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Mycobacterium fortuitum osteomyelitis of the calcaneus secondary to a puncture wound
Volume 85 Number 4
Brief clinical and laboratory observations
stituted on the affected side(s) if fluid reaccumulates after t h e t h i r d t h o r a c e n t e s i s . C h e s t t u b e d r a i n a g e in chylothorax reduces the n u m b e r of days of drainage a n d the a m o u n t of fluid drained. 1 Surgery is usually not indicated in the t r e a t m e n t of chylothorax, since the site of leakage is generally n o t apparent by gross examination at operation. 2 Patients being treated for chylothorax should n o t be fed orally. The importance of this s t a t e m e n t has n o t been fully appreciated. Work performed in laboratory animals 3-6 demonstrates that water-insoluble, long-chain fatty acids are absorbed almost entirely via the intestinal lymphatics; short-chain water-soluble fatty acids are absorbed directly into the blood stream and enter the portal circulation. A reduction in intestinal lymphatic a n d thoracic duct flow occurs w h e n long-chain fatty acids are r e m o v e d from the diet. 5, 7 This is the rationale for use of fat-free diets in these patients. However, it has also been noted in fasted animals that even water or physiologic saline given by m o u t h produces an increase in the flow of intestinal lymph. 8, 9 In m a n , it has been shown that water given by m o u t h increases thoracic l y m p h flow. l~ Since the aim in these patients is to reduce as m u c h as possible the flow of thoracic duct lymph, then nothing by m o u t h a p p e a r s t h e m o s t effective r e g i m e n . I n travenous alimentation is thus a logical substitute for oral feeding.
Mycobacterium fortuitum osteomyelitis of the calcaneus secondary to a puncture wound
517
REFERENCES
1. Decancq, H. G., Jr.: The treatment of chylothorax in children, Surg. Gynecol. Obstet. 121: 509, 1965. 2. Randolph, J. G., and Gross, R. E.: Congenital chylothorax, Arch. Surg. 74: 405, 1957. 3. Bloom, B., Chaikoff, I. L., Reinhardt, W. O., Entenman, C., and Dauben, W. G.: The quantitative significance of the lymphatic pathway in transport of absorbed fatty acids, J. Biol. Chem. 184: 1, 1950. 4. Bloom, B., Chaikoff, I. L., and Reinhardt, W. O.: Intestinal lymph as pathway for support of absorbed fatty acids of different chain lengths, Am. J. Physiol. 166: 451, 1951. 5. Simmonds, W. J.: Some observations on the increase in thoracic duct lymph flow during intestinal absorption of fat in unanaesthetized rats, Aust. J. Exp. Biol. Med. Sci. 33: 305, 1955. 6. Hyun, S. A., Vahouny, G. V., and Treadwell, C. R.: Portal absorption of fatty acids in lymph- and portal veincannulated rats, Biochim. Biophys. Acta 137: 296, 1967. 7. Shannon, A. D., and Lascelles, A. K.: Effect of skim-milk feeding on the flow and composition of thoracic duct and intestinal lymph in young calves, Aust. J. Biol. Sci. 22: 197, 1969. 8. Barrowman, J., and Roberts, K. B.: The role of the lymphatic system in the absorption of water from the intestine of the rat, Q. J. Exp. Physiol. 52: 19, 1967. 9. Simmonds, W. J.: The effect of fluid, electrolyte and food intake on thoracic duct lymph flow in unanaesthetized rats, Aust. J. Exp. Biol. Med. Sei. 32: 285, 1954. 10. Crandall, L. A., Jr., Barker, S. B., and Graham, D. G.: A study of the lymph flow from a patient with thoracic duct fistula, Gastroenterology 1: 1040, 1943.
course characterized by occasional s p o n t a n e o u s remissions and no response to c o n v e n t i o n a l a n t i t u b e r c u l o u s therapy. W e report, what is to our knowledge, the first welld o c u m e n t e d case o f p r i m a r y localized M. f o r t u i t u m osteomyelitis. CASE R E P O R T
Margan J. Chang, M.D., and Leslie L. Barton,
M.D.,* St. Louis, Mo. I N FECTION with Mycobacteriumfortuitum, a ubiquitous organism, has b e e n described previously most often in association with c u t a n e o u s a n d p u l m o n a r y lesions. 14 These rarely fatal infections usually pursue a chronic From the Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, and the Division of lnfectious Diseases at St. Louis Children's Hospital. *Reprint address: Department of'Pediatrics, St. Louis Children's Hospital, 500 S. Kingshighway, St. Louis, Mo. 63110.
