Acta Dermato-Venereologica 99-13CompleteContent | Page 36
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Multifocal Cutaneous Infections Caused by Mycobacterium szulgai without Pulmonary Involvement
Wei ZHANG # , Siyue KAN # , Haiqin JIANG, Hongsheng WANG*, Xiaofang LI* and Jianfang SUN
Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, 12, Jiangwangmiao Street, Nanjing
210042, Jiangsu Province, China. *E-mails: [email protected], [email protected]
#
These authors contributed equally to this paper.
Accepted Oct 16, 2019; E-published Oct 17, 2019
Pulmonary infection with Mycobacterium szulgai, which
resembles tuberculosis, is the most common clinical
presentation of this pathogen, especially in immuno-
compromised individuals. Extrapulmonary infections
with M. szulgai are very rare. We report here a case of
extrapulmonary multifocal cutaneous infections with M.
szulgai and review previous cases.
CASE REPORT
A 36-year-old man with no history of tuberculosis or immuno
suppression treatment presented with multifocal asymptomatic
erythematous nodules and plaques with exudate on his left hand,
right ear and left elbow for 20 years (Fig. 1). He had damaged his
left little finger 20 years previously in an accident with a sickle.
His finger had subsequently been amputated at the local hospital
due to repeated inflammation with no response to antibiotics.
One year after the amputation, the same lesions were noted on
the same site and spread to his right ear and left elbow. He was
SHORT COMMUNICATION
A
B
a heavy smoker (approximately 1 pack per day). He had no dia-
betes, hypertension or other comorbidities, and no family history
of tuberculosis or other infections. Routine laboratory tests were
normal and the patient was negative for HIV and anti-extractable
nuclear antigen (anti-ENA) autoantibodies. Chest X-ray and
computed tomography (CT) did not reveal any abnormal lesions.
Three mycological cultures were performed with no positive
results. Histopathology of a biopsied specimen from 3 sites of
involvement revealed the same pathological reaction pattern;
pseudoepitheliomatous hyperplasia with intraepithelial abscesses,
and suppurative granuloma formations were present with periphe-
ral mixed infiltration of lymphocytes, neutrophils, eosinophils,
plasmacytes and multinuclear giant cells (Fig. 2). Neutrophil
abscesses were focally formed. Löwenstein-Jensen medium was
used for mycobacterial culture. Slow growth of yellow colonies
occurred after 3–4 weeks of culture at 37°C. Acid-fast bacilli
were positive in the tissue fluid of skin lesion by Ziehl-Neelsen
staining. The characteristics of the colonies were consistent with
M. szulgai strain. Sequence analysis of hsp65 genes showed 100%
similarity with M. szulgai strain. Gene sequences were analysed
using BLAST V2.0 software (available from: http://www.ncbi.
nlm.nih.gov/BLAST/). Gene sequencing
results indicated that the strain was most
likely to be M. szulgai and a diagnosis of
M. szulgai infection was therefore made.
After diagnosis, the patient was treated
empirically with clarithromycin (500
mg/day), ethambutol (750 mg/day) and
rifampicin (450 mg/day) for 6 months.
At 4-month follow-up, the patient’s skin
lesions had greatly improved. Complete
resolution was achieved after 6 months of
antimycobacterial therapy. The patient’s
C
skin lesions recovered completely without
relapse during a 36-month follow-up.
DISCUSSION
D
G
E
H
F
I
Fig. 1. Clinical manifestations before and after treatment. Before treatment: erythematous
plaque on (A) the dorsum of the left hand, (B) the left elbow, and (C) the right ear. After 3 months of
treatment: lesions on: (D) the dorsum of the left hand, (E) the left elbow, and (F) the right ear. After
3 months of treatment: (G) scar and hypopigmentation on the dorsum of the left hand, (H) scar on
the left elbow, and (I) scar on the right ear.
This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta
Journal Compilation © 2019 Acta Dermato-Venereologica.
M. szulgai is an atypical mycobac-
terium that was first discovered in
1972 (1). M. szulgai infection is
very rare in humans, accounting
for less than 0.5% of all non-tu-
berculous mycobacteria infections
(2, 3). Pulmonary infection with M.
szulgai, which resembles tuberculo-
sis, is the most common clinically
involved site, while extrapulmo-
nary and multifocal infections are
very rare. Only 11 cases of cuta-
neous infection due to M. szulgai
have been reported in the literature
in English, including subcutaneous
doi: 10.2340/00015555-3352
Acta Derm Venereol 2019; 99: 1315–1316