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69-Year-Old Female with Pruritic Rash On Eyebrows and Lymphadenopathy On Face and Neck

Can you diagnose this case?

Heather S. Pomerantz, MD; David Chang, MD; Margaret J. Abuzeid, MD; and Brian K. White, DOSeries Editor

Signs and Symptoms

A 69-year-old woman presented with a pruritic rash involving her eyebrows, associated with lymphadenopathy of her face and neck. The lesions had developed within a week of her having had her eyebrows tattooed while in Thailand. She stated that the lesions had ruptured, had drained purulent bloody discharge, and then had crusted. Upon returning to the United States, she had been evaluated in an urgent care clinic, where she had been prescribed a regimen of clindamycin for a presumed diagnosis of cellulitis.

Although the lesions initially had improved with clindamycin, after a few days, the pruritic, papulonodular lesions over her eyebrows had returned. After the rash had failed to improve with a second course of clindamycin, she had been referred to an infectious disease clinic.

At presentation, physical examination findings were notable for the presence of erythematous nodules overlying the tattooed area (Figure 1), with associated scaling and dryness, along with tender, freely mobile preauricular and anterior cervical lymphadenopathy (Figure 2). The rest of the physical examination findings were unremarkable.

Which of the following is the most likely diagnosis?

Choose one to reveal diagnosis and discussion

Cutaneous Mycobacterium haemophilum infection
Sarcoidosis
Chemical dermatitis
Verruca vulgaris
Foreign body granuloma

ANSWER: Cutaneous Mycobacterium haemophilum Infection

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Diagnostic Tests

The patient was referred to a dermatologist for a punch biopsy of the eyebrow lesion, and the specimen was sent for histopathology and culture studies. Routine hematoxylin-eosin staining showed multiple necrotizing granulomas occupying the dermis (Figure 3), and acid-fast bacilli (AFB) and Fite special staining highlighted a few scattered mycobacterial organisms (Figure 4).

Fungal staining results were negative. AFB, fungal, and bacterial cultures were negative at 6 weeks. An additional biopsy was performed, this time of the lymph nodes, and the specimen was sent for culture studies. The AFB cultures were incubated at a lower temperature of 28°C, which eventually allowed for growth of the organism.

Figure 3: Histological section of the specimen showing a necrotizing granuloma (arrow) with tattoo ink (hematoxylin-eosin, original magnification ×100).

Figure 4: High-power view of a histological section of the AFB-stained specimen showing one of a few scattered mycobacterial organisms (original magnification, ×1000).

Growth on the mycobacterial culture media was noted at approximately 4 weeks of incubation. The specimen was then sent for 16S rRNA polymerase chain reaction assay and was identified as Mycobacterium haemophilum. Mycobacterial susceptibility testing with agar disk elution, performed at an outside laboratory, revealed the organism to be resistant to amikacin but susceptible to clarithromycin, rifampin, trimethoprim-sulfamethoxazole, linezolid, ciprofloxacin, doxycycline, and minocycline.

After review of the resistance profile and of other regimens used to treat M haemophilum infection, the patient was started on a regimen of 500 mg of ciprofloxacin twice daily, 500 mg of clarithromycin daily, and 600 mg of rifampin daily, which she tolerated without adverse effects. After 2 months of therapy, her eyebrow lesions had resolved (Figure 5), although the lymphadenopathy had not completely resolved (Figure 6).

Discussion

The diagnosis is mainly clinical, based on the history and physical examination findings. One major diagnostic criterion of primary palmar hyperhidrosis is visible and excessive sweating of the palms of at least 6 months’ duration without an apparent cause.17 At least 2 or more of the following minor criteria also must be fulfilled: bilateral and relatively symmetric involvement, impairment of daily activities, episodes at least weekly, age of onset less than 25 years, positive family history, and cessation of palmar sweating during sleep.17

Outbreaks of NTM infections after tattooing have been described worldwide and are thought to be related to contaminated ink.4-6 Commonly identified species include Mycobacterium chelonae, Mycobacterium abscessus, and Mycobacterium fortuitum.4-7 Biopsy and culture studies are necessary for diagnosis and treatment, since identification of the organism and antimicrobial susceptibilities guide therapy choices.