D. T. (SLCH No. 73-8777), a 14-year-old girl, had been in good health until 3 weeks prior to admission, when she stepped on a rake and sustained a puncture wound on the sole of her Abbreviations used SLCH: St. Louis Children's Hospital PPD: purified protein derivative NBT: nitroblue tetrazolium right foot. The wound was cleansed, packed, and she received tetanus toxoid. One week prior to admission, swelling and redness of the right foot were noted. She received one intramuscular injection of penicillin, followed by oral penicillin until the time of admis-
518
Brief clinical and laboratory observations
The Journal of Pediatrics October 1974
Fig. 1. Radiolucency in the anterior inferior portion of the calcaneus marked by arrows.
Fig. 2. Soft tissue sinues and cavity in the calcaneus outlined by radio-opaque material.
sion. No improvement in the foot lesion was noted with this therapy. At the time of admission to SLCH a painful abscess was noted o n t h e plantar aspect of her right foot, surrounded by an area of cellulitis and lymphangitis. Radiographs of the right foot (Fig. 1) revealed a 5 cm radiolucency in the anterior inferior portion of the calcaneus compatible with osteomyelitis. Complete blood count and urinalysis were within normal limits. Intermediate strength, Tween-80 stabilized, PPD skin test was negative. The wound was incised and drained and the patient was treated for 10 days with clindamycin intravenously (30 mg/ kg/24 br) and gentamicin (4 mg/kg/24 hr). She remained afebrile throughout this admission. Following discharge she was maintained on oral clindamycin (30 mg/kg/24 hr). Culture of the wound drainage grew a filamentous gram-positive rod which was sent to the Center for Disease Control for further identification. The patient was readmitted 2 months later with persistent fever, pain, and swelling of the right foot. Radiographs revealed progressive osteomyelitis of the right calcaneus. The only abn o r m a l physical findings at this time were a swollen, erythematous, tender right foot a n d some shotty right inguinal adenopathy. Complete blood count, urinalysis, chest radiographs, s e r u m glutamic oxaloacetic transaminase, s e r u m glutamic pyruvate transaminase, and serum alkaline phospha-
tase were within normal limits. Culture of the wound drainage at this time grew Staphylococcus epidermidis and enterococci. Intravenous ampicillin (120 mg/kg/24 hr) and methicillin (90 mg/kg/24 hr) therapy resulted in no clinical or radiographic improvement. Sinus tract injection of the wound revealed multiple small channels and a larger area of central lucency in the calcaneus (Fig. 2). Incision, drainage, and curettage of the osteomyelitic cavity yielded bone laden with noncaseating granulomas and acid-fast organisms. Treatment with ethambutol (15 mg/kg/24 hr) and rifampin (15 mg/kg/24 hr) was initiated; previous antibiotic therapy was discontinued. The organisms from the original culture obtained on the first admission were subsequently identified by the Center for Disease Control as Mycobacterium fortuitum, which was resistant by indirect drug susceptibility testing to all antituberculous agents. Intradermal inoculation with intermediate s t r e n g t h T w e e n 80 stabilized PPD a n d r e p r e s e n t a t i v e mycobacteriat antigens from Runyon groups I through IV including M. Jbrtuitum, as well as streptokinase/streptodornase and monilia antigens, failed to elicit delayed dermal hypersensitivity reactions. Further evaluation revealed no evidence of disseminated mycobacterial disease. Treatment with rifampin (15 mg/kg/24 hr) and ethambutol (15 mg/kg/24 hr) was continued. She has been followed in the orthopedic and infectious disease clinics. Immunologic work-up revealed a NBT dye reduction of less than 1% with a stimulated NBT of 70%. The
