Disseminated Mycobacterium chelonae cutaneous infection: recalcitrant to combined antibiotic therapy

A 25-year-old Thai housewife had a history of tuberculosis of the lymph nodes for six years that had been successfully treated with a course of anti-TB drugs. She developed several red, circumscribed, infiltrative plaques composed of umbilicated papules and pustules on her face and upper part of the body with cervical lymphadenopathy six months later. A pus smear from the lesion grew acid fast bacilli (AFB). Histopathological examination showed a mixed cell granuloma suggestive of infection. A T cell study showed a low CD4 count, and multi skin tests indicated cutaneous anergy. Culture from a biopsy specimen taken from the skin lesion grew M.chelonae; the cultures from blood, urine, and bone marrow. The lesions were not responsive to an anti TB drug given for 2 months based upon the results of the AFB positive pus smear before the culture and sensitivity reports were obtained. Since then the patient was treated with antibiotics according to the results of the sensitivity tests. A combination of amikacin and clarithromycin was started and hyperthermic therapy was later added with a partial response. Based upon the sensitivity test, kanamycin was introduced but had to be stopped because of ototoxicity. Sparfloxacin was used with an effective result but was discontinued for economic reasons. Finally, clarithromycin in combination with clofazimine and cryotherapy were given for a year before the lesions healed completely. It took a three years duration for the total course of treatment for this patient. She is still in remission after two years of follow-up period. This extensive cutaneous M.chelonae infection needed a prolonged combination of antibiotics with the addition of cryotherapy for the non-responsive lesions.