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| CASE REPORT |
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| Year : 2014 | Volume
: 7
| Issue : 1 | Page : 65-67 |
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Non-tuberculous mycobacterial soft tissue swelling in an immunocompetent patient
Virendra S Athavale, Murtaza A Calcuttawala, Daksha S Nirhale, Anirudhha Kale
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
| Date of Web Publication | 10-Dec-2013 |
Correspondence Address:
Murtaza A Calcuttawala
Dr. D. Y. Patil Medical College, Sant Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0975-2870.122788
Non-tuberculosis mycobacteria (NTM) include those mycobacterium species that are not members of the Mycobacterium tuberculosis complex. They assumed significance with the growing pandemic of the acquired immune deficiency syndrome (AIDS) since the 1980s, when Mycobacterium avium infections were found to be associated with AIDS. However, the epidemiology of NTM disease among patients without Human immunodeficiency virus infections is not well documented. We report a case of NTM soft tissue swelling in an immunocompetent 18-year-old male who responded well to local excision and antitubercular treatment. Keywords: Immunocompetent patient, non-tuberculous mycobacterial infection, soft tissue swelling
How to cite this article:
Athavale VS, Calcuttawala MA, Nirhale DS, Kale A. Non-tuberculous mycobacterial soft tissue swelling in an immunocompetent patient. Med J DY Patil Univ 2014;7:65-7 |
| Introduction | |  |
The non-tuberculous mycobacteria (NTM) include those mycobacterium species that are not members of the Mycobacterium tuberculosis  mplex; hence, the use of the terms "Non Tuberculous Mycobacteria" and "'Mycobacteria other than Tuberculosis." Although the pathogenic potential of NTM was reported throughout the 20 th century, widespread appreciation of the clinical syndromes caused by NTM began during the 1980s in association with the AIDS pandemic and the consequent dramatic increase in disseminated Mycobacterium avium complex infections. [1],[2] However, the epidemiology of NTM disease in patients without Human immunocompetent virus infection remains somewhat difficult to determine. NTM disease is relatively uncommon. [3] We present a case of NTM soft tissue infection in an immunocompetent 18-year-old male.
| Case Report | | |
An 18-year-old male patient presented with a complaint of a swelling in the lower third of the right leg associated with pain and tingling numbness since 1 year. There was no history of fever, trauma or pain during movement. The patient worked as a manual laborer in a local company. He had Bacillus Calmette Guerin (BCG) vaccine scar. Local examination revealed a soft, non-tender swelling on the lateral aspect of the right leg that was 5 × 4 cm in dimension [Figure 1] and [Figure 2]. There was no local rise in temperature.
Laboratory investigations revealed a normal hemoglobin level (13.6 gm%) and a total leukocyte count of 5200 cells/cumm. The differential leukocyte count showed 70% polymorphs, 26% lymphocytes, 2% eosinophils and 2% monocytes. The platelet count was 2.3 lac/cumm. Liver function tests did not reveal any abnormality (total serum bilirubin was 0.8 mg%, serum alkaline transaminase was 19 IU/L, serum alkaline phosphatase was 69 IU/L). Similarly, the renal function tests were normal (blood urea 15 mg%, serum creatinine 0.9 mg%, urine culture sterile). The patient was not diabetic (random blood sugar 88 mg%). Special investigations for Human immunodeficiency virus (HIV) infection, hepatitis B infection, rheumatoid factor and tuberculin tests were also negative.
X-ray of the right ankle (antero-posterior and lateral) did not reveal any bony abnormality or injury. Ultrasound of the peripheral nerve sheath tumor suggested neurofibroma. Magnetic resonance imaging showed a well-defined tubular lesion measuring 1.4 (antero-posteriorly) × 0.9 cm (transverse), extending over the length of 6.9 cm in the subcutaneous plane as noted on the lateral aspect of the right distal leg without affecting the underlying muscles and bones [Figure 3] and [Figure 4]. Fine needle aspiration cytology (FNAC) revealed necrotic material with Acid fast bacilli (AFB) suggestive of tubercular etiology.
The patient underwent surgery under spinal anesthesia, in which a longitudinal incision was taken over the swelling and removed in toto. Caseous material was found in the swelling [Figure 5], [Figure 6], [Figure 7].  | Figure 4: Magnetic resonance imaging of the leg. A well-defined tubular lesion measuring 1.4 cm (antero-posteriorly) × 0.9 cm (transverse) extending over a length of 6.9 cm in the subcutaneous plane was noted on the lateral aspect of the right distal leg without affecting the underlying muscles and bones
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Histopathological examination showed epithelioid granuloma, caseous necrosis, few Langerhans giant cells and lymphocytes, all suggestive of tubercular etiology [Figure 8]. | Figure 8: Histopathology slide. Section showing epithelioid granuloma, caseous necrosis, few Langerhans giant cells and lymphocytes. Findings suggestive of tuberculous etiology
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Tissue polymerase chain reaction (PCR) revealed atypical mycobacteria. Mycobacterium tuberculosis complex was not detected. Culture for mycobacterium was negative.
Anti-tubercular therapy was started as the histopathological exam suggested tuberculosis. The patient was started on Category 2 AKT and followed-up for a 6-month period. The patient was disease free with no recurrence.
| Discussion | | |
We reviewed the epidemiology, clinical features, diagnosis and treatment of the most common extrapulmonary diseases associated with NTM in immunocompetent persons. [4],[5],[6],[7] More than 120 recognized species of NTM share the following common features: (1) They are facultative pathogens, (2) evidence of human-to-human transmission is lacking, (3) some NTM species are ubiquitous and others have more restricted distribution, (4) treatment may be difficult and varies according to the involved organism and disease site and (5) pathogenesis is still undefined, depending on the interaction between the microorganism and the host's immune system. [1]
About 90% of the cases involve the pulmonary system; the rest involve the lymph nodes, skin, soft tissues and bones. [1],[4] Less frequently reported are central nervous system disease, keratitis and otitis media. [1],[4]
| Conclusion | | |
Although NTM cause a broad spectrum of human disease, non-specific clinical manifestations, lack of familiarity with these infections and inadequate laboratory services make definitive diagnosis of NTM diseases often delayed or even impossible. Although extrapulmonary tuberculosis is rare, it should be considered as one of the differential diagnoses in case of long-standing soft tissue swelling of unknown etiology.
| References | | |
| 1. | Falkinham JO 3 rd . Epidemiology of nontuberculous mycobacteria. Clin Microbiol Rev 1996;9:177-215. 
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| 2. | Wolinsky E. Nontuberculous mycobacteria and associated diseases. Am Rev Respir Dis 1979;119:107-59.
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| 4. | Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, et al. An official ATS/IDSA statement: Diagnosis, treatment, and prevention of nontuberculous mycobacterial disease. Am J Respir Crit Care Med 2007;175:367-416.
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| 5. | Marchevsky AM, Damsker B, Green S, Tepper S. The clinicopathological spectrum of nontuberculous mycobacterial osteoarticular infections. J Bone Joint Surg Am 1985;67:925-9.
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| 6. | Dobos KM, Quinn FD, Ashford DA, Horsburgh CR, King CH. Emergence of a unique group of necrotizing mycobacterial diseases. Emerg Infect Dis 1999;5:367-78.
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| 7. | De Groote MA, Huitt G. Infections due to rapidly growing mycobacteria. Clin Infect Dis 2006;42:1756-63.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
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