Mycobacterium Haemophilum

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Background

Mycobacterium haemophilum is a nontuberculous mycobacterium that causes skin, joint, bone, and pulmonary infections in immunocompromised persons and lymphadenitis in children.[1]

M haemophilum was first isolated from subcutaneous abscesses in a patient with Hodgkin disease. Most recent infections have occurred in patients with AIDS, in transplant recipients, and in patients receiving tumor necrosis factor-alpha inhibitors.[2, 3, 4] M haemophilum skin infection has been associated with permanent eyebrow makeup and tattoos,[5] as well as accupuncture treatments.[6]

M haemophilum is a fastidious (requires special growth media) mycobacterium that requires heme-supplemented culture media and low temperatures for growth. Because of these features, it is probably underdiagnosed.

Pathophysiology

The pathophysiology, natural habitat, and mechanism for acquisition of M haemophilum infection are not known. Water reservoirs may be the source of M haemophilum infections. Immunocompromised adults with M haemophilum infection most commonly present with skin lesions. Septic arthritis and osteomyelitis may also occur. Pulmonary infection is much less common and may follow skin disease. M haemophilum infection occasionally causes pulmonary infection initially. Mycobacteremia may occur.

Epidemiology

Frequency

United States

More than 40 cases of M haemophilum infection have been reported, including 10 cases in Arizona from 1984-1994. Most cases occurred in immunosuppressed patients. The incidence of disease is unknown.

International

Cases of M haemophilum infection have been reported sporadically from Australia, France, Germany,[7] Canada, Israel, United Kingdom, and South Africa.

Mortality/Morbidity

Sex

M haemophilum infection is more common in males than in females. This may be related to the higher incidence of HIV infection in males.

Age

History

Physical

Causes

Laboratory Studies

Imaging Studies

Other Tests

Procedures

Histologic Findings

Biopsy specimens of skin lesions show granulomatous panniculitis and caseating or noncaseating granulomas. Patients with AIDS have poorly formed granulomas. A neutrophilic infiltrate with multinucleated giant cells may be observed. AFB smear results are usually positive, revealing large, pleomorphic, or curved AFB.

Lymph node biopsy may reveal granulomas, necrosis, granulating tissue, or multinucleated giant cells, and the specimen may be smear-positive for AFB.

Medical Care

Surgical Care

Consultations

Medication Summary

Although no standardized treatment exists, a regimen that includes a combination of at least 2 drugs with low minimum inhibitory concentrations (MICs) against M haemophilum is preferred.

A 3-drug combination of ciprofloxacin, clarithromycin, and rifampin or rifabutin has been used for cutaneous disease in bone marrow transplant recipients. No standard treatment exists; optimal treatment time is unknown.

Clarithromycin (Biaxin XL)

Clinical Context:  Macrolide with activity against various nontuberculous mycobacteria. Binds to bacterial 50S ribosomal subunit and inhibits RNA-dependent protein synthesis.

Rifampin (Rifadin, Rimactane)

Clinical Context:  Important drug used in the treatment of infection with M tuberculosis and nontuberculous mycobacterial infections. Inhibits DNA-dependent RNA polymerase activity.

Ciprofloxacin (Cipro)

Clinical Context:  Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth. Other quinolones such as levofloxacin, sparfloxacin, and ofloxacin may also be effective.

Amikacin (Amikin)

Clinical Context:  Expected to be a powerful drug for mycobacteremia. Starting amikacin may be beneficial at least as long as the patient is septic.

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Further Inpatient Care

Further Outpatient Care

Prognosis

Author

Natalie C Klein, MD, PhD, Associate Director, Infectious Disease Division, Associate Professor of Medicine, The School of Medicine at Stony Brook University Medical Center

Disclosure: Nothing to disclose.

Specialty Editors

Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Aaron Glatt, MD, Chief Administrative Officer, Executive Vice President, Mercy Medical Center, Catholic Health Services of Long Island

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Disclosure: Nothing to disclose.

References

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