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Table of Contents   
CASE REPORT  
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 447-449
Breast abscess due to Mycobacterium abscessus: A rare case


1 Department of Microbiology, Chandulal Chandrakar Memorial Medical College, Kachandur, Durg, India
2 Department of Microbiology, Smt Kashibai Navale Medical College and Hospital, Narhe, Pune, India

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Date of Web Publication22-Jun-2017
 

   Abstract 

Non-tubercular mycobacterial infections (NTM-Non-tubercular mycobacterial infections) are becoming increasingly common. Mycobacterium abscessus is a rare cause of human infection and is difficult to diagnose unless suspected for the same. A 31-year-old patient, diagnosed to have right breast abscess associated with axillary lyphadenopathy with fever. When pus was sent to the microbiology laboratory, after culture it was confirmed to be due to M. abscess. Definitive identification of this species of mycobacterium was possible by growth characteristics and biochemical tests. The organism was sensitive to Kanamycin, Clarithromycin, Ciprofloxacin, and Amikacin. However, complete recovery from infection was possible after prolonged treatment with clarithromycin to which the organism was sensitive.

Keywords: Abscess, Mycobacterium, M. abscessus, NTM

How to cite this article:
Wankhade AB, Ghadage D, Bhore AV. Breast abscess due to Mycobacterium abscessus: A rare case. Ann Trop Med Public Health 2017;10:447-9

How to cite this URL:
Wankhade AB, Ghadage D, Bhore AV. Breast abscess due to Mycobacterium abscessus: A rare case. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Jun 26];10:447-9. Available from: http://www.atmph.org/text.asp?2017/10/2/447/208722

   Introduction Top


Staphylococcus aureus remains the commonest bacteria causing breast abscess. Chronic mastitis is usually caused by tuberculosis and syphilis.[1] Amongst the Mycobacteria, M. tuberculosis, M. bovis, and M. leprae are established predominating human pathogens. Disease due to non-tuberculous mycobacteria (NTM) is very rare compared with tuberculosis but there has been a significant increase in the pulmonary and non-pulmonary infections due to these mycobacteria during the last two to three decades.[2] Clinicians and microbiologists should also rule out the possibility non-tuberculous mycobacterial infection while dealing the cases of non-healing culture-negative wounds with conventional antibiotic therapy. Herewith, we are reporting the case of breast abscess due to NTM.

A 30-year-old female patient visited to the (OPD) out patient department with history of lump in right breast since last 2–3 months. It was associated with right axillary lymphadenopathy. She had fever, night sweat, and weight loss since 1 year. USG reported as? Neoplasm right breast. The pus was sent for culture in microbiology laboratory. Gram stain revealed plenty of pus cells. Zeihl-Neelsen stain revealed acid fast bacilli. The sample was cultured on blood agar and Maconkeys medium to isolate aerobic bacteria and anaerobic bacteria. It was cultured on (SDA) Sabouraud's dextrose agar for isolation of fungus. It was also cultured on Lowenstein Jensen medium for isolation of acid fast bacilli. On blood agar and Maconkeys medium revealed no bacteria after 24 h of incubation. No anaerobe and no fungus were isolated. On Lowenstein Jensen medium there were moist yellowish white smooth colonies were seen on 5th day. Colony smear showed acid fast bacilli. The results of biochemical reaction were niacin test negative, nitrate reduction test negative, semiquantitative Catalase test showed column of bubbles more than 45 mm, heat stable Catalase was positive, urease test was weakly positive, pyzinamidase test positive, iron uptake was negative. Growth on 5% NaCl at 28°C and MacConkeys agar showed growth. Phynotypically, it was identified as Mycobacterium abscessus. In vitro susceptibility testing found that the organism was susceptible to clarithromycin azithromycin, amikacin, cefoxitin, and doxycycline. Acid fast bacilli (AFB) staining and polymerase chain reaction (PCR) analysis for M. tuberculosis was also performed on the pus specimen and the results were negative. When she was investigated her ESR 18 mm, Monteux test was negative. Amongst the other investigations Hb-6gm/dl,WBC 12,700/cumm, neutrophils 83%, lymphocytes 14%, eosinophil 2%, histopathological examination revealed chronic granulomatous mastitis possibly Kochs. Repeat sample was also asked for confirmation to rule out the contamination by the saprophytic rapid grower. After the microscopy report, first line Anti-tuberculous drugs (AKT) were started with injection cefotaxim. After culture report AKT was stopped. The patient was treated with Clarithromycin and the patient responded well. Her sero-status was normal.


