复旦大学：《传染病学 Infectious Disease》课程教学资源（MBBS）教案案例（英文）Disseminated Mycobacterium abscessusInfection Following Septic Arthritis

Disseminated Mycobacterium abscessUs Infection Following Septic Arthritis A Case Report and review of the literature Shoichi Fukui, MD, Noritaka Sekiya, MD, Yasunobu Takizawa, MD, PhD, Hiroshi Morioka, mD Hirofumi Kato, MD, Akio Aono, Kinuyo Chikamatsu, Satoshi Mitarai, MD, PhD, Satomi Kobayashi, MD, Satoshi Kamei, MD, and Keigo Setoguchi, MD, PhD Medicine Volume 94, Number 21, May 2015

Disseminated Mycobacterium abscessus Infection Following Septic Arthritis A Case Report and Review of the Literature Shoichi Fukui, MD, Noritaka Sekiya, MD, Yasunobu Takizawa, MD, PhD, Hiroshi Morioka, MD, Hirofumi Kato, MD, Akio Aono, Kinuyo Chikamatsu, Satoshi Mitarai, MD, PhD, Satomi Kobayashi, MD, Satoshi Kamei, MD, and Keigo Setoguchi, MD, PhD Medicine Volume 94, Number 21, May 2015

CASE PRESENTAT○N A 75-year-old Japanese woman Chief complain: swelling of the right elbow and the wrist joint for a month She had no history of orthopedic surgery, joint trauma, or intraarticular injections joints She had a 17-year history of dermatomyositis after being diagnosed at 58 years of age, along with interstitial lung disease(ILD), pulmonary hypertension, chronic kidney disease, and raynaud phenomenon She had pulmonary tuberculosis at the age of 33, resulting in old inflammatory changes and volume loss in the left lung Later, her dermatomyositis proved to be antisynthetase syndrome with antithreonyl-tRNA synthetase antibody

CASE PRESENTATION ´ A 75-year-old Japanese woman ´ Chief complain：swelling of the right elbow and the wrist joint for a month ´ She had no history of orthopedic surgery, joint trauma, or intraarticular injections in those joints. ´ She had a 17-year history of dermatomyositis after being diagnosed at 58 years of age, along with interstitial lung disease (ILD), pulmonary hypertension, chronic kidney disease, and Raynaud phenomenon. ´ She had pulmonary tuberculosis at the age of 33, resulting in old inflammatory changes and volume loss in the left lung. ´ Later, her dermatomyositis proved to be antisynthetase syndrome with antithreonyl-tRNA synthetase antibody

Uses of immunosuppressants The last time to receive dose Psl therapy and P (4 years ago) received high-dose corticosteroid Therapy at least 3(45-60mg PSL per day continued for 4 weeks and admission tapered, with or without P-MPSL Started to remain on corticosteroids with the 9.5mg PSL diagnosis of dermatomyositis 17 years ago per day Methotrexate was only temporarily used 10 years before this event; they rere never used after that time

Uses of immunosuppressants ´ Methotrexate was only temporarily used 10 years before this event; they were never used after that time. admission Started to remain on corticosteroids with the diagnosis of dermatomyositis 17 years ago The last time to receive high￾dose PSL therapy and P-MPSL (4 years ago) 9.5mg PSL per day received high-dose corticosteroid Therapy at least 3 (45–60mg PSL per day continued for 4 weeks and tapered, with or without P-MPSL)

Physical examination Afebrile Her right elbow, forearm, and wrist joint were swollen with tenderness Erythema and warmth were noted on her right arm. No skin eruptions or nodules were found The cardiopulmonary and abdominal findings were normal Other vital signs were within normal limits

Physical examination ´ Afebrile ´ Her right elbow, forearm, and wrist joint were swollen with tenderness. Erythema and warmth were noted on her right arm. No skin eruptions or nodules were found. ´ The cardiopulmonary and abdominal findings were normal. ´ Other vital signs were within normal limits

Laboratory examinations BC9000/mL(3300-7600/mL.N%77%L%20%,M%3%,andE%0%) CRP 2.6mg/dLT(<0.3mg/dL) Cr 1.2mg/dL(.5-0.8mg/dL GFR 34.0mL/min No other abnormalities were detected on laboratory testing

Laboratory examinations ´ WBC 9000/mL (3300–7600/mL, N% 77%, L% 20%, M% 3%, and E% 0%). ´ CRP 2.6mg/dL （ <0.3mg/dL) ´ Cr 1.2mg/dL（0.5–0.8mg/dL ´ GFR 34.0mL/min ´ No other abnormalities were detected on laboratory testing

