Cutaneous Coinfection of Cytomegalovirus and Mycobacterium chelonae Accelerated by Immunosuppression

Abstract

A mildly diabetic 58-year-old male had traumatic ulceration on the left popliteal fossa, and the lesion progressed to a painful 6 cm deep ulcer. After surgical debridement and skin grafting, ulceration recurred. Pyoderma gangrenosum was clinically diagnosed after the first biopsy, indicating a noninfective ulcer. Immunosuppressive therapy (prednisolone and cyclosporine A) induced complete epithelialization in three months. Four months later, subcutaneous nonulcerated nodules appeared on the anterior area of the left lower leg. Subcutaneous induration progressed and ulceration recurred, so that immunosuppressive therapy continued for one year. Cytomegalovirus (CMV) viremia was detected, and the second biopsy demonstrated CMV inclusions of endothelial and perivascular cells in fibrosing septolobular panniculitis. Cyclosporine A was cancelled, prednisolone was tapered, and ganciclovir started. Viremia soon disappeared, but the lesion progressed to large induration with multiple ulcers measuring up to 3 cm. The third biopsy disclosed infection of Gram-positive mycobacteria, accompanying fat droplet-centered suppurative granulomas without CMV infection. Microbial culture identified Mycobacterium chelonae. Clarithromycin with thermotherapy was effective. A review of the second biopsy confirmed coinfection of CMV and Gram-positive mycobacteria. Immunostaining using a panel of anti-bacterial antibodies visualized the mycobacteria in the lesion. Positive findings were obtained with antibodies to Bacillus Calmette-Guérin, Bacillus cereus, MPT64 (Mycobacterium tuberculosis-specific 24 kDa secretory antigen), LAM (Mycobacterium tuberculosis-related lipoarabinomannan), and PAB (Propionibacterium acnes-specific lipoteichoic acid).

Immunocompromised Patients with Therapy-Refractory Chronic Skin Diseases Show Reactivation of Latent Epstein‒Barr Virus and Cytomegalovirus Infection

“…Further prospective randomized case-control studies will be needed to deliver a causal proof for the clinical benefit of ganciclovir treatment in patients showing the profile of subclinical CMV reactivation. However, previously reported cases J o u r n a l P r e -p r o o f highlight the occurrence of CMV infection in the context of immunosuppressive treatment for pyoderma gangrenosum and corroborate our findings (Kikuchi et al, 2005, Tsutsumi et al, 2021.…”

Mycobacterium chelonae infection in an immunocompromised patient presenting as multiple papulonodules on the leg

“…When immunocompetent patients are affected, it is usually following trauma to the skin, which includes both invasive and minimal procedures, intradermal and subcutaneous injections, and minor skin trauma, such as laparoscopic surgery (13), blepharoplasty (14), tattoos (15), mesotherapy (16), pedicures (17), liposuction and lipofilling (18), acupuncture (19), sclerotherapy (20), and contact lens wear (21). M. chelonae infections can also affect immunocompromised patients; for example, cancer patients (22), HIV patients (23), patients with hematological malignancies (24), patients on corticosteroid therapy (25)(26)(27) and biologic therapy, especially on tumor necrosis factor alpha inhibitors (28,29), patients with autoimmune disorders (30), and patients following organ transplantation (31), as was the case in the patient presented (6,32). Infections with RGM have been increasing over time, possibly due to greater use of immunosuppressive medications, more numerous surgical procedures, and enhanced detection, as well as increasing age of the population, which may contribute to risk factors for the disease (33).…”

Resource-Limited Management of Presumptive Pyoderma Gangrenosum in an Unsheltered Patient

“…More superficial PG lesions can be managed with topical therapy as an adjunct to systemic immunosuppression. The improvement in inflammation and pathergy can be measured as a function of the ulcer edges becoming more homogenous with the surrounding skin [ 9 ]. Even so, the complete resolution of pathogenic inflammation is not a reliable indicator of wound healing.…”