   Discussion Top


The incidence of tuberculosis has reduced in developed countries but infections due to NTM is on the rise, while in developing countries like India, tuberculosis is still a major health problem; NTM are also reported frequently as causative agents of human infections.[3] The three most commonly isolated rapidly growing mycobacteria are M. chelonae, M. fortuitum, andM. abscessus. These are widely spread in nature. These are also resistant to antibiotics, antiseptics, and disinfectant. M. abscessus, like other rapidly growing mycobacteria, grow at 35°C, but they may grow better at slightly lower temperatures.

The patient was young female with normal immune status. The rapidly growing mycobacteria have been isolated and identified in a variety of infections that have involved both immunocompromised and immunocompetent hosts. Wallace et al.[4] studied patients who had disease due to rapid grower. Disseminated infections due to NTM have been widely reported in immunocompromised individuals especially in AIDS patients.[5],[6]

These organisms are notorious for causing infections of soft tissues, tendons, bones, and joints. Surgical procedures, accidental trauma, or injections are also considered as risk factors for infections involving these organisms.[2] The other manifestations of rapidly growing mycobacterial infections were cervical lymphadenitis, keratitis, mastoid abscess, endocarditis, and disseminated disease with positive blood culture results.[7],[8] There are many reports from India, but the exact disease burden of NTM infections still remains unclear in India.[7]

Clinically, it is not possible to differentiate between tuberculosis and myco-bacterioses and thus laboratory support is a must to diagnose the condition. One of the differential diagnosis was carcinoma. Similar observation was there in the study by Maroulis et al.[9] The mainstay of therapy for subcutaneous disease caused by rapidly growing mycobacteria often includes surgical drainage and antimicrobial therapy. It is important to be aware of infections caused by NTM both from diagnostic and therapeutic points of view. In this study after microscopy report, ATT was started but ATT should not be started based only on direct microscopic finding of acid-fast bacilli from clinical samples. After identification of rapid grower in the present study, diagnosis was established by correlation of the findings of repeat culture and histopathologic examination. The definitive diagnosis, therefore, requires identification of the organism by culture and by biochemical or molecular evaluation. The organism is not frequently isolated in tissue. Resistance to anti-tuberculosis drugs is uniform among the rapidly growing mycobacteria, which is yet another important reason for recognizing this group of pathogens. The current antibiotic of choice is clarithromycin to which the patient had responded well.

In conclusion, identification and reporting of NTM from various clinical specimens along with their Antibiotic susceptibility patterns is essential to be aware of the possible spectrum of diseases. It will also helpful and preferred for management and treatment options.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Russel RC, Williams NS, Christopher JK. Bulstrode Chapter 55. In: Russel RC Williams NS Christopher JK Bulstrode eds. Bailey Love's Short Practice of Surgery. 24th ed. London Arnold; 2004:830-31.  Back to cited text no. 1
    
2.
Wolinsky E.Non tuberculous mycobacteria and associated disease.Am Rev Respir Dis1979;119:107-59.  Back to cited text no. 2
    
3.
Ferreira RM, Saad MH, Silva MG, Fonseca Lde S.Non tuberculous mycobacteria I: one year clinical isolates identification in Tertiary Hospital Aids Reference Center, Rio de Janeiro, Brazil, in pre highly active antiretroviral therapy era. Mem Inst Oswaldo Cruz2002;97:725-9.  Back to cited text no. 3
    
4.
Wallace RJ Jr, Swenson JM, Silcox VA.Spectrum of disease due to rapidly growing mycobacteria.Rev Infect Dis1983;5:657-79.  Back to cited text no. 4
    
5.
Wankhade AB, Narang R, Narang P.Isolation and identification of non tuberculous mycobacteria (NTM) from AIDS patients attending a rural hospital in central India.Ind J Public Health Res Dev2010;1:7-11.  Back to cited text no. 5
    
6.
Katoch VM.Infections due to non Tuberculous mycobacteria (NTM). Indian J Med Res2004;120:290-304.  Back to cited text no. 6
    
7.
Villanueva A, Calderon RV, Vargas BA.Report on an outbreak of postinjection abscesses due to Mycobacterium abscessus, including management with surgery and clarithromycin therapy and comparison of strains by random amplified polymorphic DNA polymerase chain reaction. Clin Infect Dis1997;24:1147-53.  Back to cited text no. 7
    
8.
Wankhade AB, Ghadage DP, Mali RJ, Bhore AV. Otomastoiditis by Mycobacterium fortuitum a rare case report.Ind J Otol2011;17:87-9.  Back to cited text no. 8
    
9.
Maroulis I, Spyropoulos C, Zolota V, Tzorakoleftherakis E.Mammary tuberculosis mimicking breast cancer: a case report.J Med Case Rep2008;2:34. DOI: 10.1186/1752-1947-2-34.  Back to cited text no. 9
    

Top
Correspondence Address:
Archana Bhimrao Wankhade
Department of Microbiology, Chandulal Chandrakar Memorial Medical College, Kachandur, Durg
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.208722

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