Tattoo-associated Mycobacterium franklinii infection

Abstract

A 36 year-old African American man with no remarkable medical history had an amateur tattoo performed on his left upper arm. Within 1 month, he developed small asymptomatic skin colored papules clustered in and around the tattoo ( Figure 1). A trial of 1% hydrocortisone ointment was ineffective and new papules continued to appear.The patient was referred to dermatology 2 months later and a punch biopsy of his eruption was performed. The biopsy revealed a dense mixed inflammatory infiltrate in the dermis comprised of lymphocytes, histiocytes, plasma cells, and neutrophils ( Figure 2A). Adjacent to the inflammatory infiltrate were large, coarse, black granules, consistent with tattoo pigment ( Figure 2B). Acid-fast bacilli and Fite stains demonstrated a small cluster of mycobacterial organisms within the infiltrate ( Figure 2C).Based on the histopathology result, tissue was obtained for routine, mycobacterial, and fungal culture and the patient was started on oral ciprofloxacin and clarithromycin. Seven days later, the mycobacterial culture was positive for growth of an acid fast organism, subsequently identified as Mycobacterium franklinii, by rpoB gene sequencing. The organism was susceptible to amikacin, doxycycline, minocycline, and clarithromycin. While the patient had not developed new lesions during the time between biopsy and culture result, the papules had persisted on oral antibiotic therapy. Based on the speciation result and his lack of improvement, he was referred to an infectious diseases specialist for further care and his regimen was altered to doxycycline and clarithromycin. DiscussionM. franklinii is an acid-fast, gram positive bacillus. It is a recently described member of rapidly growing mycobacteria which cause skin and soft tissue infections, pneumonia, and bloodstream infections in both immune competent and immune AbstractImportance: Tattoo-associated cutaneous mycobacterial infections have been reported with increasing frequency. The majority of these have been associated with M. chelonae, a rapidly growing nontuberculous mycobacterium. M. franklinii is a newly described member of the M. chelonae-abscessus group, which can cause upper respiratory and rare skin infections. It has a distinct genetic profile and anti-microbial sensitivities. Unlike M. chelonae, M. franklinii may carry the erm gene, which confers inducible macrolide antibiotic resistance. Therefore, localized infection cannot be treated with macrolide monotherapy. Observations:We report a case of a 36 year-old African American man who developed an eruption of asymptomatic papules at the site of a tattoo he received 1 month previously. A punch biopsy demonstrated mixed inflammation with a small focus of acid-fast positive organisms. Tissue culture and genetic testing using rpoB sequencing identified the organism as M. franklinii. Based on these results, he was successfully treated with a combination of doxycycline and clarithromycin. Conclusions and Relevance:It is important for dermatologists to recognize newly described non-...