NDT Advance Access published March 1, 2005 Nephrol Dial Transplant (2005) 1 of 2 doi:10.1093/ndt/gfh736
Images in Nephrology (Section Editor: G. H. Neild)
Cutaneous Mycobacterium abscessus infection after kidney transplantation Alexandra Scholze1, Christoph Loddenkemper2, Maria Gru¨nbaum2, Ines Moosmayer1, Gerd Offermann1 and Martin Tepel1 1
Nephrologie and 2Pathologie, Charite´ Campus Benjamin Franklin, Berlin, Germany
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Case A 66-year-old man presented with a 1 month history of reddish-brown, circumscribed, infiltrative papules on the extremities (Figure 1A). The lesions developed central necroses and transformed into painful abscesses (Figure 1B; posterior thigh).
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Fig. 1. (A) Reddish-brown, circumscribed papule on the extremity. (B) Development of an abscess on the posterior thigh. (C) Skin biopsy showing acute panniculitis with abscess formation (asterisk) in the mid-dermis (haematoxylin and eosin stain; magnification: 2) and (inset) Langhans-type giant cells (haematoxylin and eosin stain; magnification: 400). (D) Skin biopsy showing rapid-growing acidfast bacilli (Ziehl–Neelsen stain; magnification: 600).
Correspondence and offprint requests to: Dr Martin Tepel, Charite´ Campus Benjamin Franklin, Med. Klinik IV Nephrologie, Hindenburgdamm 30, D-12200 Berlin, Germany. Email:
[email protected]
Fig. 1. Continued.
The patient had a history of anti-neutrophil cytoplasm antibodies-associated systemic vasculitis, presenting with severe renal disease. Combination therapy with cyclophosphamide and prednisolone had been terminated after 5 weeks due to treatment-related toxicity and development of end-stage renal disease. Subsequently, the patient had been on haemodialysis
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Keywords: kidney transplantation; Mycobacterium abscessus
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Fig. 1. Continued.
A. Scholze et al.
the lesions showed regression and healing with scar formation. Mycobacterium abscessus belongs to the family of rapid-growing atypical (non-tuberculous) mycobacteria. They can be isolated from water, soil and dust and have been identified in cutaneous and joint abscesses [1,2]. Infections caused by rapid-growing atypical mycobacteria have been described in immunocompromised patients and in patients with end-stage renal failure [1–3]. It is often misdiagnosed and treated as a fungal or common bacterial infection. Infections due to M. abscessus are currently managed by using the macrolide clarithromycin for several weeks, possibly in combination with amikacin or cefoxitin [1,4]. Conflict of interest statement. None declared.
References 1. Brown-Elliott BA, Wallace RJ, Jr. Clinical and taxonomic status of pathogenic nonpigmented or late-pigmenting rapidly growing mycobacteria. Clin Microbiol Rev 2002; 15: 716–746 2. Bartralot R, Pujol RM, Garcia-Patos V et al. Cutaneous infections due to nontuberculous mycobacteria: histopathological review of 28 cases. Comparative study between lesions observed in immunosuppressed patients and normal hosts. J Cutan Pathol 2000; 27: 124–129 3. Lowry PW, Beck-Sague CM, Bland LA et al. Mycobacterium chelonae infection among patients receiving high-flux dialysis in a hemodialysis clinic in California. J Infect Dis 1990; 161: 85–90 4. Wallace RJ, Jr, Tanner D, Brennan PJ, Brown BA. Clinical trial of clarithromycin for cutaneous (disseminated) infection due to Mycobacterium chelonae. Ann Intern Med 1993; 119: 482–486
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treatment for 18 months. Then, 3 months before presentation he had been transplanted with a cadaveric kidney. The immunosuppressive regimen consisted of prednisolone, cyclosporin A and mycophenolate mofetil. The biopsy specimen obtained from the lesions showed acute panniculitis with abscess formation in the mid-dermis and few Langhans-type giant cells (Figure 1C). Numerous acid-fast bacilli could be demonstrated (Figure 1D). Culturing of a wound smear showed Mycobacterium abscessus. Drug sensitivity was tested. The patient received clarithromycin 250 mg twice daily and pyrazinamide 2 g daily. Treatment was continued for 8 months, during which
