, no. 1 (2001): doi:11288516.
Bhambri, Sanjay, Avani Bhambri, and James Q Del Rosso. "Atypical Mycobacterial Cutaneous Infections." Dermatologic clinics 27, no. 1 (2009):
doi:10.1016/j.det.2008.07.009.
Couto, S S, and C A Artacho. "Mycobacterium Fortuitum Pneumonia in a Cat and the Role of Lipid in the Pathogenesis of Atypical Mycobacterial
Infections." Veterinary pathology 44, no. 4 (2007): doi:10.1354/vp.44-4-543.
Davies, Jennifer L, Jennifer A Sibley, Sherry Myers, Edward G Clark, and Greg D Appleyard. "Histological and Genotypical Characterization of
Feline Cutaneous Mycobacteriosis: A Retrospective Study of Formalin-fixed Paraffin-embedded Tissues." Veterinary dermatology 17, no. 3 (2006):
doi:10.1111/j.1365-3164.2006.00513.x.
Elsner, Lisa, Julie Wayne, Carolyn R O'Brien, Christina McCowan, Richard Malik, John A Hayman, Maria Globan, Caroline J Lavender, and Janet A
Fyfe. "Localised Mycobacterium Ulcerans Infection in a Cat in Australia." Journal of feline medicine and surgery 10, no. 4 (2008):
doi:10.1016/j.jfms.2008.03.003.
Fabroni, Caterina, Gionata Buggiani, and Torello Lotti. "Therapy of Environmental Mycobacterial Infections." Dermatologic therapy 21, no. 3 (2008):
doi:10.1111/j.1529-8019.2008.00187.x.
Falkinham, J O. "Surrounded by Mycobacteria: Nontuberculous Mycobacteria in the Human Environment." Journal of applied microbiology 107, no. 2
(2009): doi:10.1111/j.1365-2672.2009.04161.x.
Fyfe, J A, C McCowan, C R O'Brien, M Globan, C Birch, P Revill, V R D Barrs, and others. "Molecular Characterization of a Novel Fastidious
Mycobacterium Causing Lepromatous Lesions of the Skin, Subcutis, Cornea, and Conjunctiva of Cats Living in Victoria, Australia." Journal of clinical
microbiology 46, no. 2 (2008): doi:10.1128/JCM.01186-07.
Govendir, M, J M Norris, T Hansen, D I Wigney, G Muscatello, D J Trott, and R Malik. "Susceptibility of Rapidly Growing Mycobacteria and
Nocardia Isolates From Cats and Dogs to Pradofloxacin." Veterinary microbiology 153, no. 3-4 (2011): doi:10.1016/j.vetmic.2011.06.001.
Govendir, M, T Hansen, B Kimble, J M Norris, R M Baral, D I Wigney, S Gottlieb, and R Malik. "Susceptibility of Rapidly Growing Mycobacteria
Isolated From Cats and Dogs, to Ciprofloxacin, Enrofloxacin and Moxifloxacin." Veterinary microbiology 147, no. 1-2 (2011):
doi:10.1016/j.vetmic.2010.06.011.
Gunn-Moore, Danièlle A, Sarah E McFarland, Alex Schock, Jacqueline I Brewer, Tim R Crawshaw, Richard S Clifton-Hadley, and Darren J Shaw.
"Mycobacterial Disease in a Population of 339 Cats in Great Britain: II. Histopathology of 225 Cases, and Treatment and Outcome of 184 Cases."
Journal of feline medicine and surgery 13, no. 12 (2011): doi:10.1016/j.jfms.2011.09.009.
Henderson, S M, J Baker, R Williams, and D A Gunn-Moore. "Opportunistic Mycobacterial Granuloma in a Cat Associated with a Member of the
Mycobacterium Terrae Complex." Journal of feline medicine and surgery 5, no. 1 (2003): doi:12547621.
Hughes, M S, G James, N Ball, M Scally, R Malik, D I Wigney, P Martin, S Chen, D Mitchell, and D N Love. "Identification by 16S RRNA Gene
Analyses of a Potential Novel Mycobacterial Species As An Etiological Agent of Canine Leproid Granuloma Syndrome." Journal of clinical
microbiology 38, no. 3 (2000): doi:10698979.
Jang, Spencer S, and Dwight C Hirsh. "Rapidly Growing Members of the Genus Mycobacterium Affecting Dogs and Cats." Journal of the American
Animal Hospital Association 38, no. 3 (2002): doi:12022405.
Jassies-van der Lee, A, D J Houwers, N Meertens, A G M van der Zanden, and T Willemse. "Localised Pyogranulomatous Dermatitis Due to
Mycobacterium Abscessus in a Cat: A Case Report." Veterinary journal (London, England : 1997) 179, no. 2 (2009): doi:10.1016/j.tvjl.2007.08.026.