Volume 85 Number 4 patient's white blood cells responded normally to phytohemagglutinin. Repeat intradermal inoculation of Tween 80 stabilized intermediate strength PPD and group I through IV mycobacterial antigens including M. fortuitum revealed only a 4 mm erythematous reaction to PPD-Cleveland glaze. Marked clinical and radiographic improvement has been noted over a 7 month period. DISCUSSION
Mycobacterium fortuitum, a rapidly growing R u n y o n group IV organism,4 produces visible colonies in less than one week at 37 ~ C or at room temperature on a variety of media i n c l u d i n g L o w e n s t e i n - J e n s e n . Colonies of M. fortuitum are nonpigmented and may be either rough or smooth. The organism does not produce niacin and may be grown on McConkey's agar. It is distinguished from M. abcessus on the basis of filamentous colonial growth and from the other group IV rapid growers by the aryl-sulfatase test. Organisms are grown for 3 days on solid media containing phenophthalein sulfate. Free phenophthalein (after the sulfate group is split off by aryt-sulfatase) is detected by adding a few drops of sodium carbonate. 2 M..fortuitum has been isolated from many sources including soil,5 house dust, 6 fish, frogs, cattle, 2 raw and pasteurized milk,7,8 and sputum and saliva of healthy adults. 9 This o r g a n i s m has b e e n c o n s i d e r e d a n o n pathogen in healthy individuals, although it has exhibited pathogenicity in the compromised host) ~ The most common M. fortuitum infections, cutaneous lesions and abscesses, are almost always associated with traumatic injuries, e.g., following injections, gunshot wounds, motorcycle accidents, and gardening injuries? These cutaneous infections pursue an indolent, remitting course characterized by fistula formation. Pulmonary,2,t~ ocular, t2 central nervous system, and peritoneal infections2,3with M. fortuitum also have been documented, and joint and bursal infections due to M. fortuitum have been described following steroid injections of the joint or bursaJ 3 To our knowledge, however, primary localized osteomyelitis due to M. fortuitum has never b e e n reported. I n 1972 H e r n d o n a n d associates 14 reported three soldiers who developed M. fortuitum infections of their amputation stumps a n d ultimately required debridem e n t and excision to effect a complete cure. The organism was refractory to antituberculous therapy. This organism has been reported to be sensitive to antibiotics, such as kanamycin, oxacillin, tetracycline, or streptomycin. The organism isolated from our patient was sent to the Center for Disease Control where the m i n i m u m inhibitory concentrations of a n u m b e r of
Brief clinical and laboratory observations
5 19
common antibiotics were determined. These results indicated that the organism was sensitive in vitro to ampicillin, kanamycin, gentamicin, penicillin, tetracycline, cephalothin, erythromycin, and clindamycin, and resistant to chloramphenical, nitrofurantoin, polymixin B, nalidixic acid, colistin, carbenicillin, minocycline, spectinomycin, and vancomycin. Isolation of this organism in the hospital bacteriology laboratory is facilitated by its growth on McConkey's agar. This feature differentiates it from other mycobacterial organisms and may lead to its being overlooked. In vitro sensitivity indicates that antibiotics other than antituberculous agents may b e efficacious against M. fortuitum infections.
