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Epidemiology, clinical manifestations, and diagnosis of osteomyelitis due to nontuberculous mycobacteria

INTRODUCTION

Nontuberculous mycobacteria (NTM) are a vast group of organisms that are widespread in the environment (table 1). They have been isolated from numerous environmental sources, including water and soil. NTM can cause a broad range of infections that vary depending on the particular NTM species and on the host’s immune status. In immunocompetent individuals, disease can present as pneumonia, lymphadenitis, or skin, soft tissue, and/or bone infection. Immunocompromised individuals can also present with any of these findings, but disease in such patients may also manifest as disseminated infection. Since NTM are seldom considered as a possible etiology in infections of the soft tissues and/or bones, delays in diagnosis are common.

The epidemiology, pathogenesis, clinical manifestations, and diagnosis of osteomyelitis due to NTM will be reviewed here. The treatment of osteomyelitis due to NTM is discussed separately. (See "Treatment of osteomyelitis due to nontuberculous mycobacteria in adults".)

Other manifestations of NTM infections, as well as osteomyelitis due to bacteria and Mycobacterium tuberculosis are also discussed separately. (See "Epidemiology of nontuberculous mycobacterial infections" and "Microbiology of nontuberculous mycobacteria" and "Overview of nontuberculous mycobacteria (excluding MAC) in HIV-infected patients" and "Mycobacterium avium complex (MAC) infections in HIV-infected patients" and "Rapidly growing mycobacterial infections in HIV-negative patients" and "Overview of osteomyelitis in adults" and "Pathogenesis of osteomyelitis" and "Approach to imaging modalities in the setting of suspected osteomyelitis" and "Hematogenous osteomyelitis in children: Epidemiology, pathogenesis, and microbiology" and "Hematogenous osteomyelitis in adults" and "Vertebral osteomyelitis and discitis" and "Skeletal tuberculosis".)

EPIDEMIOLOGY

Osteomyelitis is a rare manifestation of nontuberculous mycobacteria (NTM) infection, which may occur in immunocompetent and immunocompromised hosts. A wide range of NTM species can cause osteomyelitis, including both the rapidly and slowly growing mycobacteria. Osteomyelitis caused by NTM species can result from environmental exposure or nosocomial exposure and has involved either penetrating injuries or postsurgical infections, such as sternal wound infections; such cases typically occur in immunocompetent hosts [1-3].

NTM infections are commonly associated with HIV infection. M. haemophilum, M. avium complex, and M. kansasii have been the most common pathogens reported in cases of HIV-associated NTM osteomyelitis, and usually occur in the setting of disseminated disease [4]. Most cases have occurred in the setting of advanced AIDS and a CD4 count <100 cells/microL.

               

