An 85 year old female with past medical history of hypertension, hyperlipidemia and past surgical history of cholecystectomy presented to the emergency department (ED) with an abdominal pain in the left upper quadrant, which had been persistent for several days. Her vitals were BP:145/86 mm/Hg; pulse: 86 beats/minute; respiratory: 20/min; Temp: 98.3 °F (36.8 °C); SpO2-98%. Her medical history revealed that she had a diagnostic laparoscopy, common bile duct exploration, and stone extraction nine months ago. Since then, the patient had a chronically draining abdominal sinus for which she underwent diagnostic laparoscopy and multiple benign peritoneal implant biopsies 5 months prior to the current event.
Examination of the LUQ revealed a fluctuant lump in the LUQ, which was close walled with no purulence or drainage. The CT abdomen demonstrated an increased infiltration of the left rectus abdominis, left anterior abdominal wall muscles, and subcutaneous tissues in the upper abdomen, with a suspicion for infectious etiology.
The patient was evaluated by general surgery for abscess at the LUQ. The abscess was drained, the fluid was sent for a bacterial culture, and the patient was started on IV vancomycin and Zosyn. Blood cultures were collected but had no growth. The pathology report of peritoneum implants and soft tissue biopsies showed focal necrotizing granulomatous inflammation but negative special stain for fungi (GMS-F) and acid-fast bacilli (AFB). The Gram stain of her abscess fluid culture was negative with a few neutrophils. However, her culture grew spready colonies on blood and chocolate agar after 4 days of incubation (Figure 1). Since the initial Gram stain was negative, Kinyon stain was performed and was positive (not shown). It was identified by Matrix-assisted laser desorption ionization Time of Flight (MALDI-ToF) as Mycobacterium fortuitum species.
There has been recent evidence of an increased prevalence of Nontuberculous Mycobacterium (NTM), and it is becoming a major public health concern.1,2 NTM is a diverse group of ubiquitous, environmental, acid-fast organisms that can produce a wide range of diseases, most of which are found in skin and soft tissue infections (SSTI).3 Historically, NTM has been classified into Runyon groups based on the colony morphology, growth rate, and pigmentation.4 Identification is made with rapid molecular diagnostic technology. However, grouping the species of NTM is based on the growth rates and divided into rapidly growing mycobacteria (RGM) and slowly growing mycobacteria (SGM).
RGM includes species that grow on the media plates within 7 days and subdivided into 5 groups based on pigmentation and genetic similarity: Mycobacterium fortuitum, Mycobacterium chelonae/abscessus, Mycobacterium mucogenicum, and Mycobacterium smegmatis. Most SSTIs commonly associated with surgery and cosmetic procedures are caused by 3 RGM species: M fortuitum, M abscessus, and M chelonae. These infections are nonspecific in their clinical presentations and may present with abscesses, cellulitis, nodules, ulcers, panniculitis, draining sinus tracts, folliculitis, papules, and plaques. There is a delay in diagnosis of these infections, as mycobacterial cultures are not routinely performed on surgical wound infections or skin biopsy specimens which are essential for an accurate diagnosis, especially because the treatment varies depending on the species and its sensitivities.5
M. Fortuitum is a Gram positive, acid-fast, aerobic rod-shaped, saprophytic, rapidly growing NTM that is typically considered an opportunistic pathogen. They are widely distributed in the nature and can be isolated from soil, dust, natural surface and municipal water, wild and domestic animals, fish, hospital environment, contaminated medical instruments, and implants. Common culture media include Middlebrook 7H10 or 7H11 agar, BACTEC 12B broth and 5% sheep blood agar or chocolate agar. These organisms may not stain well with the Ziehl-Neelsen or Kinyoun method and may not be recognized readily with the fluorochrome method due to lipid rich long-chain mycolic acids in their cell walls. Because of the high mycolic acid content in the cell wall, it does not stain well by the Gram stain, which is likely the reason for the negative Gram stain results in our patient abscess culture.
It is well known that older biochemical tests are replaced by newer diagnostic methods including matrix associated laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and molecular methods, including line probe hybridization assays, as well as 16S ribosomal RNA sequencing. DNA line probe assays provide a rapid means of identification and currently there are two commercially available assays: INNO-LiPA MYCOBACTERIA v2 assay (Fujirebio Europe, Ghent, Belgium) and GenoType assay (Hain Lifescience GmbH, Nehren, Germany). However, neither of them is currently FDA-approved, and therefore, the use is largely restricted to the public health or reference laboratories in United States. Studies utilizing these lines probe assays have reported satisfactory sensitivity and specificity.6,7,8,9 Notably, a study by Fida et al., reported a case of Mycobacterium smegmatis that was misidentified as Mycobacterium fortuitum by a DNA line probe assay.
In our case, histopathology reported necrotizing granulomas with a negative AFB stain. There has been literature evidence reporting that these SSTIs cases present with a mixed suppurative-granulomatous inflammation, with only a few cases showing well-formed granulomas.10 In most of these pathological cases, mycobacterial stains, such as AFB or FITE, are negative. However, negative stains do not entirely exclude the diagnosis and hence medical management by clinicians should be based on the culture, which remains the gold standard method for identification of AFB.11
There is limited literature evidence of M fortuitum as an opportunistic pathogen causing disseminated infection especially in immunosuppressed patients or receiving steroids.12 A case report of chyluria caused by Mycobacterium fortuitum infection in a 64-year-old male, who was successfully treated with two weeks of amikacin, trimethoprim-sulfamethoxazole and levofloxacin followed by 24 weeks of levofloxacin and doxycycline.13 Another case of Mycobacterium fortuitum osteomyelitis of the cuboid bone following a penetrating plantar trauma. The patient underwent a single-stage surgery and resolved the infection after 5 months of treatment with gentamicin-/vancomycin.14 M. Fortuitum is resistant to all antituberculosis drugs but susceptible to macrolides, amikacin, doxycycline, fluoroquinolones, and trimethoprim-sulfamethoxazole. Therefore, an aggressive and prolonged NTM treatment is required to completely clear the infection and reduce the recurrence.
-Preeti Malik, M.D, MPH, PGY2 Pathology resident at Montefiore Medical Center.
-Phyu M. Thwe, PhD, D(ABMM), MLS(ASCP)CM is Associate Director of Infectious disease testing laboratory at Montefiore Medical Center, Bronx, NY. She completed her CPEP microbiology fellowship at the University of Texas Medical Branch in Galveston, TX. Her interest includes appropriate test utilization and extra-pulmonary tuberculosis.