FIGURE 1. X-ray of the patients right elbow joint steolysis is seen(arrow FIGURE 2. Magnetic resonance imaging shows fluid collection in the right elbow joint and forearm (arrows)

FIGURE 1. X-ray of the patient’s right elbow joint. Osteolysis is seen (arrow). FIGURE 2. Magnetic resonance imaging shows fluid collection in the right elbow joint and forearm (arrows)

M abscessus, identified by hps65 gene sequencing(100% homology, grew in blood and joint fluid cultures(BacT/ALERT system; Biome rieUx, Marcy-l'E toile, France) susceptibility testing was performed using the broth microdilution method with 10 drugs based on the recommendations of the Clinical and Laboratory standards Institute M24-A26 TABLE 1. Minimum Inhibitory Concentrations Using the Broth Microdilution method Antimicrobial Agent MIC,μg/mL Amikacin Cefoxitin 128 profoxac Clarithromycin Doxycycline >16 Imipenem Moxifloxacin Trimethoprim-sul famethoxazole >8/152 Tobramycin MIC=minimum inhibitory concentration

´ M abscessus, identified by hps65 gene sequencing (100% homology), grew in blood and joint fluid cultures (BacT/ALERT system; Biome ´rieux, Marcy-l’E ´toile, France). ´ susceptibility testing was performed using the broth microdilution method with 10 drugs based on the recommendations of the Clinical and Laboratory Standards Institute M24-A26

Treatment A surgical debridement of the right elbowjoint, forearm, and wrist joint was performed. The extra fluid in the patient's right elbow joint and forearm was completely removed Sputum cultures were negative for mycobacter Vancomycin→ clarith mycin, amikacin Micafungin -fluconazole &imipenem/ cilastatin 4 week 6 week Febrile, blood cultures mission turned positive Candida albicans candida died due to endophthalmitis respiratory failure

Treatment ´ A surgical debridement of the right elbowjoint, forearm, and wrist joint was performed. The extra fluid in the patient’s right elbow joint and forearm was completely removed. ´ Sputum cultures were negative for mycobacteria. PSL Vancomycin→clarithr omycin, amikacin, &imipenem/ cilastatin. admission Febrile, blood cultures turned positive Candida albicans & candida endophthalmitis. 4 week 6 week Micafungin→fluconazole died due to respiratory failure

Disseminated m abscessus infection Disseminated nontuberculosis mycobacterial infections in non-HIV-infected patients are considered uncommon A review of the past case reports and case series of disseminated m abscessus infections in non-HIV-infected patients was conducted by searching PubMed. The search of reports from 1953 to 2014 used the search terms ''dissemination 'disseminated infection M abscessus, and non-tuberculosis mycobacteria 34 cases of disseminated m abscessus infections were reviewed Disseminated m abscessus infections are defined by at least one of the following characteristics: involvement of >1 organ, involvement of >2 groups of lymph nodes, or positive blood culfure

Disseminated M abscessus infection ´ Disseminated nontuberculosis mycobacterial infections in non-HIV-infected patients are considered uncommon. ´ A review of the past case reports and case series of disseminated M abscessus infections in non-HIV-infected patients was conducted by searching PubMed. The search of reports from 1953 to 2014 used the search terms ‘‘dissemination,’’‘‘disseminated infection,’’ ‘‘M abscessus,’’ and ‘‘non-tuberculosis mycobacteria.’’ ´ 34 cases of disseminated M abscessus infections were reviewed. ´ Disseminated M abscessus infections are defined by at least one of the following characteristics: involvement of >1 organ, involvement of >2 groups of lymph nodes, or positive blood culture

Backgrounds Immunosuppressive backgrounds: organ transplants and corticosteroid therapy for autoimmune diseases st of the patients listed in had immunosuppressive backgrounds, 8 tients had a history of organ transplant, and 3 other patients received corticosteroid treatment All these patients were in actively immunocompromised status, which meant the status with concurrent use of prednisolone or other immunosuppressive agents for visceral transplantations or autoimmune diseases at the time of infection Our patient was treated with corticosteroid therapy for a long time, which could have been a risk for dissemination

Backgrounds ´ Immunosuppressive backgrounds: organ transplants and corticosteroid therapy for autoimmune diseases. ´ Most of the patients listed in had immunosuppressive backgrounds, 8 patients had a history of organ transplant, and 3 other patients received corticosteroid treatment. ´ All these patients were in actively immunocompromised status, which meant the status with concurrent use of prednisolone or other immunosuppressive agents for visceral transplantations or autoimmune diseases at the time of infection. ´ Our patient was treated with corticosteroid therapy for a long time, which could have been a risk for dissemination