Non-tuberculous mycobacterial infection of the musculoskeletal system

Abstract

Non-tuberculous mycobacterial (NTM) infection of the musculoskeletal tissue is a rare disease. An early and accurate diagnosis is often difficult because of the indolent clinical course and difficulty of isolating pathogens. Our goal was to determine the clinical features of musculoskeletal NTM infection and to present the treatment outcomes. A total of 29 patients (nine females, 20 males between 34 and 85 years old, mean age 61.7 years; 34 to 85) with NTM infection of the musculoskeletal system between 1998 to 2011 were identified and their treatment retrospectively analysed. Microbiological studies demonstrated NTM in 29 patients: the isolates were Mycobacterium intracellulare in six patients, M. fortuitum in three, M. abscessus in two and M. marinum in one. In the remaining patients we failed to identify the species. The involved sites were the hand/wrist in nine patients the knee in five patients, spine in four patients, foot in two patients, elbow in two patients, shoulder in one, ankle in two patients, leg in three patients and multiple in one patient. The mean interval between the appearance of symptoms and diagnosis was 20.8 months (1.5 to 180). All patients underwent surgical treatment and antimicrobial medication according to our protocol for chronic musculoskeletal infection: 20 patients had NTM-specific medication and nine had conventional antimicrobial therapy. At the final follow-up 22 patients were cured, three failed to respond to treatment and four were lost to follow-up. Identifying these diseases due the initial non-specific presentation can be difficult. Treatment consists of surgical intervention and adequate antimicrobial therapy, which can result in satisfactory outcomes.

Nontuberculous Mycobacterial Musculoskeletal Infection Cases from a Tertiary Referral Center, Colorado, USA

“…One of the most notable findings from the 3 previous case series studying NTM musculoskeletal infections was that, in all studies, the overwhelming majority of the patients were immunocompetent (26)(27)(28). In contrast, half the patients in our study were immunosuppressed as a result of either an underlying medical condition or a medication used to treat rheumatologic disease.…”

“…We present a series of cases of NTM musculoskeletal infections requiring surgical intervention and antimycobacterial chemotherapy that were managed at UCH and NJH over a 6-year period. NTM musculoskeletal infections have been reported in the literature sporadically due to their rare occurrence; 2 previous case series documented 29 cases over 13 years in South Korea (27) and 8 cases of PJI by NTM over 4 decades at the Mayo Clinic in the United States (26). In a 6-year period, we have identified 14 case-patients treated at our institutions with unique characteristics, in comparison to previous studies (25)(26)(27)(28).…”

“…NTM musculoskeletal infections have been reported in the literature sporadically due to their rare occurrence; 2 previous case series documented 29 cases over 13 years in South Korea (27) and 8 cases of PJI by NTM over 4 decades at the Mayo Clinic in the United States (26). In a 6-year period, we have identified 14 case-patients treated at our institutions with unique characteristics, in comparison to previous studies (25)(26)(27)(28). Specifically, the cases we report indicate the importance of a low threshold for suspicion and testing for NTM in any patient who has an unidentified musculoskeletal infection, particularly with evidence of granuloma formation on pathology.…”

“…Previous case reports and series of NTM musculoskeletal infections have focused on the demographics, diagnosis, and treatment of patients with these difficult-to-manage infections (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24). Patients were often immunocompetent persons who contracted an NTM disease after direct inoculation via traumatic skin puncture (25)(26)(27)(28). In a series of 29 cases from South Korea, all patients required surgical intervention in addition to antimicrobial drugs; 3 patients failed to respond despite aggressive treatment, and an additional 4 were lost to follow-up.…”

Prosthetic Joint Infection due to Mycobacterium avium-intracellulare in a Patient with Rheumatoid Arthritis: A Case Report and Review of the Literature

“…In this patient, mycobacteria were likely introduced during a THA revision and persisted for years prior to disease onset in the setting of exogenous immunosuppression [ 11 ]. TNF-alpha antagonists, particularly infliximab, predispose patients to mycobacterial infections by blocking macrophage activation and intracellular killing [ 12 ].…”