Case Reports in Medicine setting of a new rash and fever [2]. Such infections accounted for 21% of all and 40.5% of serious infections in a large series of patients receiving anti-TNF agents [4]. In recent years, the risk for immunosuppression-induced reactivation of tuberculosis has been well documented and led to pretreatment testing for latent infection and prophylactic chemotherapy of individuals at risk [5]. On the other hand, infections with atypical mycobacteria are less recognized outside the infectious diseases specialty [6]. Nevertheless, studies from large databases of patients on immunosuppressants have reported one case of atypical mycobacterial infection for every 4–10 cases of tuberculosis [7]. Interestingly, a recent survey reported twice as many infections with nontuberculous mycobacteria as compared to cases of tuberculosis in patients receiving anti-TNF agents for various conditions [8]. Similar to our patient, nontuberculous mycobacterial disease frequently localizes to the skin and soft tissues [9]. The microorganism responsible for the skin infection in our patient was M. chelonae. To our knowledge, no published report of such infection exists in the IBD literature. However, in recent studies in anti- TNF-treated patients with various conditions, M. chelonae accounted for 10% of all mycobacterial or 4% of non- tuberculous mycobacterial infections, respectively [8, 9]. In the IBD population, infections with atypical mycobacteria such as M. gordonae, M. fortuitum, M. marinum, and M. xenopi have been reported [10–12]. Recently, Toruner et al. studied the presentation of and risk factors for opportunistic infections among IBD patients [10]. Although all immunosuppressive drugs (cor- ticosteroids, immunomodulators, biologicals) increased the risk of infection, this risk was disproportionally elevated when combinations of drugs were administered. Caution, therefore, is needed when prescribing such medications and regular reassessment is required in order to discontinue any unnecessary therapies. This is of particular relevance to the present case, as our patient was treated with corticosteroids for an extended period, before admission to our unit. This, in combination to azathioprine administration, most probably led to the development of mycobacterial infection. The ability to discontinue both medications after the diagnosis of M. chelonae infection, without a ﬂare in disease activity, emphasizes the need for constant cost/beneﬁt evaluation in the treatment of IBD patients. In particular, current guide- lines for the treatment of IBD clearly state that prolonged administration of corticosteroids to maintain remission is not an acceptable option. Corticosteroid-sparing agents such as thiopurines and methotrexate should be used followed by early introduction of biologicals in treatment failures. Furthermore, the development of a febrile skin lesion in our patient was mistakenly considered as pyoderma gangreno- sum, a diagnosis which led to inﬂiximab administration and the eventual unmasking of the mycobacterial infection. Nevertheless, the occurrence of pyoderma gangrenosum in our patient was highly unlikely, given the corticosteroid use and the quiescent phase of colitis. Had a colonoscopy been performed in our patient before the initiation of inﬂiximab, it might have helped therapeutic decisions. If no active inﬂammation were seen, it might have questioned 3 the diagnosis of pyoderma gangrenosum and prompted early consultation by a dermatologist and/or infectious diseases specialist. In fact, such an approach is strongly recommended by current guidelines on the management of infectious complications in IBD patients receiving immuno- suppressants [2]. This is of particular importance as skin infections, including those caused by atypical mycobacteria, can easily be confused with the various dermatological manifestations of IBD. Similar to the present case, the initial clinical impression for these lesions has been reported very often to be misleading [13]. In addition, gastroenterologists may not be familiar with the speciﬁc conditions required for the growth of these microorganisms in culture. In our case, initial cultures were performed in regular media and reported negative, as no growth was observed after incubation for 48 hours. Nevertheless, when the possibility of atypical mycobacteria was considered, cultures were left to incubate for several days, resulting to the growth of M. chelonae. Indeed, it has been recently suggested that infection with non-tuberculous mycobacteria must be suspected when routine microbiological tests are negative [14]. 4. Conclusion We present a rare case of skin infection with M. chelonae in a patient with IBD. It is important that clinical gastroen- terologists recognize atypical mycobacterial infections in this group of patients and be able to thoroughly investigate and aggressively treat those conditions. Conﬂict of Interests The authors declare that there is no conﬂict of interests. References [1] J. F. Rahier, S. Ben-Horin, Y. Chowers et al., “European evidence-based Consensus on the prevention, diagnosis and management of opportunistic infections in inﬂammatory bowel disease,” Journal of Crohn’s and Colitis, vol. 3, no. 2, pp. 47–91, 2009. [2] N. Viget, G. Vernier-Massouille, D. Salmon-Ceron, Y. Yaz- danpanah, and J. F. Colombel, “Opportunistic infections in patients with inﬂammatory bowel disease: prevention and diagnosis,” Gut, vol. 57, no. 4, pp. 549–558, 2008. [3] F. T. Veloso, “Review article: skin complications associated with inﬂammatory bowel disease,” Alimentary Pharmacology and Therapeutics, vol. 20, supplement 4, pp. 50–53, 2004. [4] C. Salliot, L. Gossec, A. Ruyssen-Witrand et al., “Infec- tions during tumour necrosis factor-α blocker therapy for rheumatic diseases in daily practice: a systematic retrospective study of 709 patients,” Rheumatology, vol. 46, no. 2, pp. 327– 334, 2007. [5] Y. Zabana, E. Dome`nech, A. L. S. Roma´n et al., “Tuberculous chemoprophylaxis requirements and safety in inﬂammatory bowel disease patients prior to anti-TNF therapy,” Inﬂamma- tory Bowel Diseases, vol. 14, no. 10, pp. 1387–1391, 2008. [6] E. M. T. Salvana, G. S. Cooper, and R. A. Salata, “Mycobac- terium other than tuberculosis (MOTT) infection: an emerg- ing disease in inﬂiximab-treated patients,” Journal of Infection, vol. 55, no. 6, pp. 484–487, 2007.