A 66-year-old woman presented with pustular lesions of her face, trunk, and limbs and an acute arthritis of the knees and elbows. She had a complex medical background and had been on immunosuppressants for three years after a liver transplant. Tissue samples from her skin lesions and synovial fluid showed acid-fast bacilli. Mycobacterium haemophilum, an atypical mycobacteria, was later grown on culture. During her treatment with combination antibiotic therapy, she developed a pronounced generalised lymphadenopathy. Histology showed features of a diffuse B-cell lymphoma, a posttransplant lymphoproliferative disorder (PTLD). 1. Presentation In October 2012 a 66-year-old, Filipino, retired psychiatric nurse attended the rheumatology department in a wheelchair. She gave a 3-week history of painful and swollen knees, ankles, and elbows. Walking had become difficult. Systemically she was unwell and described weight loss (five kilograms over a month), malaise, and anorexia. Widespread tender and raised pustular skin lesions (Figures 1 and 2) were noted over her face, arms, chest, and legs. She reported that these were itchy and painful and had failed to improve with a two-week course of oral flucloxacillin (500？mg QDS). Further examination revealed that she was clinically anaemic and confirmed a large joint polyarthritis with bilateral knee effusions. Other systems examination was unremarkable. Figure 1 Figure 2 2. Past Medical History and Medications Her significant medical history included a liver transplant, in 2009, for a primary malignant neoplasm (hepatocellular carcinoma). Her other past medical history included idiopathic thrombocytopenic purpura, type 2 diabetes (diet controlled), chronic kidney disease (stage 3), vitamin B12 deficiency, a hysterectomy (for menorrhagia), and secondary osteoporosis due to steroids. As part of her antirejection regime she had been taking mycophenolate mofetil (2 grams daily) and low dose prednisolone (5 milligrams daily). She also took alendronic acid (70？mg weekly) and calcium carbonate/cholecalciferol (1.5？g/400？IU daily). For her recent joint pains she had been using paracetamol and codeine. 3. Investigations Initial blood tests showed a Hb of 7.0？g/dL (hypochromic and microcytic), CRP 168？mg/L, WCC 9.6 109/L, neutrophils 9.0 109/L, urea 10？mmol/L, and creatinine 122？μmol/L. She was admitted to hospital and transfused with three units of blood. Investigations included an upper gastrointestinal endoscopy which revealed multiple shallow ulcers and positive Helicobacter pylori urease test. Her left knee aspirate showed
References
[1]
D. Sompolinsky, A. Lagziel, D. Naveh, and T. Yankilevitz, “Mycobacterium haemophilum sp. nov., a new pathogen of humans,” International Journal of Systematic Bacteriology, vol. 28, no. 1, pp. 67–75, 1978.
[2]
J. A. Lindeboom, L. E. S. B. van Coppenraet, D. van Soolingen, J. M. Prins, and E. J. Kuijper, “Clinical manifestations, diagnosis, and treatment of Mycobacterium haemophilum infections,” Clinical Microbiology Reviews, vol. 24, no. 4, pp. 701–717, 2011.
[3]
R. J. Olsen, P. L. Cernoch, and G. A. Land, “Mycobacterial synovitis caused by slow-growing nonchromogenic species: eighteen cases and a review of the literature,” Archives of Pathology and Laboratory Medicine, vol. 130, no. 6, pp. 783–791, 2006.
[4]
C. F. Kelley, W. S. Armstrong, and M. E. Eaton, “Disseminated Mycobacterium haemophilum infection,” The Lancet Infectious Diseases, vol. 11, no. 7, pp. 571–578, 2011.
[5]
D. A. White, T. E. Kiehn, A. Y. Bondoc, and S. A. Massarella, “Pulmonary nodule due to Mycobacterium haemophilum in an immunocompetent host,” American Journal of Respiratory and Critical Care Medicine, vol. 160, no. 4, pp. 1366–1368, 1999.
[6]
E.-Y. Jang, S.-O. Lee, S.-H. Choi et al., “Case of pyomyositis due to Mycobacterium haemophilum in a renal transplant recipient,” Journal of Clinical Microbiology, vol. 45, no. 11, pp. 3847–3849, 2007.
[7]
S. Elsayed and R. Read, “Mycobacterium haemophilum osteomyelitis: case report and review of the literature,” BMC Infectious Diseases, vol. 6, article 70, 2006.
[8]
M. J. Millar, C. Bulliard, C. Balachandran, and A. J. Maloof, “Mycobacterium hemophilum infection presenting as filamentary keratopathy in an immunocompromised adult,” Cornea, vol. 26, no. 6, pp. 764–766, 2007.
