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Letter
Iatrogenic Mycobacterium
simiae Skin Infection in an Immunocompetent Patient
Jaime Piquero,* Vanesa Piquero Casals,* Edgar Larotta Higuera,* Mitchell
Yakrus,† David Sikes,† and Jacobus H. de Waard‡
*Departamento de Dermatología, Clínica Sanatrix, Caracas, Venezuela; †Centers
for Disease Control and Prevention, Atlanta, Georgia, USA; and ‡Laboratorio
de Tuberculosis, Instituto de Biomedicina, Caracas, Venezuela
Suggested citation
for this article:
Piquero J, Casals VP, Higuera EL, Yakrus M, Sikes D, de Waard JH. Iatrogenic
Mycobacterium simiae skin infection in an immunocompetent patient.
Emerg Infect Dis [serial on the Internet]. 2004 May [date cited].
Available from: http://www.cdc.gov/ncidod/EID/vol10no5/03-0681.htm
To the Editor: We report a case of a 36-year-old woman who sought
treatment for 45 firm and erythematous nodular lesions on her face and
neck. A physical examination showed no other abnormalities. Results of
a chest x-ray and routine laboratory tests were normal. The patient tested
negative for hepatitis B and HIV. Three weeks before she sought treatment,
the patient reported receiving multiple intradermal microinjections in
her face and neck for cosmetic purposes (mesotherapy) with an unlicensed
product consisting of a solution of glycosaminoglycans. The injections
had been administered by an unlicensed practitioner in a nonmedical office
setting. The patient stated that 2 days after the therapy, a fever developed;
it persisted for several days, along with redness at the inoculation sites,
which gradually developed into nodules.
Standard staining of a biopsied specimen from the lesion site was negative
for bacteria, fungi, and mycobacteria. A histopathologic examination of
a biopsy specimen showed an unspecific granulomatous infiltrate. Culture
for common bacteria and fungi was negative, but culture of a sterile nodule
aspirate on Lowenstein-Jensen medium was positive for acid-fast bacteria
after 5 weeks. By using restriction endonuclease analysis of the 65-kDa
heat shock protein gene (1), we found that the isolate
showed a pattern compatible with Mycobacterium simiae. Identification
was subsequently confirmed by high performance liquid chromatography of
mycolic acids at the Centers for Disease Control and Prevention, Atlanta,
Georgia. The isolate was tested for drug susceptibility against a panel
of drugs and found to be resistant to most drugs tested (streptomycin,
isoniazid, rifampin, ethambutol, ethionamide, rifabutin, ciprofloxacin,
kanamycin, capreomycin, p-aminosalicylic acid, ofloxacin, and amikacin)
and susceptible to clarithromycin at an MIC of 1 mg/mL. Treatment with
clarithromycin was started, and the granulomas slowly cleared after 9
months of treatment.
To our knowledge, this is the first reported case of an iatrogenic skin
infection caused by M. simiae in an immunocompetent person. M.
simiae is a species of nontuberculous mycobacterium commonly found
in nature, but its role as a pathogen has been controversial. The slow-growing,
photochromogenic mycobacterium has been isolated from both surface and
tap water and has been associated with a nosocomial pseudo-outbreak suspected
to have originated from a contaminated hospital water supply (2).
M. simiae rarely causes disease in immunocompetent patients; most
infections are associated with AIDS patients. (3–5).
Although this patient responded to treatment with clarithromycin, no
established optimal therapeutic regimen exists against this species of
Mycobacterium. M. simiae is often multidrug resistant, but
successful therapy with clarithromycin in combination with ethambutol
and ciprofloxacin has been reported in AIDS patients (6,7).
We conclude that M. simiae can cause skin infections if injected
directly into the dermis. Prolonged treatment is necessary to cure the
patient of the infection. This report underscores the risk from alternative
therapies performed with unlicensed products and by unlicensed practitioners.
Unusual infectious agents should be considered when diagnosing skin infection
in patients who have received injections for cosmetic purposes.
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