Pedicure-associated Mycobacterium chelonae infection in a hospitalized patient
Authors: Adriana N. Schmidt, John A. Zic, Alan S. Boyd
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: The Vanderbilt University Dermatology Consult Service was asked to evaluate a 60-year-old man with a history of nonischemic cardiomyopathy, congestive heart failure, and a 1-week history of painful swelling and ulcerations on his bilateral lower extremities. The patient had insulin-dependent diabetes, took numerous medications, and was awaiting a heart transplant. He had been administered vancomycin and piperacillin/tazobactam at an outside hospital without effect. At the time of his dermatology consultation, the skin of his lower legs exhibited diffuse and variable erythema with numerous punched out ulcerations and erythematous papules (Fig 1). Punch biopsy performed at the time of consultation demonstrated suppurative dermal inflammation with positive results for mycobacteria on acid-fast bacillus test (Fig 2). Upon further investigation, the patient's family disclosed that the patient regularly went for pedicures at a local nail salon, with his last visit having occurred 1 month before admission.Fig 2Mycobacterial infection of the lower extremities: Acid-fast bacillus test and staining on histology from right lower extremity.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A second biopsy was performed and sent for culture. Within 5 days this tissue grew Mycobacterium chelonae and he was discharged from the hospital with prescriptions for azathioprine, doxycycline, and ciprofloxacin for his skin infection. Because he would require prolonged antibiotic administration to sufficiently clear the infection, he was removed from the transplantation list. One month later the patient was readmitted for worsening heart failure. In the interim he had taken his antibiotics with slow, steady improvement in his mycobacterial cellulitis. Even so, he died of heart failure before he could be put back on the heart transplant list. The occurrence of rapidly growing mycobacterial infections after nail salon pedicures has been well documented in the literature. Winthrop et al1Winthrop K.L. Abrams M. Yakrus M. Schwartz I. Ely J. Gillies D. et al.An outbreak of mycobacterial furunculosis associated with footbaths at a nail salon.N Engl J Med. 2002; 346: 1366-1371Crossref PubMed Scopus (172) Google Scholar reported the first epidemiologic investigation of a large outbreak of mycobacterial furunculosis due to a single strain of Mycobacterium fortuitum among otherwise healthy people who had received pedicures using whirlpool footbaths at a nail salon in California. There have since been several case reports of lower extremity soft tissue infections in predominantly immunocompetent individuals due to rapidly growing mycobacteria (RGM).2Redboard K.P. Shearer D.A. Gloster H. Younger B. Connelly B.L. Kindel S.E. et al.Atypical Mycobacterium furunculosis occurring after pedicures.J Am Acad Dermatol. 2006; 54: 520-524Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 3Stout J.E. Gadkowski B. Rath S. Alspaugh J.A. Miller M.B. Cox G.M. Pedicure-associated rapidly growing mycobacterial infection: an endemic disease.Clin Infect Dis. 2011; 53: 787-792Crossref PubMed Scopus (39) Google Scholar, 4Sniezek P.J. Graham B.S. Busch H.B. Lederman E.R. Lim M.L. Poggemyer K. et al.Rapidly growing mycobacterial infections after pedicures.Arch Dermatol. 2003; 139: 629-634Crossref PubMed Scopus (83) Google Scholar, 5Winthrop K.L. Albridge K. South D. Albrecht P. Abrams M. Samuel M.C. et al.The clinical management and outcome of nail salon-acquired Mycobacterium skin infection.Clin Infect Dis. 2004; 38: 38-44Crossref PubMed Scopus (73) Google Scholar Skin microtrauma due to shaving has been identified as a risk factor for disease.1Winthrop K.L. Abrams M. Yakrus M. Schwartz I. Ely J. Gillies D. et al.An outbreak of mycobacterial furunculosis associated with footbaths at a nail salon.N Engl J Med. 2002; 346: 1366-1371Crossref PubMed Scopus (172) Google Scholar, 4Sniezek P.J. Graham B.S. Busch H.B. Lederman E.R. Lim M.L. Poggemyer K. et al.Rapidly growing mycobacterial infections after pedicures.Arch Dermatol. 2003; 139: 629-634Crossref PubMed Scopus (83) Google Scholar Our case is unique because the patient may have died because the prolonged treatment course necessary to clear his mycobacterial infection precluded heart transplantation. Treatment regimens for RGM vary depending on the isolate of the Mycobacterium, how localized the infection is, and the immune status of the patient. In immunocompetent individuals, treatment of RGM infections requires an average of 4 months with at least 2 antibiotics.4Sniezek P.J. Graham B.S. Busch H.B. Lederman E.R. Lim M.L. Poggemyer K. et al.Rapidly growing mycobacterial infections after pedicures.Arch Dermatol. 2003; 139: 629-634Crossref PubMed Scopus (83) Google Scholar More extensive or severe disease requires the initial use of parenteral antibiotics and 6 to 12 months of treatment.5Winthrop K.L. Albridge K. South D. Albrecht P. Abrams M. Samuel M.C. et al.The clinical management and outcome of nail salon-acquired Mycobacterium skin infection.Clin Infect Dis. 2004; 38: 38-44Crossref PubMed Scopus (73) Google Scholar As was the case with our patient, diagnosis may be delayed until skin biopsies are performed.4Sniezek P.J. Graham B.S. Busch H.B. Lederman E.R. Lim M.L. Poggemyer K. et al.Rapidly growing mycobacterial infections after pedicures.Arch Dermatol. 2003; 139: 629-634Crossref PubMed Scopus (83) Google Scholar Furthermore, swab cultures may be negative and RGM take 3 to 7 days to grow on blood agar. Our case highlights the challenges associated with treating atypical mycobacterial infections. We hope to emphasize the importance of educating immunocompromised patients to avoid pedicure salons especially when open wounds or skin trauma is involved.