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Literature review current through: Sep 2014. | This topic last updated: May 29, 2014.
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References
Top
  1. Wallace RJ Jr, Swenson JM, Silcox VA, Bullen MG. Treatment of nonpulmonary infections due to Mycobacterium fortuitum and Mycobacterium chelonei on the basis of in vitro susceptibilities. J Infect Dis 1985; 152:500.
  2. Wallace RJ Jr, Brown BA, Silcox VA, et al. Clinical disease, drug susceptibility, and biochemical patterns of the unnamed third biovariant complex of Mycobacterium fortuitum. J Infect Dis 1991; 163:598.
  3. Wallace RJ Jr, Brown-Elliott BA, Wilson RW, et al. Clinical and laboratory features of Mycobacterium porcinum. J Clin Microbiol 2004; 42:5689.
  4. Hirsch R, Miller SM, Kazi S, et al. Human immunodeficiency virus-associated atypical mycobacterial skeletal infections. Semin Arthritis Rheum 1996; 25:347.
  5. Petitjean G, Fluckiger U, Schären S, Laifer G. Vertebral osteomyelitis caused by non-tuberculous mycobacteria. Clin Microbiol Infect 2004; 10:951.
  6. Rahman I, Bhatt H, Chillag S, Duffus W. Mycobacterium chelonae vertebral osteomyelitis. South Med J 2009; 102:1167.
  7. Minematsu A, Sawai T, Matsutake T, et al. [A case of Mycobacterium intracellulare pulmonary infection with vertebral osteomyelitis]. Kansenshogaku Zasshi 2011; 85:527.
  8. Chan ED, Kong PM, Fennelly K, et al. Vertebral osteomyelitis due to infection with nontuberculous Mycobacterium species after blunt trauma to the back: 3 examples of the principle of locus minoris resistentiae. Clin Infect Dis 2001; 32:1506.
  9. Hirakawa A, Miyamoto K, Ohno Y, et al. Two-stage (posterior and anterior) surgical treatment of spinal osteomyelitis due to atypical mycobacteria and associated thoracolumbar kyphoscoliosis in a nonimmunocompromised patient. Spine (Phila Pa 1976) 2008; 33:E221.
  10. Takakuwa O, Oguri T, Kasai D, et al. [A case of spinal osteomyelitis due to Mycobacterium intracellulare with pulmonary Mycobacterium avium complex]. Nihon Kokyuki Gakkai Zasshi 2010; 48:759.
  11. Zelazny AM, Root JM, Shea YR, et al. Cohort study of molecular identification and typing of Mycobacterium abscessus, Mycobacterium massiliense, and Mycobacterium bolletii. J Clin Microbiol 2009; 47:1985.
  12. Hoffman PC, Fraser DW, Robicsek F, et al. Two outbreaks of sternal wound infection due to organisms of the Mycobacterium fortuitum complex. J Infect Dis 1981; 143:533.
  13. Narasimhan SL, Austin TW. Prosthetic valve endocarditis due to Mycobacterium fortuitum. Can Med Assoc J 1978; 119:154.
  14. Jauregui L, Arbulu A, Wilson F. Osteomyelitis, pericarditis, mediastinitis, and vasculitis due to mycobacterium chelonei. Am Rev Respir Dis 1977; 115:699.
  15. Mullin D, Jothi S, Healy D. Mycobacterium chelonae infections involving the head and neck. Ann Otol Rhinol Laryngol 2009; 118:714.
  16. Kim RS, Kim JS, Choi DH, et al. M. chelonae soft tissue infection spreading to osteomyelitis. Yonsei Med J 2004; 45:169.
  17. Tejan-Sie SA, Avery RK, Mossad SB. Mycobacterium fortuitum osteomyelitis in a peripheral blood stem cell transplant recipient. Scand J Infect Dis 2000; 32:94.
  18. Meredith FT, Sexton DJ. Mycobacterium abscessus osteomyelitis following a plantar puncture wound. Clin Infect Dis 1996; 23:651.