M haemophilum is considered a fastidious species that prefers incubation temperatures of 28°C to 30°C in iron-rich media.12 Infection with it is likely underdiagnosed given the difficulties in incubation and identification.13 When a lymphocutaneous NTM infection is suspected, and the initial biopsy and culture results are negative, a repeated biopsy should be obtained and sent for mycobacterial culture testing with specific instructions to incubate the specimen at a lower temperature of 30°C and to add iron-rich media such as chocolate to optimize recovery.

Isolates are often susceptible to clarithromycin, rifampin, and sulfonamides.12 Accordingly, treatment often includes clarithromycin, rifampin or rifabutin, and ciprofloxacin, although no consensus exists on optimal therapy or duration.11,12 Localized infections often are treated with surgical excision.9,14

Heather S. Pomerantz, MD, is a physician in the Department of Infectious Disease at San Antonio Military Medical Center in San Antonio, Texas.

David Chang, MD, is a physician in the Department of Infectious Disease at San Antonio Military Medical Center in San Antonio, Texas.

Margaret J. Abuzeid, MD, is a physician in the Department of Pathology at San Antonio Military Medical Center in San Antonio, Texas.

Brian K. White, DO, is a physician in the Department of Infectious Disease at San Antonio Military Medical Center in San Antonio, Texas.

References
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    2. Kazandjieva J, Tsankov N. Tattoos: dermatological complications. Clin Dermatol. 2007;25(4):375-382.
    3. Frew JW, Nguyen RTD. Tattoo-associated mycobacterial infections: an emerging public health issue. Med J Aust. 2015;203(5):223.
    4. Drage LA, Ecker PM, Orenstein R, Phillips PK, Edson RS. An outbreak of Mycobacterium chelonae infections in tattoos. J Am Acad Dermatol. 2010;62(3):501-506.
    5. Centers for Disease Control and Prevention (CDC). Tattoo-associated nontuberculous mycobacterial skin infections—multiple states, 2011-2012. MMWR Morb Mortal Wkly Rep. 2012;61(33):653-656.
    6. Stefaniak TJ, Dobosz Ł, Kaczor M, Ćwigoń M. Diagnosis and treatment of primary hyperhidrosis. Pol Przegl Chir. 2013;85(9):527-543.
    7. Philips RC, Hunter-Ellul LA, Martin JE, Wilkerson MG. Mycobacterium fortuitum infection arising in a new tattoo. Dermatol Online J. 2014;20(6). https://escholarship.org/uc/item/6bs3q0h0. Published January 1, 2014. Accessed February 7, 2018.
    8. Kay MK, Perti TR, Duchin JS. Tattoo-associated Mycobacterium haemophilum skin infection in immunocompetent adult, 2009. Emerg Infect Dis. 2011;17(9):1734-1736.
    9. Giulieri S, Morisod B, Edney T, et al. Outbreak of Mycobacterium haemophilum infections after permanent makeup of the eyebrows. Clin Infect Dis. 2011;52(4):488-491.
    10. Saubolle MA, Kiehn TE, White MH, Rudinsky MF, Armstrong D. Mycobacterium haemophilum: microbiology and expanding clinical and geographic spectra of disease in humans. Clin Microbiol Rev. 1996;9(4):435-447.
    11. Shah MK, Sebti A, Kiehn TE, Massarella SA, Sepkowitz KA. Mycobacterium haemophilum in immunocompromised patients. Clin Infect Dis. 2001;33(3):330-337.
    12. Griffith DE, Aksamit T, Brown-Elliott BA, et al; ATS Mycobacterial Diseases Subcommittee. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. 2007;175(4):367-416.
    13. Pfyffer GE. Mycobacterium: general characteristics, laboratory detection, and staining procedures. In: Jorgensen JH, Pfaller MA, Carroll KC, et al, eds. Manual of Clinical Microbiology. Vol 1. 11th ed. Washington, DC: ASM Press; 2015:chap 30.
    14. Gonzalez-Santiago TM, Drage LA. Nontuberculous mycobacteria: skin and soft tissue infections. Dermatol Clin. 2015;33(3):563-577.