Your SlideShare is downloading. ×
Mycobacterium Chelonae Abscessus Lower Extremity Infection in the Double Transplant Patient
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Introducing the official SlideShare app

Stunning, full-screen experience for iPhone and Android

Text the download link to your phone

Standard text messaging rates apply

Mycobacterium Chelonae Abscessus Lower Extremity Infection in the Double Transplant Patient

444
views

Published on

Published in: Education, Health & Medicine

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
444
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
3
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Cleveland Clinic/Kaiser Permanente Residency Program M.chelonae abscessus Lower Extremity Infection in the DoubleTransplant Patient Jennifer Gerres DPM, PGY-2
  • 2. Objectives ✤ Mycobacterium chelonae abscessus is a rare cause of human infection ✤ Present an atypical manifestation in an immunosuppressed patient ✤ Review of the literature ✤ Proclivity for the renal transplant patient
  • 3. Case Study
  • 4. History of Present Illness ✤ December 2010, a 56yo male presents with pain to the right 4th MTPJ ✤ 2 months prior ✤ Clipping toenails and accidentally clipped right 4th toe ✤ Developed pain and edema ✤ Saw his local podiatrist in Michigan ✤ I&D performed, and per patient, purulent material was expressed, but no culture taken
  • 5. History of Present Illness ✤ 2 weeks after I&D ✤ Noticed increased pain and erythema at anesthetic injection site of the right 4th toe ✤ Returned to podiatrist, who prescribed empiric Augmentin x 10 days without improvement ✤ Epsom salt soaks twice daily ✤ Radiograph of right foot: calcified vessels ✤ ABI/PVR: small vessel disease
  • 6. History of Present Illness ✤ The patient describes the pain thusly: ✤ It begins at night, worsens until the morning, and resolves by midmorning ✤ Sharp, “tight-feeling” at the base of the right 4th toe ✤ Review of Systems ✤ Denies n/v/f/c/night sweats/weight change/loss of appetite ✤ Previous right foot surgery ✤ Distal chevron bunionectomy ✤ “It took 6 months for the incision to heal”
  • 7. Past Medical History ✤ DM Type I x 35 years ✤ Status-post cadaveric pancreas transplant 10 years prior ✤ Status-post living-donor kidney transplant 10 years prior ✤ Aortic Stenosis ✤ Glaucoma (legally blind) ✤ Hypothyroidism ✤ Irritable bowel syndrome
  • 8. ✤ Past Surgical History ✤ Cadaveric pancreas transplant ✤ Living-donor kidney transplant ✤ Multiple eye surgeries ✤ Right HAV surgery 3 years prior ✤ Allergies ✤ No known drug allergies
  • 9. Medications ✤ Prednisone ✤ Tacrolimus anhydrous (Prograf) ✤ Mycophenolate mofetil (Cellcept) ✤ Bupropion ✤ Zetia ✤ Prilosec ✤ Synthroid ✤ Betimol 0.5% eye drops ✤ Lotemax 0.5% eye drops ✤ Aspirin 81mg ✤ Calcium carbonate/VitD3
  • 10. ✤ Social History ✤ Lives by Lake Michigan ✤ Often spends his summers on the beaches ✤ Illicit drug use: denies
  • 11. Physical Exam: Right Foot ✤ Vascular: DP/PT pulses palpable. No edema. No dependent rubor ✤ Neurological: Light touch intact. SWMF 5.07 intact to all sites ✤ Musculoskeletal: Pain with ROM of the 4th MTPJ ✤ Pain on palpation at the 4th MTPJ and the 3rd interspace ✤ Negative Mulder’s click ✤ No pain to palpation of the 4th toe ✤ Dermatological: telangiectasias to dorsal forefoot ✤ No palpable mass ✤ Erythema to the distal pulp of the 4th toe as well as to the dorsal 4th MTPJ ✤ The erythema is blanchable
  • 12. Ancillary Studies ✤ MRI without contrast ✤ Nonspecific soft tissue edema ✤ No focal soft tissue abnormality ✤ ABI/PVR ✤ Right: 1.16 TBI: 0.42 small vessel disease ✤ Left: 1.1 TBI: 0.63
  • 13. Plan ✤ ADMISSION ✤ Course of IV antibiotics ✤ IV Zosyn and Vancomycin ✤ During admission ✤ Patient remained afebrile ✤ Minimal resolution of erythema to the 4th MTPJ, but no resolution of pain ✤ Labs ✤ No leukocytosis ✤ ESR: 2 ✤ CRP: 0.1 ✤ Uric acid: wnl
  • 14. ✤ Six-week course of IV antibiotics ✤ Despite the six-week course of IV antibiotics... ✤ The erythema failed to improve ✤ Patient continued to have pain at the right 4th MTPJ After Discharge
  • 15. SixWeeks After Discharge ✤ Evaluated by Podiatry and Infectious Disease ✤ Plan ✤ Admission ✤ Underlying ischemia? ✤ Multidisciplinary approach
  • 16. During Admission ✤ Vitals: afebrile ✤ Physical exam remained unchanged ✤ Labs ✤ No leukocytosis ✤ ESR: 1 ✤ CRP: 0.1 ✤ Procalcitonin: <0.05 ✤ MRI with contrast ✤ Mild, nonspecific subcutaneous and muscular edema
  • 17. ✤ After a multidisciplinary discussion, it was determined to halt the current administration of antibiotics ✤ Evaluate the patient in the outpatient setting ✤ Weekly photographs and phone calls ✤ The patient provided weekly updates until February 2011
  • 18. Two Months from Initial Presentation ✤ Increased pain to the right 4th MTPJ ✤ New complaint of a “lump” to the area ✤ Denied n/v/f/c/night sweats
