- Email: [email protected]
Nonpigmented Mycobacterial Skin Abscesses: A Rare Postoperative Complication in a Cancer Patient
416
MYCOBACTERIAL SKIN INFECTIONS, POSTOPERATIVE INFECTIONS
19. Azzarelli B, Roessmann U: Pathogenesis of central nervous system infiltration in acute leukemia. Arch Pathol Lab Med 101:203, 1977 20. Lee SS, Kim HK, Choi SC, et al: Granulocytic sarcoma occurring in the maxillary gingiva demonstrated by magnetic resonance imaging. Oral Surg Oral Med Oral Pathol 92:689, 2001 21. Dreizen S, McCredie KB, Keating MJ, et al: Malignant gingival and skin “infiltrates” in adult leukemia. Oral Surg 55:572, 1983 22. Meiss A, Butler J, Osborne B, et al: Granulocytic sarcoma in nonleukemic patients. Cancer 58:2697, 1986 23. Cotran RS, Kumar V, Robbins SL: Acute myeloblastic leukemia AML, in Robbins Pathologic Basis of Disease (ed 4), Philadelphia, PA, Saunders, 1989, pp 724-728 24. Guermazi A, Feger C, Rousselot P: Granulocytic sarcoma (chloroma): Imaging findings in adults and children. AJR Am J Roentgenol 178:319, 2002
25. Fellbaum C, Hansman ML: Immunohistochemical differential diagnosis of granulocytic sarcoma and malignant lymphomas on formalin fixed material. Virchows Arch Pathol Anat Histopathol 416:351, 1990 26. Brunning R, McKenna R: Atlas of Tumor Pathology. Tumors of Bone Marrow (Third Series). Washington, DC, Armed Forces Institute of Pathology, 1994, pp 19-37 27. Meis JM, Butler JJ, Osborne BM, et al: Granulocytic sarcoma in nonleukemic patients. Cancer 58:2697, 1986 28. Cankaya H, Ugras S, Dilek I: Head and neck granulocytic sarcoma with acute myeloid leukemia: Three rare cases. Ear Nose Throat J 80:224, 2001 29. Imrie KR, Kovacs MJ, Selby D, et al: Isolated chloroma: The effect of early antileukemic therapy. Ann Intern Med 123:351, 1995 30. Vicente JC, Rodríguez JS, López A, et al: Isolated granulocytic sarcoma: Report of a case in the oral cavity. J Oral Maxillofac Surg 48:748, 1990
J Oral Maxillofac Surg 67:416-418, 2009
Nonpigmented Mycobacterial Skin Abscesses: A Rare Postoperative Complication in a Cancer Patient Christopher M. Harris, DMD, MD, LCDR, DC, USN,* David Kim, DMD, MD,† and Ghali E. Ghali, DDS, MD‡ A 26-year-old Vietnamese female presented to the Department of Oral and Maxillofacial Surgery for evaluation of a left lateral tongue lesion that had been present for approximately 4 months and had recently rapidly increased in size. Her past medical history was not significant. The patient denied tobacco, alcohol, or illicit substance abuse. On exam, the lesion was a 2.5-cm exophytic, friable mass (Fig 1). No cervical lymphadenopathy was noted on exam. A preoperative workup included a chest ra*Residency Program Director, Department of Oral and Maxillofacial Surgery, Naval Medical Center, Portsmouth, VA. †Residency Program Director, Oral and Maxillofacial Surgery, Head and Neck Surgery, Louisiana Health Sciences Center, Shreveport, LA. ‡Professor and Chairman, Oral and Maxillofacial Surgery, Head and Neck Surgery, Louisiana Health Sciences Center, Shreveport, LA. Address correspondence and reprint requests to Dr Harris: Naval Medical Center, OMS, Charette Health Care Center, Portsmouth, Virginia 23708-2197; e-mail: [email protected] This is a US government work. There are no restrictions on its use. Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons 0278-2391/09/6702-0027$36.00/0 doi:10.1016/j.joms.2008.06.048
FIGURE 1. Left lateral tongue squamous cell carcinoma. Harris, Kim, and Ghali. Mycobacterial Skin Infections, Postoperative Infections. J Oral Maxillofac Surg 2008.