  19. Brown BA, Springer B, Steingrube VA, et al. Mycobacterium wolinskyi sp. nov. and Mycobacterium goodii sp. nov., two new rapidly growing species related to Mycobacterium smegmatis and associated with human wound infections: a cooperative study from the International Working Group on Mycobacterial Taxonomy. Int J Syst Bacteriol 1999; 49 Pt 4:1493.
  20. Wallace RJ Jr, Nash DR, Tsukamura M, et al. Human disease due to Mycobacterium smegmatis. J Infect Dis 1988; 158:52.
  21. Sato Y, Tamura K, Seita M. Multiple osteomyelitis due to Mycobacterium avium with no pulmonary presentation in a patient of sarcoidosis. Intern Med 1992; 31:489.
  22. Jones AR, Bartlett J, McCormack JG. Mycobacterium avium complex (MAC) osteomyelitis and septic arthritis in an immunocompetent host. J Infect 1995; 30:59.
  23. Weigl JA, Haas WH. Postoperative Mycobacterium avium osteomyelitis confirmed by polymerase chain reaction. Eur J Pediatr 2000; 159:64.
  24. Pombo D, Woods ML 2nd, Burgert SJ, et al. Disseminated mycobacterium avium complex infection presenting as osteomyelitis in a normal host. Scand J Infect Dis 1998; 30:622.
  25. Frosch M, Roth J, Ullrich K, Harms E. Successful treatment of mycobacterium avium osteomyelitis and arthritis in a non-immunocompromised child. Scand J Infect Dis 2000; 32:328.
  26. Stone AB, Schelonka RL, Drehner DM, et al. Disseminated Mycobacterium avium complex in non-human immunodeficiency virus-infected pediatric patients. Pediatr Infect Dis J 1992; 11:960.
  27. Kourtis AP, Ibegbu CC, Snitzer JA, Nesheim SR. Recurrent multifocal osteomyelitis due to Mycobacterium avium complex. Clin Infect Dis 1996; 23:1194.
  28. Yano T, Okuda S, Kato K, et al. Mycobacterium kansasii osteomyelitis in a patient with AIDS on highly active antiretroviral therapy. Intern Med 2004; 43:1084.
  29. Tsai CW, Wang JT, Tsai CC, Yeh KH. Disseminated Mycobacterium kansasii infection in an HIV-negative patient presenting with mimicking multiple bone metastases. Diagn Microbiol Infect Dis 2006; 54:211.
  30. Bernard L, Vincent V, Lortholary O, et al. Mycobacterium kansasii septic arthritis: French retrospective study of 5 years and review. Clin Infect Dis 1999; 29:1455.
  31. Williams B, Neth O, Shingadia D, et al. Mycobacterium kansasii causing septic arthritis and osteomyelitis in a child. Pediatr Infect Dis J 2010; 29:88.
  32. Elsayed S, Read R. Mycobacterium haemophilum osteomyelitis: case report and review of the literature. BMC Infect Dis 2006; 6:70.
  33. Lindeboom JA, Bruijnesteijn van Coppenraet LE, van Soolingen D, et al. Clinical manifestations, diagnosis, and treatment of Mycobacterium haemophilum infections. Clin Microbiol Rev 2011; 24:701.
  34. Lewis FM, Marsh BJ, von Reyn CF. Fish tank exposure and cutaneous infections due to Mycobacterium marinum: tuberculin skin testing, treatment, and prevention. Clin Infect Dis 2003; 37:390.
  35. Wilson KC, Bielska B, Farber HW. Mycobacterium marinum osteomyelitis. Orthopedics 2003; 26:331.
  36. Sivan M, Bose D, Athanasou N, McNally M. Mycobacterium marinum osteomyelitis of a long bone. Joint Bone Spine 2008; 75:600.
  37. Shih JY, Hsueh PR, Chang YL, et al. Osteomyelitis and tenosynovitis due to Mycobacterium marinum in a fish dealer. J Formos Med Assoc 1997; 96:913.
  38. Clark RB, Spector H, Friedman DM, et al. Osteomyelitis and synovitis produced by Mycobacterium marinum in a fisherman. J Clin Microbiol 1990; 28:2570.
  39. Barton A, Bernstein RM, Struthers JK, O'Neill TW. Mycobacterium marinum infection causing septic arthritis and osteomyelitis. Br J Rheumatol 1997; 36:1207.
