Multiple Cases of Cutaneous Mycobacterium massiliense Infection in a “Hot Spa” in Japan

Abstract

Seven body polishers working in the same "hot spa" presented with multiple red nodules and papules on their hands and forearms. A causative agent was successfully isolated from two of the subjects and from a swab sample collected from the underside of a bed cover in the body-polishing facility. The two cutaneous isolates and the environmental isolate were rapidly growing mycobacteria that formed nonphotochromogenic smooth or smooth/rough colonies on Ogawa egg slants. They were identified as Mycobacterium massiliense by multigenotypic analysis using the 16S rRNA, hsp65, and rpoB genes and the 16S-23S rRNA internal transcribed spacer (ITS) region. However, the use of the 16S rRNA gene sequence and/or DNA-DNA hybridization (DDH Mycobacteria Kit) alone would not distinguish M. massiliense from mycobacteria in the M. chelonae-M. abscessus group. The three isolates were significantly more susceptible to clarithromycin, doxycycline, and minocycline than the M. abscessus and M. bolletii reference strains. One cutaneous isolate and the environmental isolate were in a related cluster by randomly amplified polymorphic DNA PCR (RAPD-PCR). Of the several mycobacterial species found in the day spa, only M. massiliense was isolated from biopsy specimens of the skin lesions, suggesting that this bacterium is a human skin pathogen. This is the first known report of cutaneous M. massiliense infections that could not be attributed to a prior invasive procedure. This is also the first report of M. massiliense infection in Japan.Mycobacterium massiliense was initially isolated from the sputum of a patient with pneumonia in France in 2004 (1). Epidemiologically, M. massiliense has been recognized as an emerging pathogen in the United States (16,24) and Brazil, where outbreaks have been associated with postsurgical and cosmetic procedures (2, 4, 22). In Korea, an outbreak was linked to intramuscular injections of an antimicrobial agent (9). This bacterium was also the source of a lethal case of sepsis in Italy and has been found in cystic fibrosis patients in France (15,20). Among pulmonary M. abscessus group isolates, almost half of the isolates in Korea and 30% of those in the Netherlands are M. massiliense (8,21). It has been suggested that M. massiliense should be reclassified taxonomically as a subspecies of M. abscessus (11). The clinical significance of differentiating these two species has also been explored (7). However, M. massiliense has not been fully characterized. Although mycobacteria are a frequent source of dermal infection, M. massiliense has never been reported as an etiological agent. This report describes the first case of an M. massiliense dermal infection in Japan. Case ReportsIn November 2007, a 49-year-old female who worked as a body polisher in a hot spa developed multiple red nodules and papules on her hands and forearms. The number of lesions gradually increased over several months, precipitating a visit to a local hospital in June 2008 (case 1). A skin biopsy specimen of a nodule stained with hematoxylin a...

Discrimination of Mycobacterium abscessus subsp. massiliense from Mycobacterium abscessus subsp. abscessus in Clinical Isolates by Multiplex PCR

“…abscessus-M. abscessus subsp. bolletii in susceptibility to various antimycobacterial drugs has also been observed in our laboratory (17). A significant difference between M. abscessus subsp.…”

“…massiliense is more susceptible to azithromycin than M. abscessus subsp. abscessus but not to clofazimine, meropenem, and panipenem (17). Thus, correct and rapid species identification could facilitate the clinical treatment of mycobacterial infections (7).…”

“…DNA extraction. DNA extraction was performed as described previously (17). In brief, a loopful of bacilli was suspended in 400 l sterilized phosphate-buffered saline supplemented with 0.05% Tween 80 and stored at Ϫ80°C until the extraction was performed.…”

“…massiliense, and M. abscessus subsp. bolletii found at nucleotide position 1007 or 1008 or 1407 or 1408 and additional 3-bp mismatches with M. chelonae at nucleotide positions 999, 1039, and 1265 (17). However, differences were observed with the sequences of hsp65, rpoB, and the ITS region (Table 3).…”

“…This bacterium was also the source of a lethal case of sepsis in Italy (12) and has been found in cystic fibrosis patients in France (13). Several cases of bacteremia and cutaneous pulmonary infections have also been reported in Japan (14)(15)(16)(17).…”