diograph, computed tomography scans of the neck, and laboratory studies. These studies were negative for metastatic disease. An incisional biopsy was performed, which showed a poorly differentiated squamous cell carcinoma. She was staged as a T2 N0 M0- Stage 2. The patient was taken to the operating room where a panendoscopy, left partial glossectomy, and left modified radical neck dissection was performed. A
417
HARRIS, KIM, AND GHALI
radial forearm free flap was used to reconstruct the tongue defect. Perioperative antibiotics and steroids (Unasyn [Pfizer, New York, NY] 3 g i.v. every 6 hours ⫻ 3 days and Decadron [Merck, Whitehouse Station, NJ] 8 mg i.v. every 6 hours ⫻ 3 days) were used according to our institution’s protocol. Her postoperative course was complicated by a hematoma on postoperative day 2. This was managed in the operating room, and no further complications were encountered during her hospital stay. The patient’s case was presented at the multidisciplinary tumor board, and postoperative radiation therapy was not recommended. Two months postoperatively the patient presented to her referring physician with an erythematous nodule in her left submandibular area. A course of antibiotics (Augmentin; GlaxoSmithKline, ResearchTriangle Park, NC) was prescribed for 2 weeks without resolution. A culture was not taken. The patient soon began to develop more nodules and ulcerations along the incision line on the side of her left neck dissection (Fig 2). Needle aspiration of these lesions was performed on several occasions. Each attempt yielded negative results for malignancy or organisms upon Gram stain and culturing. Cytology showed only inflammatory cells. The patient was placed on several courses of broad spectrum antibiotics and was referred to the Infectious Disease (ID) service. Approximately 4 weeks after culture harvesting and prior to seeing the ID service, her needle aspirate cultures showed 2 species of nonpigmented, rapidly growing mycobacteria, Mycobacterium cholenae and Mycobacterium abscessus. The patient was then started on Clarithromycin by the ID service for these atypical mycobacterial skin abscesses with eventual resolution of the lesions.
FIGURE 2. Erythematous skin nodules in left submandibular and infra-auricular area. Harris, Kim, and Ghali. Mycobacterial Skin Infections, Postoperative Infections. J Oral Maxillofac Surg 2008.
Discussion Mycobacterium cholenae, Mycobacterium abscessus, and Mycobacterium fortuitum are ubiquitous environmental organisms that may cause chronic infections of the skin, lungs, and other soft tissues.1-4 Disseminated disease may occur as well. Mycobacterium cholenae and Mycobacterium abscessus are nonpigmented, rapidly growing organisms that are commonly seen in nosocomial mycobacterial infections, particularly in immunocompromised patients. There are numerous organisms included in the group of Mycobacterium classified as rapidly growing Mycobacterium (RGM). The clinically important species include Mycobacterium cholenae, Mycobacterium abscessus, and Mycobacterium fortuitum.2 These organisms have been implicated as the etiology of many conditions.5,6 In many reports, skin diseases such as chronic skin ulcerations and abscesses are the predominant manifestations.2,7-13 Mycobacterial infections are becoming increasingly important. They tend to be seen in patients who have had surgical procedures and trauma. They have also been reported in immunocompromised patients. They have been associated with surgical site infections, contaminated water supplies, ophthalmologic infections, and with contaminated medical devices.1 Significant delays in diagnosis and therapy are common. Uslan et al3 reported a median time of 86 days between emergence of symptoms and definitive diagnosis. Clinically, the patient’s diagnosis is frequently delayed because of the lack of acquired or complete microbiologic (aerobic, anaerobic, fungal, and acid fast bacilli) specimens when treating skin infections. Standard culture techniques with bacteriologic media and fluorescence microscopy are common methods to discover the presence of mycobacteria. This method cannot identify an exact species. Routine bacteriologic culture techniques with numerous rounds of biochemical tests and reculturing may take several weeks for final species identification.14 Current laboratory techniques now have the ability to identify these organisms through polymerase chain reaction, gene-sequencing techniques, and antibiotic susceptibility patterns that allow for more rapid identification of the organism. Familiarity with the antibiotic susceptibility patterns of nontuberculous mycobacteria is essential in deciding upon empiric therapy for suspected infections. Broad spectrum antibiotics are likely to be prescribed in the clinical setting where no cultures were taken or where there is a delay in species identification. Including antibiotics to which these organisms are susceptible is warranted with a nonresponding chronic infection.15
418
MYCOBACTERIAL SKIN INFECTIONS, POSTOPERATIVE INFECTIONS
Mycobacterium cholenae, Mycobacterium abscessus, and Mycobacterium fortuitum are generally resistant to all the antituberculosis medications. Routine susceptibility testing for these drugs is not recommended because of prevalence of resistance in all the RGMs.15-17 Clarithromycin has been shown to have susceptibility in most isolates of Mycobacterium cholenae and Mycobacterium abscessus, and is the recommended oral drug for therapy. Amikacin, imipenem, linezolid, sulfonamides, and cefoxitin also show activity against most RGMs. Laboratory testing should be directed at susceptibility against clarithromycin, amikacin, cefoxitin, and imipenem instead of antituberculous medications.15,18
Summary Atypical mycobacteria are an exceedingly rare cause of postoperative wound infections. Their chronic nature, difficulty in diagnosis, and prolonged treatment course require the clinician to maintain a high degree of suspicion when faced with a nonresponding wound infection. It is crucial that a complete investigation into the etiology of all wound infections is carried out, particularly in all nonresponding infections. This case clearly shows the need for the clinician to be abreast of the etiology of atypical infections, as well as the appropriate use of various culturing techniques and medical therapy.