  40. Aubry A, Chosidow O, Caumes E, et al. Sixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolates. Arch Intern Med 2002; 162:1746.
  41. van der Werf TS, van der Graaf WT, Tappero JW, Asiedu K. Mycobacterium ulcerans infection. Lancet 1999; 354:1013.
  42. Walsh DS, Portaels F, Meyers WM. Buruli ulcer (Mycobacterium ulcerans infection). Trans R Soc Trop Med Hyg 2008; 102:969.
  43. Lagarrigue V, Portaels F, Meyers WM, Aguiar J. [Buruli ulcer: risk of bone involvement! Apropos of 33 cases observed in Benin]. Med Trop (Mars) 2000; 60:262.
  44. Toll A, Gallardo F, Ferran M, et al. Aggressive multifocal Buruli ulcer with associated osteomyelitis in an HIV-positive patient. Clin Exp Dermatol 2005; 30:649.
  45. O'Brien DP, Athan E, Hughes A, Johnson PD. Successful treatment of Mycobacterium ulcerans osteomyelitis with minor surgical debridement and prolonged rifampicin and ciprofloxacin therapy: a case report. J Med Case Rep 2008; 2:123.
  46. Hsueh PR, Hsiue TR, Jarn JJ, et al. Disseminated infection due to Mycobacterium scrofulaceum in an immunocompetent host. Clin Infect Dis 1996; 22:159.
  47. Phoa LL, Khong KS, Thamboo TP, Lam KN. A case of Mycobacterium scrofulaceum osteomyelitis of the right wrist. Ann Acad Med Singapore 2000; 29:678.
  48. Valero G, Peters J, Jorgensen JH, Graybill JR. Clinical isolates of Mycobacterium simiae in San Antonio, Texas. An 11-yr review. Am J Respir Crit Care Med 1995; 152:1555.
  49. Kuipers EJ, Hazenberg HJ, Ploeger B, et al. Nontuberculous mycobacterial sternal osteomyelitis in a patient without predisposing condition. Neth J Med 1991; 38:122.
  50. Huminer D, Dux S, Samra Z, et al. Mycobacterium simiae infection in Israeli patients with AIDS. Clin Infect Dis 1993; 17:508.
  51. Al-Abdely HM, Revankar SG, Graybill JR. Disseminated Mycobacterium simiae infection in patients with AIDS. J Infect 2000; 41:143.
  52. Kulasegaram R, Richardson D, Macrae B, de Ruiter A. Mycobacterium xenopi osteomyelitis in a patient on highly active antiretroviral therapy (HAART). Int J STD AIDS 2001; 12:404.
  53. Danesh-Clough T, Theis JC, van der Linden A. Mycobacterium xenopi infection of the spine: a case report and literature review. Spine (Phila Pa 1976) 2000; 25:626.
  54. Meybeck A, Fortin C, Abgrall S, et al. Spondylitis due to Mycobacterium xenopi in a human immunodeficiency virus type 1-infected patient: case report and review of the literature. J Clin Microbiol 2005; 43:1465.
  55. Tappe D, Langmann P, Zilly M, et al. Osteomyelitis and skin ulcers caused by Mycobacterium szulgai in an AIDS patient. Scand J Infect Dis 2004; 36:883.
  56. Meyer JJ, Gelman SS. Multifocal osteomyelitis due to Mycobacterium szulgai in a patient with chronic lymphocytic leukemia. J Infect 2008; 56:151.
  57. Luque AE, Kaminski D, Reichman R, Hardy D. Mycobacterium szulgai osteomyelitis in an AIDS patient. Scand J Infect Dis 1998; 30:88.
  58. Hurr H, Sorg T. Mycobacterium szulgai osteomyelitis. J Infect 1998; 37:191.
  59. Gur H, Porat S, Haas H, et al. Disseminated mycobacterial disease caused by Mycobacterium szulgai. Arch Intern Med 1984; 144:1861.
  60. Edwards MS, Huber TW, Baker CJ. Mycobacterium terrae synovitis and osteomyelitis. Am Rev Respir Dis 1978; 117:161.
  61. Rougraff BT, Reeck CC Jr, Slama TG. Mycobacterium terrae osteomyelitis and septic arthritis in a normal host. A case report. Clin Orthop Relat Res 1989; :308.
