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Chronic granulomatous Mycobacterium avium skin pseudotumour
Clinical Picture
Chronic granulomatous Mycobacterium avium skin pseudotumour Dany Nassar, Nicolas Ortonne, Bernard Grégoire-Krikorian, Jean-Claude Roujeau Lancet Infect Dis 2009; 9: 136 Department of Dermatology (D Nassar MD, Prof J-C Roujeau MD) and Department of Pathology (N Ortonne MD), CHU Henri Mondor Créteil, France; and Department of Dermatology, CHD Felix Guyon, Saint-Denis, Réunion, France (B Grégoire-Krikorian MD) Correspondence to: Dr Dany Nassar, Department of Dermatology, CHU Henri Mondor, 51 Avenue du Marichal de Lattre de Tassigny, 94100 Créteil, France [email protected]
A
A 43-year-old woman from Réunion, France, presented with a nodular infiltrated painless lesion of the right cheek and ear (figure, A). The lesion began 7 years ago as an infiltrated plaque on the ear lobe. The first biopsy samples showed giant cell granulomas, leading to the diagnosis of cutaneous sarcoidosis. Tuberculin skin test was negative. She was treated with oral steroids, which were initially effective, but relapse occurred on decreasing dosages. The patient was then treated with hydroxychloroquine, but this was stopped because of retinitis. Thalidomide, methotrexate, and ciclosporin were not effective. The lesion extended to the cheek and the whole external ear. She then had three perfusions of infliximab without any improvement. After that, she was referred to our dermatology department. Clinical B
C
examination revealed an infracentimetric cervical right lymphadenopathy. Chest radiography was normal and tuberculin skin test was negative. A second histology specimen was taken, which showed a granulomatous lymphocytic infiltrate (figure, B; black arrow, granulomas; green arrow, giant multinucleated cells). We ruled out granulomatous lymphoma by the absence of atypical lymphocytes and the absence of clonal T and B cells in the infiltrate. A separate punch biopsy was sent for direct examination and culture for mycobacteria species. The culture was positive on the second week with Mycobacterium avium indentified by PCR. The diagnosis was chronic granulomatous M avium infection. The unusual growth might have resulted from the use of drugs with immunosuppressive effect. The patient was given a 6-month treatment with clarithromycin 500 mg twice a day, ethambutol 20 mg/kg per day, and rifabutine 300 mg per day. The lesion gradually flattened, leaving only some macular pigmented marks in its place (figure, C). M avium skin infections do occur in healthy individuals. They can take unusual forms and grow into a granulomatous pseudotumour in immunosuppressed patients or those taking anti-tumour necrosis factor therapies. The diagnosis is made on skin biopsy culture and molecular identification. Conflicts of interest We declare that we have no conflicts of interest.
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Chronic granulomatous Mycobacterium avium skin pseudotumour Dany Nassar, Nicolas Ortonne, Bernard Grégoire-Krikorian, Jean-Claude Roujeau Lancet Infect Dis 2009; 9: 136 Department of Dermatology (D Nassar MD, Prof J-C Roujeau MD) and Department of Pathology (N Ortonne MD), CHU Henri Mondor Créteil, France; and Department of Dermatology, CHD Felix Guyon, Saint-Denis, Réunion, France (B Grégoire-Krikorian MD) Correspondence to: Dr Dany Nassar, Department of Dermatology, CHU Henri Mondor, 51 Avenue du Marichal de Lattre de Tassigny, 94100 Créteil, France [email protected]
A
A 43-year-old woman from Réunion, France, presented with a nodular infiltrated painless lesion of the right cheek and ear (figure, A). The lesion began 7 years ago as an infiltrated plaque on the ear lobe. The first biopsy samples showed giant cell granulomas, leading to the diagnosis of cutaneous sarcoidosis. Tuberculin skin test was negative. She was treated with oral steroids, which were initially effective, but relapse occurred on decreasing dosages. The patient was then treated with hydroxychloroquine, but this was stopped because of retinitis. Thalidomide, methotrexate, and ciclosporin were not effective. The lesion extended to the cheek and the whole external ear. She then had three perfusions of infliximab without any improvement. After that, she was referred to our dermatology department. Clinical B
C
examination revealed an infracentimetric cervical right lymphadenopathy. Chest radiography was normal and tuberculin skin test was negative. A second histology specimen was taken, which showed a granulomatous lymphocytic infiltrate (figure, B; black arrow, granulomas; green arrow, giant multinucleated cells). We ruled out granulomatous lymphoma by the absence of atypical lymphocytes and the absence of clonal T and B cells in the infiltrate. A separate punch biopsy was sent for direct examination and culture for mycobacteria species. The culture was positive on the second week with Mycobacterium avium indentified by PCR. The diagnosis was chronic granulomatous M avium infection. The unusual growth might have resulted from the use of drugs with immunosuppressive effect. The patient was given a 6-month treatment with clarithromycin 500 mg twice a day, ethambutol 20 mg/kg per day, and rifabutine 300 mg per day. The lesion gradually flattened, leaving only some macular pigmented marks in its place (figure, C). M avium skin infections do occur in healthy individuals. They can take unusual forms and grow into a granulomatous pseudotumour in immunosuppressed patients or those taking anti-tumour necrosis factor therapies. The diagnosis is made on skin biopsy culture and molecular identification. Conflicts of interest We declare that we have no conflicts of interest.
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www.thelancet.com/infection Vol 9 February 2009