References 1. Vijayaraghavan R, Chandrashekkar R, Sujatha Y, et al: Hospital outbreak of atypical mycobacterial infection of port sites after laparoscopic surgery. J Hosp Infect 64:344, 2006 2. Esteban J, Fernandez Roblas R, Garcia Cia JI, et al: Clinical significance and epidemiology of non-pigmented rapidly growing mycobacteria in a university hospital. J Infect 54: 135, 2007
3. Uslan DZ, Kowalski TJ, Wengenack NL, et al: Skin and soft tissue infections due to rapidly growing mycobacteria. Arch Dermatol 142:1287, 2006 4. Palwade PK, Dhurat RS, Tendolkar UM, et al: Chronic cutaneous disease caused by the rapid growers Mycobacterium fortuitum and chelonae. Br J Dermatol 154:774, 2006 5. Wolinsky E: Nontuberculous mycobacteria and associated diseases. Am Rev Respir Dis 119:107, 1979 6. Wolinsky E: Mycobacterial diseases other than tuberculosis. Clin Infect Dis 15:1, 1992 7. Murillo J, Torres J, Bofill L, et al: Skin and wound infection by rapidly growing mycobacteria: An unexpected complication of liposuction. Arch Dermatol 346:1347, 2000 8. Winthrop KL, Abrams, Yakrus M, et al: An outbreak of mycobacterial furunculosis associated with footbaths at a nail salon. N Engl J Med 346:1366, 2002 9. Wallace RJ, Brown BA, Onyi GO: Skin, soft tissue and bone infections due to Mycobacterium chelonae: Importance of prior corticosteroid therapy, frequency of disseminated infections, and resistance to oral antimicrobials other than clarithromycin. J Infect Dis 166:405, 1992 10. Ara M, de Santamaria CS, Zaballos P, et al: Mycobacterium chelonae infection with multiple cutaneous lesions after treatment with acupuncture. Int J Dermatol 42: 632, 2003 11. Behroozan DS, Christian MM, Moy RL: Mycobacterium fortuitum infection following neck liposuction: a case report. Dermatol Surg 26:588, 2000 12. Haiavy J, Tobin H: Mycobacterium fortuitum breast implants infection in prosthetic breast implants. Plas Reconstr Surg 109:2124, 2002 13. Rao J, Golden TA, Fitzpatrick RE: Atypical mycobacterium infection following blepharoplasty and full face skin resurfacing with CO2 laser. Dermatol Surg 28:768, 2002 14. Silcox VA, Good RC, Floyd MM: Identification of clinically significant Mycobacterium fortuitum complex isolates. J Clin Microbiol 14:686, 1981 15. Brown BA, Wallace RJ, Onyi GO: Activities of four macrolides, including clarithromycin, against Mycobacterium fortuitum, Mycobacterium chelonae, and Mycobacterium chelonae-like organisms. Antimicrob Agents Chemother 36:180, 1992 16. Brown-Elliot BA, Griffith DE, Wallace RJ: Newly described or emerging human species of nontuberculous mycobacteria. Infect Dis Clin North Am 16:187, 2002 17. DeGroote MA, Huitt G: Infections due to rapidly growing mycobacteria. Clin Infect 42:1756, 2006 18. Wallace RJ, Brown-Elliot BA, Ward SC: Activities of linezolid against rapidly growing mycobacteria. Antimicrob Agents Chemother 45:764, 2001
MYCOBACTERIAL SKIN INFECTIONS, POSTOPERATIVE INFECTIONS