  62. Eskesen AN, Skråmm I, Steinbakk M. Infectious tenosynovitis and osteomyelitis caused by Mycobacterium nonchromogenicum. Scand J Infect Dis 2007; 39:179.
  63. Lazzarini L, Amina S, Wang J, et al. Mycobacterium tuberculosis and Mycobacterium fortuitum osteomyelitis of the foot and septic arthritis of the ankle in an immunocompetent patient. Eur J Clin Microbiol Infect Dis 2002; 21:468.
  64. Kwan K, Ho ST. Mycobacterium chelonae and Mycobacterium fortuitum infection following open fracture: a case report and review of the literature. Indian J Med Microbiol 2010; 28:248.
  65. Holland SM, Eisenstein EM, Kuhns DB, et al. Treatment of refractory disseminated nontuberculous mycobacterial infection with interferon gamma. A preliminary report. N Engl J Med 1994; 330:1348.
  66. Rosenzweig SD, Holland SM. Defects in the interferon-gamma and interleukin-12 pathways. Immunol Rev 2005; 203:38.
  67. Dorman SE, Holland SM. Interferon-gamma and interleukin-12 pathway defects and human disease. Cytokine Growth Factor Rev 2000; 11:321.
  68. Baerlecken N, Jacobs R, Stoll M, et al. Recurrent, multifocal Mycobacterium avium-intercellulare infection in a patient with interferon-gamma autoantibody. Clin Infect Dis 2009; 49:e76.
  69. Goodhart GL. Mycobacterium fortuitum osteomyelitis following trauma. J Orthop Trauma 1993; 7:142.
  70. Minkin BI, Mills CL, Bullock DW, Burke FD. Mycobacterium kansasii osteomyelitis of the scaphoid. J Hand Surg Am 1987; 12:1092.
  71. Gardam M, Lim S. Mycobacterial osteomyelitis and arthritis. Infect Dis Clin North Am 2005; 19:819.
  72. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 23-2000. A 49-year-old man with acquired immunodeficiency syndrome and a tibial lesion. N Engl J Med 2000; 343:281.
  73. Paradisi F, Corti G. Skeletal tuberculosis and other granulomatous infections. Baillieres Best Pract Res Clin Rheumatol 1999; 13:163.
  74. Shah MK, Sebti A, Kiehn TE, et al. Mycobacterium haemophilum in immunocompromised patients. Clin Infect Dis 2001; 33:330.
  75. Aberg JA, Chin-Hong PV, McCutchan A, et al. Localized osteomyelitis due to Mycobacterium avium complex in patients with Human Immunodeficiency Virus receiving highly active antiretroviral therapy. Clin Infect Dis 2002; 35:E8.
  76. Corrales-Medina V, Symes S, Valdivia-Arenas M, Boulanger C. Localized Mycobacterium avium complex infection of vertebral and paravertebral structures in an HIV patient on highly active antiretroviral therapy. South Med J 2006; 99:174.
  77. Kahlon SS, East JW, Sarria JC. Mycobacterium-avium-intracellulare complex immune reconstitution inflammatory syndrome in HIV/AIDS presenting as osteomyelitis. AIDS Read 2008; 18:515.
  78. Lefkowitz RA, Singson RD. Considering Mycobacterium haemophilum in the differential diagnosis for lytic bone lesions in AIDS patients who present with ulcerating skin lesions. Skeletal Radiol 1998; 27:334.
  79. Theodorou DJ, Theodorou SJ, Kakitsubata Y, et al. Imaging characteristics and epidemiologic features of atypical mycobacterial infections involving the musculoskeletal system. AJR Am J Roentgenol 2001; 176:341.
  80. Wall SD, Fisher MR, Amparo EG, et al. Magnetic resonance imaging in the evaluation of abscesses. AJR Am J Roentgenol 1985; 144:1217.
  81. Marchevsky AM, Damsker B, Green S, Tepper S. The clinicopathological spectrum of non-tuberculous mycobacterial osteoarticular infections. J Bone Joint Surg Am 1985; 67:925.
  82. http://www.gen-probe.com/products-services/culture-identification (Accessed on July 10, 2012).