REFERENCES
1. Corpe, R. F., Smith, C. E., and Stergus, I.: Death due to Mycobacteriumfortuitum, J.A.M.A. 177: 262, 1961. 2. Hand, W. L., and Sanford, J. P.: Mycobacteriumfortuitum-A human 0athogen, Ann. Intern. Med. 73: 971, 1970. 3. Lincoln, E. M., and Gilbert, L. A.: Disease in children due to mycobacteria other than mycobacterium tuberculosis, Am. Rev. Respir. Dis. 105: 683, 1972. 4. Runyon, E. H.: Anonymous mycobacteria in pulmonary disease, Med. Clin. North Am. 43: 273, 1959. 5. Wolinsky, E., and Rynearson, T: K.: Mycobacteria in soil and their relation to disease associated strains, Am. Rev. Respir. Dis. 97: 1032, 1968. 6. Singer, E., and Rodda, G. M. J.: Non-specific sensitization to tuberculin: Mycobacteria in water, Tubercle 46: 209, 1965. 7. Chapman, J. S., and Speight, M.: Isolation of atypical mycobacteria from pasteurized milk, Am. Rev. Respir. Dis. 98: 1052, 1968. 8. Chapman, J. S., Bernard, J. S., and Speight, M.: Isolation of mycobacteria from raw milk, Am. Rev. Respir. Dis. 91: 351, 1965. 9. Edwards, L. B., and Palmer, C. E.: Isolation of atypical mycobacteria from healthy persons, Am. Rev. Respir. Dis. 80: 747, 1959. 10. Dalinka, M. K., and Hemming, V. G.: Atypical mycobacterial osteomyelitis, report of a case associated with acute lymphoblastic leukemia, J. Can. Assoc. Radiol. 22: 173, 1971. 11. Phillips, S., and Larkin, J. C.: Atypical pulmonary tuberculosis caused by unclassified mycobacteria, Ann. Intern. Med. 60: 401, 1964. 12. Zimmerman, L. E., Turner, L., and McTigue, J. W.: Mycobacterium fortuitum infection of the cornea, Arch. Ophthalmol. 82: 596, 1969. 13. Kelly, P. J., Karlson, A. G., Weed, L. A., and Lipscomb, P. R.: Infection of synovial tissues by mycobacteria other than Mycobacterium tuberculosis, J. Bone Joint Surg. 49-A: 1521, 1967. 14. Herndon, J. H., Dantzker, D. R., and Lanone, A. M.: Mycobacterium fortuitum infections involving the extremities, J. Bone Joint Surg. 54-A: 1279, 1972.
Brief clinical and laboratory observations
stituted on the affected side(s) if fluid reaccumulates after t h e t h i r d t h o r a c e n t e s i s . C h e s t t u b e d r a i n a g e in chylothorax reduces the n u m b e r of days of drainage a n d the a m o u n t of fluid drained. 1 Surgery is usually not indicated in the t r e a t m e n t of chylothorax, since the site of leakage is generally n o t apparent by gross examination at operation. 2 Patients being treated for chylothorax should n o t be fed orally. The importance of this s t a t e m e n t has n o t been fully appreciated. Work performed in laboratory animals 3-6 demonstrates that water-insoluble, long-chain fatty acids are absorbed almost entirely via the intestinal lymphatics; short-chain water-soluble fatty acids are absorbed directly into the blood stream and enter the portal circulation. A reduction in intestinal lymphatic a n d thoracic duct flow occurs w h e n long-chain fatty acids are r e m o v e d from the diet. 5, 7 This is the rationale for use of fat-free diets in these patients. However, it has also been noted in fasted animals that even water or physiologic saline given by m o u t h produces an increase in the flow of intestinal lymph. 8, 9 In m a n , it has been shown that water given by m o u t h increases thoracic l y m p h flow. l~ Since the aim in these patients is to reduce as m u c h as possible the flow of thoracic duct lymph, then nothing by m o u t h a p p e a r s t h e m o s t effective r e g i m e n . I n travenous alimentation is thus a logical substitute for oral feeding.
