Mycobacterium chelonae/abscessus complex infection in a liver transplant patient

A 25‐year‐old woman presented in October 1999 with fever, nausea, vomiting, and a nodular eruption that had developed over the previous 7 days. Her past medical history was significant for chronic sclerosing cholangitis, which necessitated a liver transplantation in 1994 and a second one in 1998 due to graft rejection. Upon admission, she was taking the following medications: prednisone 20 mg q.d., cyclosporine 375 mg p.o. b.i.d., sirolimus 10 mg p.o. q.d., levofloxacin 500 mg p.o. q.d., and ganciclovir 1000 mg p.o. t.i.d. On skin examination, there were tender, nonfluctuant, erythematous, subcutaneous nodules, 0.3–1.0 cm in diameter, scattered on her arms and legs (see Fig. 1 ). While undergoing diagnostic evaluation, the patient was empirically treated with intravenous antimicrobials for presumed sepsis as well as increased dosages of glucocorticosteroids for the possibility of acute graft rejection. Her laboratory data were significant for elevated liver function tests, blood urea nitrogen, and creatinine. A punch biopsy of a nodule on her left forearm showed a neutrophilic and histiocytic lobular and septal panniculitis (see Fig. 2 ), and all special stains, including acid‐fast bacillus (AFB) stains, and tissue cultures were negative for infectious organisms. Erythema nodosum‐like nodules on the leg image Septal and lobular panniculitis in a skin nodule from the arm (× 75) image Although the patient's eruption was compatible with erythema nodosum both clinically and histologically, it failed to improve during the next few weeks with an increased dosage of glucocorticosteroids. A second skin biopsy was then performed on a lower extremity nodule and it revealed a necrotizing panniculitis with numerous AFB. Within 7 days, skin tissue culture grew Mycobacterium chelonae/abscessus complex sensitive to amikacin and clarithromycin, but resistant to cefoxitin, doxycycline, ciprofloxacin, sulfamethoxasole/trimethoprim, and erythromycin. Re‐examination of the initial biopsy revealed a very small focus of AFB which was not previously recognized. Due to persistently elevated liver function tests, the patient underwent a liver biopsy which was negative for AFB on histopathologic examination. A tissue culture from the liver, however, grew M. chelonae/abscessus complex which had the same sensitivity and resistance profile as the organism isolated from the skin. A bone marrow biopsy and culture, as well as repeated blood cultures, were all negative for AFB. The patient was initially started on 2.25 g of piperacillin/tazobactam every 6 h for the first day and then switched to clarithomycin 500 mg p.o. b.i.d. and continued on levofloxacin 500 mg p.o. q.d. The skin nodules rapidly decreased in size within several days; however, new lesions appeared on the upper and lower extremities during the next month. The eruption regressed significantly with the addition of intravenous amikacin 800 mg q.d. to the antimicrobial regimen, but again new nodules and intermittent fevers reappeared over the course of the next month. During the next 2 months, the patient was treated aggressively with even more antimicrobial drugs including: gentamicin, imipenem/cilastin, piperacillin/tazobactam, erythromycin, levofloxacin, amikacin, amphotericin B, azithromycin, and vancomycin, but each short period of improvement was followed by a relapse. The patient remained on clarithromycin 250 mg p.o. q.d. and new erythema nodosum‐like skin nodules of M. chelonae/abscessus complex infection did not recur. The patient expired due to multiorgan system failure secondary to sepsis, necrotizing pancreatitis, and liver graft failure. This occurred 9 months after the first appearance of her M. chelonae/abscessus complex skin nodules.