  • 19. PLAN
  • 20. Plan ✤ Aspiration ✤ Anaerobe/aerobe ✤ AFB stain and culture ✤ Fungal culture and smear ✤ Nocardia ✤ Mycoplasma ✤ Admission
  • 21. During Admission ✤ Patient remained afebrile ✤ Labs ✤ No leukocytosis ✤ ESR and CRP remained unchanged ✤ Microbiology ✤ Rapid-growing, acid fast bacilli
  • 22. At Discharge ✤ Final cultures demonstrated ✤ Mycobacterium chelonae abscessus ✤ S: clarithromycin/azithromycin, linezolid, tigecycline ✤ Antibiotic regimen ✤ Tigecycline 50mg IV q12h ✤ Azithromycin 500mg PO ✤ Linezolid 600mg PO q12h ✤ Local wound care for ulceration
  • 23. At Six Months
  • 24. Discussion
  • 25. Mycobacterium chelonae abscessus ✤ Multi-drug resistant, rapid-growing acid fast bacilli ✤ Chopra et al. J Antimicrob Chemother, 2011: ✤ Systematic review, screening 1040 approved drugs, antimicrobial and non-antimicrobial ✤ Discovered 32 compounds with significant antimicrobial activity ✤ Illustrated the resilience of this group ✤ Biofilm ✤ Ubiquitous and fastidious ✤ Found: water
  • 26. Mycobacterium chelonae abscessus ✤ Cause of nosocomial, post-surgical wound, and post-injection abscesses ✤ Clustered cases of infection ✤ Foot baths, contaminated water supply or injected material ✤ Infrequently, a cause of infection ✤ Immunocompromised ✤ Solid organ transplants ✤ Cutaneous lesions of the extremities ✤ Arthritis and tenosynovitis; meningitis; and disseminated infection
  • 27. Mycobacterium chelonae abscessus ✤ Several reported cases among solid organ transplant patients ✤ Cooper et al. Am J Med, 1989: ✤ Identified 7 renal transplant patients ✤ Distinct pattern emerged: ✤ Indolent, tender nodules isolated to the lower extremities ✤ Absence of systemic symptoms and no leukocytosis ✤ Garrison et al. Transpl Infect Dis, 2009: ✤ Found 25 cases involving solid organ transplant recipients ✤ 4 received renal transplants
  • 28. Mycobacterium chelonae abscessus ✤ Diagnosis and treatment are complex ✤ Lesion biopsy and wound culture with susceptibility ✤ Resistance patterns unpredictable ✤ Naturally resistant to conventional anti-TB drugs ✤ No guidelines as to duration of therapy ✤ IDSA ✤ 4 months for skin and soft tissue infections ✤ 6 months for bone infections ✤ Chernenko et al. J Hear Lung Transplant, 2006: ✤ 12 to 18 months of combination therapy in the immunocompromised ✤ Surgical intervention
  • 29. Conclusion ✤ Multi-drug resistant acid-fast bacilli with proclivity for the immunocompromised ✤ Treatment of these infections are complex ✤ Culture and sensitivity are imperative ✤ Aspiration and/or debridement necessary to improve outcome
  • 30. References ✤ Morales P, Gil A, Santos M. Mycobacterium abscessus infection in transplant recipients. Transplantation Proceedings. 2010;42:3058-306 ✤ Morris-Jones R, Fletcher C, Morris-Jones S, et al. Mycobacterium abscessus : a cutaneous infection in a patient on renal replacement therapy. Clin Exp Dermatol. 2001;26:415-418 ✤ Garrison, AP, Morris MI, Lewis SD, et al. Mycobacterium abscessus infection in solid organ trasnplant recipients : report of three cases and review of the literature. Transpl Infect Dis. 2009;11:541-548 ✤ Moore M, Frerichs JB. An unusual acid-fast infection of the knee with subcutaneous, abscess-like lésions of the gluteal région ; report of a case with a study of the organism, Mycobacterium abscessus, n. sp. J Invest Dermatol. 1953 ;20 :133-169 ✤ Chopra S, Matsuyama K, Hutson C, Madrid P. Identification of antimicrobial activity among FDA-approved drugs for combating Mycobacterium abscessus and Mycobacterium chelonae. J Antimicrob Chemother. 2011;66:1533-1436 ✤ Kwon YH, Lee GY, Kim WS, Kim JK. A case of skin and soft tissue infection caused by mycobacterium abscessus. Ann Dermatol (Seoul). 2009;21(1) :84-87 ✤ Doucette K, Fishman JA. Nontuberculous mycobacterial infection in hematopoietic stem cell and solid organ transplant recipients. Clin Infect Dis. 2004;38(10):1428-1439 ✤ Galil K, Miller LA, Yakrus MA, et al. Abscesses due to Mycobacterium abscessus linked to injection of unapproved alternative medication. Emerg Infect Dis. 1999;5:681-687 ✤ Cooper JF, Lichtenstein MJ, Graham BS, Schaffner W. Mycobacterium chelonae: A cause of nodular skin lesions with a proclivity for renal transplant recipients. Am J Med. 1989;86(2):173-177 ✤ Prinz BM, Michaelis S, Kettelhack N, et al. Subcutaneous infection with Mycobacterium abscessus in a rental transplant recipient. Dermatology. 2004;208(3)259-261 ✤ Scholze A, Loddenkemper C, Grumbaum M, et al. Cutaneous Mycobacterium abscessus infection after kidney transplantation. Nephrol Dial Transplant. 2005;20(8): 1764-1765 ✤ Chernenko SM, Humar A, Hutcheon M, et al. Mycobacterium abscessus infections in lung transplant recipients : the international experience. J Hear Lung Transplant. 2006;25(12):1447-1455
  • 31. ThankYou