[9]
D. Modi, D. Pyatetsky, D. P. Edward et al., “Mycobacterium haemophilum a rare cause of endophthalmitis,” Retina, vol. 27, no. 8, pp. 1148–1151, 2007.
[10]
M. Keller, A. Mak, L. Thibert, P. Rene, and M. B. Klein, “Mycobacterium haemophilum epididymal abscess in a renal transplant patient,” Journal of Clinical Microbiology, vol. 46, no. 7, pp. 2459–2460, 2008.
[11]
P. Phowthongkum, A. Puengchitprapai, N. Udomsantisook, S. Tumwasorn, and C. Suankratay, “Spindle cell pseudotumor of the brain associated with Mycobacterium haemophilum and Mycobacterium simiae mixed infection in a patient with AIDS: the first case report,” International Journal of Infectious Diseases, vol. 12, no. 4, pp. 421–424, 2008.
[12]
M. K. Kay, T. R. Perti, and J. S. Duchin, “Tattoo-associated Mycobacterium haemophilum skin infection in immunocompetent adult, 2009,” Emerging Infectious Diseases, vol. 17, no. 9, pp. 1734–1736, 2011.
[13]
C. Hamsch, W. Hartschuh, A. Enk, and K. Flux, “A chinese tattoo paint as a vector of atypical mycobacteria-outbreak in 7 patients in Germany,” Acta Dermato-Venereologica, vol. 91, no. 1, pp. 63–64, 2011.
[14]
U. Wollina, “Nodular skin reactions in eyebrow permanent makeup: two case reports and an infection by Mycobacterium haemophilum,” Journal of Cosmetic Dermatology, vol. 10, no. 3, pp. 235–239, 2011.
[15]
J. A. H. Lindeboom, C. F. Kuijper, and M. Van Furth, “Inguinal lymphadenitis caused by Mycobacterium haemophilum in an immunocompetent child,” Pediatric Infectious Disease Journal, vol. 26, no. 1, pp. 84–86, 2007.
[16]
C. M. Whipps, C. Lieggi, and R. Wagner, “Mycobacteriosis in zebrafish colonies,” ILAR Journal, vol. 53, pp. 95–105, 2012.
[17]
S. J. Hernandez-Divers and D. Shearer, “Pulmonary mycobacteriosis caused by Mycobacterium haemophilum and M marinum in a royal python,” Journal of the American Veterinary Medical Association, vol. 220, no. 11, pp. 1661–1663, 2002.
[18]
H.-H. Pai, W. C. Chen, and C. F. Peng, “Isolation of non-tuberculous mycobacteria from hospital cockroaches (Periplaneta americana),” Journal of Hospital Infection, vol. 53, no. 3, pp. 224–228, 2003.
[19]
B. Jacob, B. M. DeBey, and D. Bradway, “Spinal intradural Mycobacterium haemophilum granuloma in an American Bison (Bison bison),” Veterinary Pathology, vol. 43, no. 6, pp. 998–1000, 2006.
[20]
M. A. Saubolle, T. E. Kiehn, M. H. White, M. F. Rudinsky, and D. Armstrong, “Mycobacterium haemophilum: microbiology and expanding clinical and geographic spectra of disease in humans,” Clinical Microbiology Reviews, vol. 9, no. 4, pp. 435–447, 1996.
[21]
M. R. Abbott and D. D. Smith, “The pathogenic effects of Mycobacterium haemophilum in immunosuppressed albino mice,” Journal of Medical Microbiology, vol. 13, no. 4, pp. 535–540, 1980.
[22]
J. A. Lindeboom, “Surgical treatment for non tuberculous mycobacterium (NTM) cervicofacial lymhadenitis in children,” Journal of Oral and Maxillofacial Surgery, vol. 70, no. 2, pp. 345–348, 2012.
[23]
C. L. Teh, K. O. Kong, A. P. Y. Chong, and H. Badsha, “Mycobacterium haemophilum infection in an SLE patient on mycophenolate mofetil,” Lupus, vol. 11, no. 4, pp. 249–252, 2002.
[24]
A. Aslam, R. L. Green, L. Motta, M. Ghrew, C. E. Griffiths, and R. B. Warren, “Cutaneous Mycobacterium haemophilum infection in a patient receiving infliximab for psoriasis,” British Journal of Dermatology, vol. 168, no. 2, pp. 446–447, 2013.