Mycobacterium fortuitum osteomyelitis of the calcaneus secondary to a puncture wound
517
REFERENCES
1. Decancq, H. G., Jr.: The treatment of chylothorax in children, Surg. Gynecol. Obstet. 121: 509, 1965. 2. Randolph, J. G., and Gross, R. E.: Congenital chylothorax, Arch. Surg. 74: 405, 1957. 3. Bloom, B., Chaikoff, I. L., Reinhardt, W. O., Entenman, C., and Dauben, W. G.: The quantitative significance of the lymphatic pathway in transport of absorbed fatty acids, J. Biol. Chem. 184: 1, 1950. 4. Bloom, B., Chaikoff, I. L., and Reinhardt, W. O.: Intestinal lymph as pathway for support of absorbed fatty acids of different chain lengths, Am. J. Physiol. 166: 451, 1951. 5. Simmonds, W. J.: Some observations on the increase in thoracic duct lymph flow during intestinal absorption of fat in unanaesthetized rats, Aust. J. Exp. Biol. Med. Sci. 33: 305, 1955. 6. Hyun, S. A., Vahouny, G. V., and Treadwell, C. R.: Portal absorption of fatty acids in lymph- and portal veincannulated rats, Biochim. Biophys. Acta 137: 296, 1967. 7. Shannon, A. D., and Lascelles, A. K.: Effect of skim-milk feeding on the flow and composition of thoracic duct and intestinal lymph in young calves, Aust. J. Biol. Sci. 22: 197, 1969. 8. Barrowman, J., and Roberts, K. B.: The role of the lymphatic system in the absorption of water from the intestine of the rat, Q. J. Exp. Physiol. 52: 19, 1967. 9. Simmonds, W. J.: The effect of fluid, electrolyte and food intake on thoracic duct lymph flow in unanaesthetized rats, Aust. J. Exp. Biol. Med. Sei. 32: 285, 1954. 10. Crandall, L. A., Jr., Barker, S. B., and Graham, D. G.: A study of the lymph flow from a patient with thoracic duct fistula, Gastroenterology 1: 1040, 1943.
course characterized by occasional s p o n t a n e o u s remissions and no response to c o n v e n t i o n a l a n t i t u b e r c u l o u s therapy. W e report, what is to our knowledge, the first welld o c u m e n t e d case o f p r i m a r y localized M. f o r t u i t u m osteomyelitis. CASE R E P O R T
Margan J. Chang, M.D., and Leslie L. Barton,
M.D.,* St. Louis, Mo. I N FECTION with Mycobacteriumfortuitum, a ubiquitous organism, has b e e n described previously most often in association with c u t a n e o u s a n d p u l m o n a r y lesions. 14 These rarely fatal infections usually pursue a chronic From the Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, and the Division of lnfectious Diseases at St. Louis Children's Hospital. *Reprint address: Department of'Pediatrics, St. Louis Children's Hospital, 500 S. Kingshighway, St. Louis, Mo. 63110.
D. T. (SLCH No. 73-8777), a 14-year-old girl, had been in good health until 3 weeks prior to admission, when she stepped on a rake and sustained a puncture wound on the sole of her Abbreviations used SLCH: St. Louis Children's Hospital PPD: purified protein derivative NBT: nitroblue tetrazolium right foot. The wound was cleansed, packed, and she received tetanus toxoid. One week prior to admission, swelling and redness of the right foot were noted. She received one intramuscular injection of penicillin, followed by oral penicillin until the time of admis-
518
Brief clinical and laboratory observations
The Journal of Pediatrics October 1974
Fig. 1. Radiolucency in the anterior inferior portion of the calcaneus marked by arrows.
Fig. 2. Soft tissue sinues and cavity in the calcaneus outlined by radio-opaque material.