19. Azzarelli B, Roessmann U: Pathogenesis of central nervous system infiltration in acute leukemia. Arch Pathol Lab Med 101:203, 1977 20. Lee SS, Kim HK, Choi SC, et al: Granulocytic sarcoma occurring in the maxillary gingiva demonstrated by magnetic resonance imaging. Oral Surg Oral Med Oral Pathol 92:689, 2001 21. Dreizen S, McCredie KB, Keating MJ, et al: Malignant gingival and skin “infiltrates” in adult leukemia. Oral Surg 55:572, 1983 22. Meiss A, Butler J, Osborne B, et al: Granulocytic sarcoma in nonleukemic patients. Cancer 58:2697, 1986 23. Cotran RS, Kumar V, Robbins SL: Acute myeloblastic leukemia AML, in Robbins Pathologic Basis of Disease (ed 4), Philadelphia, PA, Saunders, 1989, pp 724-728 24. Guermazi A, Feger C, Rousselot P: Granulocytic sarcoma (chloroma): Imaging findings in adults and children. AJR Am J Roentgenol 178:319, 2002
25. Fellbaum C, Hansman ML: Immunohistochemical differential diagnosis of granulocytic sarcoma and malignant lymphomas on formalin fixed material. Virchows Arch Pathol Anat Histopathol 416:351, 1990 26. Brunning R, McKenna R: Atlas of Tumor Pathology. Tumors of Bone Marrow (Third Series). Washington, DC, Armed Forces Institute of Pathology, 1994, pp 19-37 27. Meis JM, Butler JJ, Osborne BM, et al: Granulocytic sarcoma in nonleukemic patients. Cancer 58:2697, 1986 28. Cankaya H, Ugras S, Dilek I: Head and neck granulocytic sarcoma with acute myeloid leukemia: Three rare cases. Ear Nose Throat J 80:224, 2001 29. Imrie KR, Kovacs MJ, Selby D, et al: Isolated chloroma: The effect of early antileukemic therapy. Ann Intern Med 123:351, 1995 30. Vicente JC, Rodríguez JS, López A, et al: Isolated granulocytic sarcoma: Report of a case in the oral cavity. J Oral Maxillofac Surg 48:748, 1990
J Oral Maxillofac Surg 67:416-418, 2009
Nonpigmented Mycobacterial Skin Abscesses: A Rare Postoperative Complication in a Cancer Patient Christopher M. Harris, DMD, MD, LCDR, DC, USN,* David Kim, DMD, MD,† and Ghali E. Ghali, DDS, MD‡ A 26-year-old Vietnamese female presented to the Department of Oral and Maxillofacial Surgery for evaluation of a left lateral tongue lesion that had been present for approximately 4 months and had recently rapidly increased in size. Her past medical history was not significant. The patient denied tobacco, alcohol, or illicit substance abuse. On exam, the lesion was a 2.5-cm exophytic, friable mass (Fig 1). No cervical lymphadenopathy was noted on exam. A preoperative workup included a chest ra*Residency Program Director, Department of Oral and Maxillofacial Surgery, Naval Medical Center, Portsmouth, VA. †Residency Program Director, Oral and Maxillofacial Surgery, Head and Neck Surgery, Louisiana Health Sciences Center, Shreveport, LA. ‡Professor and Chairman, Oral and Maxillofacial Surgery, Head and Neck Surgery, Louisiana Health Sciences Center, Shreveport, LA. Address correspondence and reprint requests to Dr Harris: Naval Medical Center, OMS, Charette Health Care Center, Portsmouth, Virginia 23708-2197; e-mail: [email protected] This is a US government work. There are no restrictions on its use. Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons 0278-2391/09/6702-0027$36.00/0 doi:10.1016/j.joms.2008.06.048
FIGURE 1. Left lateral tongue squamous cell carcinoma. Harris, Kim, and Ghali. Mycobacterial Skin Infections, Postoperative Infections. J Oral Maxillofac Surg 2008.
