A retrospective review of cases of Mycobacterium haemophilum

Transcription

1 A retrospective review of cases of Mycobacterium haemophilum infection in Western Australia. ABSTRACT BACKGROUND: Mycobacterium haemophilum is an emerging mycobacterial pathogen causing a wide spectrum of clinical infections. AIM: To collect clinical and epidemiological data on cases of M. haemophilum infection between 1980 and METHODS: Cases were identified by searching the WA Mycobacterial Reference Laboratory database. Data was standardised by the use of definitions. Statistical analysis with Fisher's exact test was performed with the aid of Stata (8.2) statistical software. RESULTS: Fifty-one cases of M. haemophilum infection were identified. Diagnostic specimens include skin (20/51, 39%) and lymph node biopsies (15/51, 29%), four cases of disseminated M. haemophilum infection, four cases of septic arthritis and other miscellaneous sites. Two deaths are attributed to M. haemophilum infection. Among the adults fourteen were healthy with predominantly skin infections (14/35, 40%) and the rest (21/35, 60%) were immunocompromised, on corticosteroids (16/35, 46%) or had a malignancy (9/35, 26%). The majority of patients (38/51, 74%) received medical therapy. Among the children, all but one had surgery with good outcomes. Adults with co-morbidities were less likely to be cured than healthy adults

2 (p=0.003). Adults treated with medical and surgical therapy were more likely to be cured than with medical therapy alone (p=0.009). CONCLUSIONS: In children, lymphadenitis is the main clinical manifestation and surgical excision achieves good outcomes. Both healthy and immunosuppressed adults with M. haemophilum infection were identified. Combination medical and surgical therapy achieves better cure rates than medical therapy. A high index of suspicion is required for the diagnosis of M. haemophilum infection.

3 MATERIALS AND METHODS This is a retrospective clinical case study of all Mycobacterium haemophilum isolates in Western Australia between 1980 and Cases were identified by searching the WA Mycobacterial Reference Laboratory database. This laboratory identifies and stores all the mycobacterial isolates in Western Australia, including isolates from rural and private laboratories. Ethics approval was granted from teaching hospitals to review case files. Private specialists and general practitioners completed standardised data collection sheets. Data included demographics, site of organism isolation, medical co-morbidities, immunosuppression, histopathology, treatment, outcomes and side effects from therapy. Where possible, a summary of the clinical picture was obtained. Susceptibility testing of the M. haemophilum isolates was not performed. Definitions used to attempt standardisation of data collection were adapted from two sources, the American Thoracic Society diagnostic criteria for non-tuberculous mycobacterial lung disease (1) and the CDC definitions of mycobacterial disease (2). Infection was defined as the isolation of M. haemophilum from skin biopsy or sterile sites (blood, synovium, lymph node, etc) plus where possible, histopathology consistent with granulomatous inflammation. Pulmonary infection was defined as respiratory symptoms compatible with pneumonia plus an infiltrate, nodule or a cavity (chest radiograph or CT scan) and 3 positive sputa or broncheoalveolar lavage samples or 1 positive sputum and blood culture or histopathology consistent with M. haemophilum infection. Disseminated disease was defined as the isolation of M. haemophilum from blood or bone marrow or from multiple sites. Cure was defined as

4 the resolution of signs and symptoms two months after the cessation of therapy. Neutropaenia was defined as polymorphonuclear cells (PMN) < 0.5x109/L within 30 days of diagnosis of M. haemophilum infection. Co-morbidity was defined as the presence of diabetes mellitus, malignancy, solid organ or haematopoietic stem cell transplantation (HSCT), HIV/AIDS, chemotherapy, neutropaenia or significant corticosteroid exposure (equivalent to prednisolone 20mg/day for at least 2 weeks before the diagnosis of infection). Statistical analysis (significance defined as p<0.05) with Fisher's exact test was performed with the aid of Stata (8.2) statistical software.

5 Results Fifty-three cases of M. haemophilum isolation were identified. Fifty-one cases fulfilled the case definition of infection and were included in further analyses. The majority of cases occurred in adults (35/51, 69%). In this group there were more female (24/35, 69%) than males (11/35, 31%). In contrast, among the children there were more males (10/16, 62%) than females (6/16, 38%). The age range was 1 to 96 years with a median of Sites of infection Skin (20/51, 39%) and lymph nodes (15/51, 29%) accounted for the majority of the infections (68%). The remaining third of cases were represented by septic arthritis (4/51, 8%), skin and lymph node involvement (5/51, 10%), disseminated disease (4/51, 8%) and other miscellaneous sites (lung infections, bursitis, IV line related; see appendix 1, fig. 1). 1.1 M. haemophilum infection in children The age range was 1-16 years with the most children (13/16, 81%) under the age of 5. One child had Type I diabetes mellitus, the rest were otherwise healthy. The main manifestation of disease was lymphadenitis (12/16, 75%). Most cases involved cervical nodes and in all but one case, multiple lymph nodes were affected.