sion. No improvement in the foot lesion was noted with this therapy. At the time of admission to SLCH a painful abscess was noted o n t h e plantar aspect of her right foot, surrounded by an area of cellulitis and lymphangitis. Radiographs of the right foot (Fig. 1) revealed a 5 cm radiolucency in the anterior inferior portion of the calcaneus compatible with osteomyelitis. Complete blood count and urinalysis were within normal limits. Intermediate strength, Tween-80 stabilized, PPD skin test was negative. The wound was incised and drained and the patient was treated for 10 days with clindamycin intravenously (30 mg/ kg/24 br) and gentamicin (4 mg/kg/24 hr). She remained afebrile throughout this admission. Following discharge she was maintained on oral clindamycin (30 mg/kg/24 hr). Culture of the wound drainage grew a filamentous gram-positive rod which was sent to the Center for Disease Control for further identification. The patient was readmitted 2 months later with persistent fever, pain, and swelling of the right foot. Radiographs revealed progressive osteomyelitis of the right calcaneus. The only abn o r m a l physical findings at this time were a swollen, erythematous, tender right foot a n d some shotty right inguinal adenopathy. Complete blood count, urinalysis, chest radiographs, s e r u m glutamic oxaloacetic transaminase, s e r u m glutamic pyruvate transaminase, and serum alkaline phospha-
tase were within normal limits. Culture of the wound drainage at this time grew Staphylococcus epidermidis and enterococci. Intravenous ampicillin (120 mg/kg/24 hr) and methicillin (90 mg/kg/24 hr) therapy resulted in no clinical or radiographic improvement. Sinus tract injection of the wound revealed multiple small channels and a larger area of central lucency in the calcaneus (Fig. 2). Incision, drainage, and curettage of the osteomyelitic cavity yielded bone laden with noncaseating granulomas and acid-fast organisms. Treatment with ethambutol (15 mg/kg/24 hr) and rifampin (15 mg/kg/24 hr) was initiated; previous antibiotic therapy was discontinued. The organisms from the original culture obtained on the first admission were subsequently identified by the Center for Disease Control as Mycobacterium fortuitum, which was resistant by indirect drug susceptibility testing to all antituberculous agents. Intradermal inoculation with intermediate s t r e n g t h T w e e n 80 stabilized PPD a n d r e p r e s e n t a t i v e mycobacteriat antigens from Runyon groups I through IV including M. Jbrtuitum, as well as streptokinase/streptodornase and monilia antigens, failed to elicit delayed dermal hypersensitivity reactions. Further evaluation revealed no evidence of disseminated mycobacterial disease. Treatment with rifampin (15 mg/kg/24 hr) and ethambutol (15 mg/kg/24 hr) was continued. She has been followed in the orthopedic and infectious disease clinics. Immunologic work-up revealed a NBT dye reduction of less than 1% with a stimulated NBT of 70%. The
Volume 85 Number 4 patient's white blood cells responded normally to phytohemagglutinin. Repeat intradermal inoculation of Tween 80 stabilized intermediate strength PPD and group I through IV mycobacterial antigens including M. fortuitum revealed only a 4 mm erythematous reaction to PPD-Cleveland glaze. Marked clinical and radiographic improvement has been noted over a 7 month period. DISCUSSION
Mycobacterium fortuitum, a rapidly growing R u n y o n group IV organism,4 produces visible colonies in less than one week at 37 ~ C or at room temperature on a variety of media i n c l u d i n g L o w e n s t e i n - J e n s e n . Colonies of M. fortuitum are nonpigmented and may be either rough or smooth. The organism does not produce niacin and may be grown on McConkey's agar. It is distinguished from M. abcessus on the basis of filamentous colonial growth and from the other group IV rapid growers by the aryl-sulfatase test. Organisms are grown for 3 days on solid media containing phenophthalein sulfate. Free phenophthalein (after the sulfate group is split off by aryt-sulfatase) is detected by adding a few drops of sodium carbonate. 