diograph, computed tomography scans of the neck, and laboratory studies. These studies were negative for metastatic disease. An incisional biopsy was performed, which showed a poorly differentiated squamous cell carcinoma. She was staged as a T2 N0 M0- Stage 2. The patient was taken to the operating room where a panendoscopy, left partial glossectomy, and left modified radical neck dissection was performed. A
417
HARRIS, KIM, AND GHALI
radial forearm free flap was used to reconstruct the tongue defect. Perioperative antibiotics and steroids (Unasyn [Pfizer, New York, NY] 3 g i.v. every 6 hours ⫻ 3 days and Decadron [Merck, Whitehouse Station, NJ] 8 mg i.v. every 6 hours ⫻ 3 days) were used according to our institution’s protocol. Her postoperative course was complicated by a hematoma on postoperative day 2. This was managed in the operating room, and no further complications were encountered during her hospital stay. The patient’s case was presented at the multidisciplinary tumor board, and postoperative radiation therapy was not recommended. Two months postoperatively the patient presented to her referring physician with an erythematous nodule in her left submandibular area. A course of antibiotics (Augmentin; GlaxoSmithKline, ResearchTriangle Park, NC) was prescribed for 2 weeks without resolution. A culture was not taken. The patient soon began to develop more nodules and ulcerations along the incision line on the side of her left neck dissection (Fig 2). Needle aspiration of these lesions was performed on several occasions. Each attempt yielded negative results for malignancy or organisms upon Gram stain and culturing. Cytology showed only inflammatory cells. The patient was placed on several courses of broad spectrum antibiotics and was referred to the Infectious Disease (ID) service. Approximately 4 weeks after culture harvesting and prior to seeing the ID service, her needle aspirate cultures showed 2 species of nonpigmented, rapidly growing mycobacteria, Mycobacterium cholenae and Mycobacterium abscessus. The patient was then started on Clarithromycin by the ID service for these atypical mycobacterial skin abscesses with eventual resolution of the lesions.
FIGURE 2. Erythematous skin nodules in left submandibular and infra-auricular area. Harris, Kim, and Ghali. Mycobacterial Skin Infections, Postoperative Infections. J Oral Maxillofac Surg 2008.
Discussion Mycobacterium cholenae, Mycobacterium abscessus, and Mycobacterium fortuitum are ubiquitous environmental organisms that may cause chronic infections of the skin, lungs, and other soft tissues.1-4 Disseminated disease may occur as well. Mycobacterium cholenae and Mycobacterium abscessus are nonpigmented, rapidly growing organisms that are commonly seen in nosocomial mycobacterial infections, particularly in immunocompromised patients. There are numerous organisms included in the group of Mycobacterium classified as rapidly growing Mycobacterium (RGM). The clinically important species include Mycobacterium cholenae, Mycobacterium abscessus, and Mycobacterium fortuitum.2 These organisms have been implicated as the etiology of many conditions.5,6 In many reports, skin diseases such as chronic skin ulcerations and abscesses are the predominant manifestations.2,7-13 Mycobacterial infections are becoming increasingly important. They tend to be seen in patients who have had surgical procedures and trauma. They have also been reported in immunocompromised patients. They have been associated with surgical site infections, contaminated water supplies, ophthalmologic infections, and with contaminated medical devices.1 Significant delays in diagnosis and therapy are common. Uslan et al3 reported a median time of 86 days between emergence of symptoms and definitive diagnosis. Clinically, the patient’s diagnosis is frequently delayed because of the lack of acquired or complete microbiologic (aerobic, anaerobic, fungal, and acid fast bacilli) specimens when treating skin infections. Standard culture techniques with bacteriologic media and fluorescence microscopy are common methods to discover the presence of mycobacteria. This method cannot identify an exact species. Routine bacteriologic culture techniques with numerous rounds of biochemical tests and reculturing may take several weeks for final species identification.14 Current laboratory techniques now have the ability to identify these organisms through polymerase chain reaction, gene-sequencing techniques, and antibiotic susceptibility patterns that allow for more rapid identification of the organism. Familiarity with the antibiotic susceptibility patterns of nontuberculous mycobacteria is essential in deciding upon empiric therapy for suspected infections. Broad spectrum antibiotics are likely to be prescribed in the clinical setting where no cultures were taken or where there is a delay in species identification. Including antibiotics to which these organisms are susceptible is warranted with a nonresponding chronic infection.15
418
MYCOBACTERIAL SKIN INFECTIONS, POSTOPERATIVE INFECTIONS
Mycobacterium cholenae, Mycobacterium abscessus, and Mycobacterium fortuitum are generally resistant to all the antituberculosis medications. Routine susceptibility testing for these drugs is not recommended because of prevalence of resistance in all the RGMs.15-17 Clarithromycin has been shown to have susceptibility in most isolates of Mycobacterium cholenae and Mycobacterium abscessus, and is the recommended oral drug for therapy. Amikacin, imipenem, linezolid, sulfonamides, and cefoxitin also show activity against most RGMs. Laboratory testing should be directed at susceptibility against clarithromycin, amikacin, cefoxitin, and imipenem instead of antituberculous medications.15,18
Summary Atypical mycobacteria are an exceedingly rare cause of postoperative wound infections. Their chronic nature, difficulty in diagnosis, and prolonged treatment course require the clinician to maintain a high degree of suspicion when faced with a nonresponding wound infection. It is crucial that a complete investigation into the etiology of all wound infections is carried out, particularly in all nonresponding infections. This case clearly shows the need for the clinician to be abreast of the etiology of atypical infections, as well as the appropriate use of various culturing techniques and medical therapy.