6 There were 4 cases of skin infection associated with local lymphadenitis. In 6/9 (66%) cases of cervical lymphadenitis there was a history of sticky or weepy eyes, conjunctivitis or tear duct obstruction six to twelve weeks prior to the development of the lymphadenitis. 1.2 M. haemophilum infection in adults Half of the adult cases (18/35, 51%) were infections of the skin and soft tissues. The presentations varied such as cellulitis, scaly rashes, chronic pyoderma gangrenosumlike ulcers and skin infection at the site of old IV lines. However, the most common skin infection was multiple non-painful papular or nodular lesions. The case histories in appendix 2 exemplify skin infections due to M. haemophilum. Lymphadenitis was only present in three adults (3/35, 9%). In one quarter of the adult cases there were multiple infected sites. Among the adult cases with complete data sets, the majority (19/28, 68%) had one or more co-morbidities. This group included HSCT and solid organ transplant recipients and HIV infected patients. A significant number of adults (46%, 16/35) were on corticosteroids and nine (9/35, 26%) had a malignancy. One third of those with multiple co-morbidities had a single skin lesion (10/28, 36%) but three (3/28, 11%) immunocompromised patients with skin infection also fitted the case definition for disseminated disease. There were three cases of M. haemophilum infection associated with IV lines in HSCT patients, two cases of lung disease as well as a case of olecranon bursitis in an elderly debilitated man.

7 Fourteen of the adults (14/35, 40%) were apparently healthy. The majority had infections involving skin and lymph nodes but there were also two patients with septic arthritis of the small joints of the hand after gardening injuries. 2. Sources of infection Several cases had a history suggestive of a source for the infection, such as the cases of septic arthritis described above. Another patient had an injury whilst repairing a car engine and in three cases an IV line was associated with the infection. There was an association with water exposure in two other cases. 3. Deaths due to M. haemophilum infection M. haemophilum infection was the likely cause of death in two patients. A 79-year-old man with multiple medical problems on corticosteroids and methotrexate died of probable M. haemophilum pneumonia. He was admitted with pneumonia complicated by a para-pneumonic effusion. The patient died within 6 days of admission to hospital. M. haemophilum was cultured from the sputum and blood cultures two weeks later (see case 29 in appendix 3). A 58-year-old male with acute myeloid leukaemia died of a lung haemorrhage three weeks after a cycle of chemotherapy. He had a lung lesion on chest radiograph and was treated for invasive fungal disease. M. haemophilum was cultured from three sputa specimens (case 30).

8 There are two other cases where M. haemophilum contributed to the deaths of the patients (cases 31 and 32). 4. Management of M. haemophilum infection Data was available for 42 (42/51, 82%) of the cases. Of these, the majority (35/42, 85%) received antimicrobial therapy. Various combinations were used with nearly half of the cases (18/42, 43%) being treated with clarithromycin as the backbone of therapy. Rifampicin and ciprofloxacin were the other two most commonly used antimicrobial agents. Eighteen cases (18/42, 43%) also had surgery. All but one of the children had surgical excision of the lymph nodes. In 62% (10/16) of cases they also received medical therapy and clarithromycin was the most frequently used antimicrobial agent. All cases achieved cure. In contrast with the children cohort, the majority of adults (25/28, 89%) had antibiotics. The most common antimicrobial combination was clarithromycin and rifampicin (16/28, 57%). Clarithromycin, rifampicin and ciprofloxacin was used in one third of adult cases (8/28, 29%). The median duration of therapy for healthy adults was 5 months (range, 2-15 compared with 9 months for immunocompromised adults (range, Ten adults (10/28, 37%) had side effects requiring either cessation of therapy or a significant reduction in the drug doses. The majority of side effects occurred with rifamicins (drug interactions, uveitis, rash, fever, myalgia, leukopaenia) or clarithromycin (mainly gastrointestinal

9 intolerance). Ciprofloxacin caused nausea, vomiting and an altered mental state in three patients. Adjuvant surgery such as lymph node excision, wound debridement or joint washout was performed in nine adults (9/28, 32%). Overall cure was achieved in 60% (17/28) of adults but three immunocompromised patients who were diagnosed late and did not receive therapy died. All otherwise healthy adults were cured, whereas only 7/17 (41%) of those with comorbidities achieved a treatment cure (p= 0.003). Adults who had medical therapy were more likely to be cured (17/28, 60%) than those who did not received medical therapy (3/28, 11%) (p=0.041). All adults who had medical and surgical therapy were cured compared with 8/17 (47%) of cases where they only received medical therapy (p=0.009). None of the antimicrobial combinations achieved a statistically significant association with outcome. Age, infection at multiple sites and length of therapy were not significantly associated with outcome (see appendix 4, table 3.).