2 M..fortuitum has been isolated from many sources including soil,5 house dust, 6 fish, frogs, cattle, 2 raw and pasteurized milk,7,8 and sputum and saliva of healthy adults. 9 This o r g a n i s m has b e e n c o n s i d e r e d a n o n pathogen in healthy individuals, although it has exhibited pathogenicity in the compromised host) ~ The most common M. fortuitum infections, cutaneous lesions and abscesses, are almost always associated with traumatic injuries, e.g., following injections, gunshot wounds, motorcycle accidents, and gardening injuries? These cutaneous infections pursue an indolent, remitting course characterized by fistula formation. Pulmonary,2,t~ ocular, t2 central nervous system, and peritoneal infections2,3with M. fortuitum also have been documented, and joint and bursal infections due to M. fortuitum have been described following steroid injections of the joint or bursaJ 3 To our knowledge, however, primary localized osteomyelitis due to M. fortuitum has never b e e n reported. I n 1972 H e r n d o n a n d associates 14 reported three soldiers who developed M. fortuitum infections of their amputation stumps a n d ultimately required debridem e n t and excision to effect a complete cure. The organism was refractory to antituberculous therapy. This organism has been reported to be sensitive to antibiotics, such as kanamycin, oxacillin, tetracycline, or streptomycin. The organism isolated from our patient was sent to the Center for Disease Control where the m i n i m u m inhibitory concentrations of a n u m b e r of
Brief clinical and laboratory observations
5 19
common antibiotics were determined. These results indicated that the organism was sensitive in vitro to ampicillin, kanamycin, gentamicin, penicillin, tetracycline, cephalothin, erythromycin, and clindamycin, and resistant to chloramphenical, nitrofurantoin, polymixin B, nalidixic acid, colistin, carbenicillin, minocycline, spectinomycin, and vancomycin. Isolation of this organism in the hospital bacteriology laboratory is facilitated by its growth on McConkey's agar. This feature differentiates it from other mycobacterial organisms and may lead to its being overlooked. In vitro sensitivity indicates that antibiotics other than antituberculous agents may b e efficacious against M. fortuitum infections.
REFERENCES
1. Corpe, R. F., Smith, C. E., and Stergus, I.: Death due to Mycobacteriumfortuitum, J.A.M.A. 177: 262, 1961. 2. Hand, W. L., and Sanford, J. P.: Mycobacteriumfortuitum-A human 0athogen, Ann. Intern. Med. 73: 971, 1970. 3. Lincoln, E. M., and Gilbert, L. A.: Disease in children due to mycobacteria other than mycobacterium tuberculosis, Am. Rev. Respir. Dis. 105: 683, 1972. 4. Runyon, E. H.: Anonymous mycobacteria in pulmonary disease, Med. Clin. North Am. 43: 273, 1959. 5. Wolinsky, E., and Rynearson, T: K.: Mycobacteria in soil and their relation to disease associated strains, Am. Rev. Respir. Dis. 97: 1032, 1968. 6. Singer, E., and Rodda, G. M. J.: Non-specific sensitization to tuberculin: Mycobacteria in water, Tubercle 46: 209, 1965. 7. Chapman, J. S., and Speight, M.: Isolation of atypical mycobacteria from pasteurized milk, Am. Rev. Respir. Dis. 98: 1052, 1968. 8. Chapman, J. S., Bernard, J. S., and Speight, M.: Isolation of mycobacteria from raw milk, Am. Rev. Respir. Dis. 91: 351, 1965. 9. Edwards, L. B., and Palmer, C. E.: Isolation of atypical mycobacteria from healthy persons, Am. Rev. Respir. Dis. 80: 747, 1959. 10. Dalinka, M. K., and Hemming, V. G.: Atypical mycobacterial osteomyelitis, report of a case associated with acute lymphoblastic leukemia, J. Can. Assoc. Radiol. 22: 173, 1971. 11. Phillips, S., and Larkin, J. C.: Atypical pulmonary tuberculosis caused by unclassified mycobacteria, Ann. Intern. Med. 60: 401, 1964. 12. Zimmerman, L. E., Turner, L., and McTigue, J. W.: Mycobacterium fortuitum infection of the cornea, Arch. Ophthalmol. 82: 596, 1969. 13. Kelly, P. J., Karlson, A. G., Weed, L. A., and Lipscomb, P. R.: Infection of synovial tissues by mycobacteria other than Mycobacterium tuberculosis, J. Bone Joint Surg. 49-A: 1521, 1967. 14. Herndon, J. H., Dantzker, D. R., and Lanone, A. M.: Mycobacterium fortuitum infections involving the extremities, J. Bone Joint Surg. 54-A: 1279, 1972.