References 1. Vijayaraghavan R, Chandrashekkar R, Sujatha Y, et al: Hospital outbreak of atypical mycobacterial infection of port sites after laparoscopic surgery. J Hosp Infect 64:344, 2006 2. Esteban J, Fernandez Roblas R, Garcia Cia JI, et al: Clinical significance and epidemiology of non-pigmented rapidly growing mycobacteria in a university hospital. J Infect 54: 135, 2007
3. Uslan DZ, Kowalski TJ, Wengenack NL, et al: Skin and soft tissue infections due to rapidly growing mycobacteria. Arch Dermatol 142:1287, 2006 4. Palwade PK, Dhurat RS, Tendolkar UM, et al: Chronic cutaneous disease caused by the rapid growers Mycobacterium fortuitum and chelonae. Br J Dermatol 154:774, 2006 5. Wolinsky E: Nontuberculous mycobacteria and associated diseases. Am Rev Respir Dis 119:107, 1979 6. Wolinsky E: Mycobacterial diseases other than tuberculosis. Clin Infect Dis 15:1, 1992 7. Murillo J, Torres J, Bofill L, et al: Skin and wound infection by rapidly growing mycobacteria: An unexpected complication of liposuction. Arch Dermatol 346:1347, 2000 8. Winthrop KL, Abrams, Yakrus M, et al: An outbreak of mycobacterial furunculosis associated with footbaths at a nail salon. N Engl J Med 346:1366, 2002 9. Wallace RJ, Brown BA, Onyi GO: Skin, soft tissue and bone infections due to Mycobacterium chelonae: Importance of prior corticosteroid therapy, frequency of disseminated infections, and resistance to oral antimicrobials other than clarithromycin. J Infect Dis 166:405, 1992 10. Ara M, de Santamaria CS, Zaballos P, et al: Mycobacterium chelonae infection with multiple cutaneous lesions after treatment with acupuncture. Int J Dermatol 42: 632, 2003 11. Behroozan DS, Christian MM, Moy RL: Mycobacterium fortuitum infection following neck liposuction: a case report. Dermatol Surg 26:588, 2000 12. Haiavy J, Tobin H: Mycobacterium fortuitum breast implants infection in prosthetic breast implants. Plas Reconstr Surg 109:2124, 2002 13. Rao J, Golden TA, Fitzpatrick RE: Atypical mycobacterium infection following blepharoplasty and full face skin resurfacing with CO2 laser. Dermatol Surg 28:768, 2002 14. Silcox VA, Good RC, Floyd MM: Identification of clinically significant Mycobacterium fortuitum complex isolates. J Clin Microbiol 14:686, 1981 15. Brown BA, Wallace RJ, Onyi GO: Activities of four macrolides, including clarithromycin, against Mycobacterium fortuitum, Mycobacterium chelonae, and Mycobacterium chelonae-like organisms. Antimicrob Agents Chemother 36:180, 1992 16. Brown-Elliot BA, Griffith DE, Wallace RJ: Newly described or emerging human species of nontuberculous mycobacteria. Infect Dis Clin North Am 16:187, 2002 17. DeGroote MA, Huitt G: Infections due to rapidly growing mycobacteria. Clin Infect 42:1756, 2006 18. Wallace RJ, Brown-Elliot BA, Ward SC: Activities of linezolid against rapidly growing mycobacteria. Antimicrob Agents Chemother 45:764, 2001