10

11 DISCUSSION AND LITERATURE REVIEW M. haemophilum infection was first described in an Israeli woman with Hodgkin s disease in 1978 by Sompolinsky et al. (3). There has been over 100 cases of M. haemophilum infection reported worldwide (4-8). In Australia, there have been 104 isolations of M. haemophilum between 1977 and 2003 (9). This study describes 51 patients with M. haemophilum infection in Western Australia. The awareness of this organism as a human pathogen is increasing, which is reflected in the number of reported cases in the literature in recent years. A degree of clinical suspicion is required for the isolation of M. haemophilum. It is a non-pigmented, slow growing atypical mycobacterium with requirement for iron containing compounds and lower temperatures for growth (ideally 30 0 C to 32 0 C). M. haemophilum is traditionally grown in Lowenstein Jensen (LJ)-pyruvate media supplemented with ferric ammonium citrate (FAC). A recent Australian study found that chocolate agar consistently produces growth earlier than the best of the LJ-formulations, typically within seven days (9). Therefore, if M. haemophilum is suspected as an aetiological agent, samples can be cultured on conventional chocolate agar at 30 0 C to 32 0 C and be incubated for at least 7 days. The spectrum of disease, the natural history, the epidemiology, optimum management and outcomes of M. haemophilum infection are largely unknown.

12 This case series includes fourteen adults with M. haemophilum infection who are otherwise healthy (14/35, 40%). Skin infections and lymphadenitis were the main infections in this group. However, two cases of septic arthritis due to direct trauma to the joint are also described. There have been previous reports of M. haemophilum infection in healthy adults mostly causing cellulitis or single skin lesions (7, 10) and a case of a lung nodule due to M. haemophilum (11). Most cases in the literature have occurred in individuals with a range of immunocompromise, often due to HIV infection (4, 8, 12-19) or due to haematopoetic (6, 20, 21) or solid organ transplantation (4, 22, 23). The bulk of the cases in immunocompromised adults (23/35, 66%) in this series occurred in HSCT and solid organ transplant recipients and only two cases occurred in HIV patients. A large number of immunocompromised adults were on corticosteroids (16/35, 46%) and nine (9/35, 26%) had a malignancy. The sites of involvement are different between the healthy and immunocompromised adults. Among the immunocompromised adults, eight cases presented with a single skin lesion. However, there was a range of other types of infections including three cases of IV line related bacteraemia and IV site skin infections, two cases of lung disease, a case of olecranon bursitis and three patients had disseminated disease. The cases of disseminated disease were bacteraemia with secondary skin or septic arthritis involvement and lung disease and presumably reflect a significant degree of impaired cell mediated immunity in these patients. CD4 T cell counts were only available for two HIV infected individuals.

13 The children cohort were predominantly very young (under the age of 5) with involvement of multiple lymph nodes in the cervical region. A recent Danish study found that M. haemophilum, in contrast with other atypical mycobacteria, causes involvement of multiple rather than single lymph nodes (25) and cervical lymphadenitis appears to be the most common manifestation of M. haemophilum infection in healthy children (1, 25-30). A novel finding among the children cases is a history of sticky or weepy eyes, conjunctivitis or tear duct obstruction of at least 6 weeks duration prior to the development of the lymphadenitis. This was found in 6/9 (66%) cases of cervical lymphadenitis in children and was not accounted for by other causes. It resolved with removal of the lymph nodes. This manifestation suggests the eye as a potential portal of entry for M. haemophilum in children. A similar infection occurred in one of the adults in this case series and it further illustrates the potential for water as a source of M. haemophilum infection. A 52 yearold woman who performed daily sinus washes with tap water, presented with a 6- week history of a weepy right eye associated with right-sided parotid gland swelling. A biopsy of the medial canthus of the eye and lacrimal duct showed granulomatous inflammation. An aspirate of the parotid and submandibular glands grew M. haemophilum. She was treated for six months and also required surgical debridement for resolution of her infection. Little is known about the environmental reservoir and the route of infection of M. haemophilum. A recent report found a statistically significant association between contact with swimming water and M. haemophilum infection in children (25). In our

