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Atypical Mycobacterial Infections of the Upper Extremity: Becoming More Atypical?
Mariela Lopez, MD; Julie Amthor, BS; Kevin Murphy, MD
Plastic and Reconstructive Surgery, University of Texas Medical Branch, Galveston, TX

Background: Atypical mycobacterial infections of the upper extremity are relatively uncommon, yet cause chronic indolent symptoms that frequently defy prompt clinical and laboratory diagnosis with consequent prolongation of disability for patients. Our institution on the Gulf Coast has successfully diagnosed and treated an increasing number of these infections, noting new uncommon patterns of infection with more aggressive mycobacterial strains. The purpose of this study is to review our experience with upper extremity atypical mycobacterial infections and verify the developing trends we are encountering in our patient population.

Methods: An IRB-approved retrospective chart review was performed at our institution for patients with positive non-tuberculous mycobacterial cultures of the hand, forearm, or elbow from 2000-2013. Patient demographics, source of transmission, symptom duration before diagnosis, mycobacterial strain, operative interventions, antibiotic treatments, and outcomes were recorded.

Results: We identified 33 patients with a mean age of 50 years (9-71years) that were equally distributed by gender. The mean symptomatic period before diagnosis was 9 months (1-60 months) and mean follow-up was 9 months (1-48 months). Forty-two percent had identifiable causes of immune dysfunction including solid organ transplants (heart, lung, liver), uncontrolled diabetes, HIV, rheumatoid arthritis, lupus, and asplenia. Fifty-eight percent appeared immunocompetent. Only 10 % were smokers.

Patients were infected most frequently by M. marinum (42%), M. abscessus (24%), M. fortuitum (21%), and other less common strains. Although only 12% of patients had a marine-related source of transmission, 75% of these grew M. marinum. Most patients had non-marine causes including lacerations, insect bites, animal bites, and tattoos as well as unidentifiable sources.

All patients required incision and drainage (100%), flexor/extensor tenosynovectomy (18%), or carpal decompression (6%). Clarithromycin was the most commonly used antibiotic for an average duration of 5 months. One symptom-free patient with myeloma remains on treatment indefinitely. Ninety-seven percent had complete resolution of disease. One patient died of unrelated causes.

Conclusion: Atypical mycobacterial infections have an indolent course that may be difficult to diagnose. Marine-related injury mechanisms may heighten clinical suspicion however the majority of infections in this study are not marine-related. While M. marinum remains the most prevalent strain, an increasing number of infections are from rapidly progressive M. abscessus and M. fortuitum, which may require earlier operative intervention and more prolonged courses of antibiotics. Atypical mycobacterial infections affect both immunocompromised as well as seemingly healthy individuals. Good outcomes are possible with accurate diagnosis and appropriate management.

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