Khan, Fida A, and Rashida Khakoo. "Nontuberculous Mycobacterial Cutaneous Infections: An Updated Review." Cutis; cutaneous medicine for the
practitioner 88, no. 4 (2011): doi:22106729.
Kipar, A, I Schiller, and W Baumgärtner. "Immunopathological Studies on Feline Cutaneous and (muco)cutaneous Mycobacteriosis." Veterinary
immunology and immunopathology 91, no. 3-4 (2003): doi:12586480.
Kothavade, R J, R S Dhurat, S N Mishra, and U R Kothavade. "Clinical and Laboratory Aspects of the Diagnosis and Management of Cutaneous and
Subcutaneous Infections Caused by Rapidly Growing Mycobacteria." European journal of clinical microbiology & infectious diseases : official
publication of the European Society of Clinical Microbiology (2012)doi:10.1007/s10096-012-1766-8.
Malik, R, D I Wigney, D Dawson, P Martin, G B Hunt, and D N Love. "Infection of the Subcutis and Skin of Cats with Rapidly Growing
Mycobacteria: A Review of Microbiological and Clinical Findings." Journal of feline medicine and surgery 2, no. 1 (2000):
doi:10.1053/jfms.2000.0051.
Malik, R, L Gabor, P Martin, D H Mitchell, and D J Dawson. "Subcutaneous Granuloma Caused by Mycobacterium Avium Complex Infection in a
Cat." Australian veterinary journal 76, no. 9 (1998): doi:9791710.
Malik, R, M S Hughes, G James, P Martin, D I Wigney, P J Canfield, S C A Chen, D H Mitchell, and D N Love. "Feline Leprosy: Two Different
Clinical Syndromes." Journal of feline medicine and surgery 4, no. 1 (2002): doi:10.1053/jfms.2001.0151.
Meeks, C, J K Levy, P C Crawford, L L Farina, F Origgi, R Alleman, O M Seddon, A Salcedo, B J Hirsch, and S G Hirsch. "Chronic Disseminated
Mycobacterium Xenopi Infection in a Cat with Idiopathic CD4+ T Lymphocytopenia." Journal of veterinary internal medicine / American College of
Veterinary Internal Medicine 22, no. 4 (2008): doi:10.1111/j.1939-1676.2008.0108.x.
Morita, Y, H Kimur, K Kozawa, M Nagata, H Tsuchiya, M Kato, and S Maruyama. "Cutaneous Infection in a Cat Caused by Mycobacterium Avium
Complex Serovar 6." The Veterinary record 152, no. 4 (2003): doi:12572948.
Rallis, Efstathios, and Elma Koumantaki-Mathioudaki. "Treatment of Mycobacterium Marinum Cutaneous Infections." Expert opinion on
pharmacotherapy 8, no. 17 (2007): doi:10.1517/14656566.8.17.2965.
Rüfenacht, Silvia, Katja Bögli-Stuber, Thomas Bodmer, Valérie F Bornand Jaunin, Danielle C Gonin Jmaa, and Danièlle A Gunn-Moore.
"Mycobacterium Microti Infection in the Cat: A Case Report, Literature Review and Recent Clinical Experience." Journal of feline medicine and
surgery 13, no. 3 (2011): doi:10.1016/j.jfms.2011.01.012.
Studdert, V P, and K L Hughes. "Treatment of Opportunistic Mycobacterial Infections with Enrofloxacin in Cats." Journal of the American Veterinary
Medical Association 201, no. 9 (1992): doi:1331001.
2
White, S D, P J Ihrke, A A Stannard, C Cadmus, C Griffin, S A Kruth, E J Rosser, S I Reinke, and S Jang. "Cutaneous Atypical Mycobacteriosis in
Cats." Journal of the American Veterinary Medical Association 182, no. 11 (1983): doi:6863137.
Wilson, Victoria B, Raquel R Rech, Michaela G Austel, Cynthia L Bauer, Kenneth S Latimer, Susan Sanchez, and Elizabeth W Howerth. "Pathology
in Practice. Cutaneous Mycobacteriosis." Journal of the American Veterinary Medical Association 238, no. 2 (2011): doi:10.2460/javma.238.2.171.
Xavier Emmanuel, Francis, Amie-Louise Seagar, Christine Doig, Alan Rayner, Pauline Claxton, and Ian Laurenson. "Human and Animal Infections
with Mycobacterium Microti, Scotland." Emerging infectious diseases 13, no. 12 (2007): doi:10.3201/eid1312.061536.
Youssef, Sameh, Marie Archambault, Wendy Parker, and Julie Yager. "Pyogranulomatous Panniculitis in a Cat Associated with Infection by the
Mycobacterium Fortuitum/peregrinum Group." The Canadian veterinary journal. La revue vétérinaire canadienne 43, no. 4 (2002): doi:11963662.
3