14 study, a water source is suggested from the young woman described above and a young child who developed multiple skin lesions of the arm associated with axillary lymphadenitis after cleaning a fish tank. M. haemophilum has only been isolated from human specimens, but reports of infections from diverse geographical locations suggest that M. haemophilum s habitat is not restricted to a particular area (5, 21). Lung infection due to M. haemophilum appears to have an unfavourable prognosis. Two patients whose deaths can be attributed to M. haemophilum infection died of lung infection, either pneumonia or cavitatory lung disease. These patients were significantly immunocompromised and died before therapy could be instituted. Four other reports have remarked on the poor outcome and almost universal death among patients with M. haemophilum lung infection (4, 6, 20, 31). Interestingly, there is one case report of an apparently healthy woman with a lung nodule due to M. haemophilum who recovered uneventfully (11). In this study, M. haemophilum significantly contributed to the deaths in two other cases. An elderly man with M. haemophilum bursitis and possibly osteomyelitis of the left olecranon did not receive therapy and the mycobacterium was cultured from the bursa fluid one week after he passed away. The fourth death in our case series was in an HIV infected patient who had many opportunistic infections, one of which was multiple skin lesions and septic arthritis of the wrist due to M. haemophilum. Despite the growing number of case reports of M. haemophilum infection, optimal therapeutic modalities are unknown and outcomes have not been evaluated. In this

15 series, therapies included antimicrobials, surgery or a combination of the two. The most common antimicrobial combination was clarithromycin and rifampicin. Clarithromycin, rifampicin and ciprofloxacin combination was used in one third of adults. Due to the small sample size, none of the combinations achieved statistically significant associations with outcome. There were significant side effects in ten adults (10/28, 37%) leading to change, dose reduction of antibiotics or cessation of therapy. However, patients who received medical therapy, regardless of the combination of antimicrobials, were more likely to be cured (17/28, 60%) than if they did not receive medical therapy (3/28, 11%) (p=0.041). All adults who had adjuvant surgery achieved a cure compared with only 8/17 (47%) of those who only had medical therapy (p=0.009). Among immunocompromised adults, 13/19 (71%) of those who underwent surgical debridement as well as medical therapy were cured compared with no cures among those who did not have surgery. Immunocompromised adults were much less likely to be cured than healthy adults (p=0.003). Among the children the main therapy (13/16, 81%) was surgical excision of lymph nodes and there was a 100% cure rate. In ten children (10/16, 62%) adjuvant clarithromycin therapy was administered. Lymphadenitis caused by atypical mycobacteria in children can be successfully treated by excision of the affected lymph node (25, 28). Similar observations have been made in children with lymphadenitis due to M. haemophilum (25, 27). Antimicrobial choices for M. haemophilum infection remain difficult. Multiple combinations of antimicrobial agents with varying degrees of success have been

16 reported. The most active in vitro agents are rifamicins, macrolides, quinolones, amikacin, and clofazimine whereas ethambutol, isoniazid, tetracyclines, cefoxitin, trimethoprim-sulphamethoxazole and streptomycin are relatively inactive against M. haemophilum (32). Methodologies for determining the in vitro antimicrobial susceptibility patterns of M. haemophilum are not standardised, they vary from study to study and have been adapted from methods for other slow growing non-tuberculous mycobacteria. Another complicating factor in susceptibility testing for M. haemophilum is the potential for antagonism of hemin on the in vitro activity of antimicrobial agents, such as isoniazid (32, 37). Furthermore, susceptibility testing for this organism is not performed in the routine microbiology laboratory. There are few studies with small numbers of cases correlating in vitro susceptibilities and clinical outcomes (4, 12-14, 32-36). There have been no trials to compare antibiotic combinations. It has been suggested that at least two and preferably three drugs including clarithromycin, rifampicin and a quinolone such as ciprofloxacin for at least 6 months, is needed for therapy for M. haemophilum skin and soft tissue infections (15, 21, 33). Longer courses of therapy including intravenous amikacin have been advocated for serious M. haemophilum infections such as bacteraemia or lung infection (4). From our data we derive that that children do well with surgical excision of the involved lymph nodes. Adults have better outcomes with a combination approach of medical and surgical therapy, especially immunocompromised patients who tend to have severe and difficult to treat infections that often relapse and whose outcome is worse. Moreover, these patients require long therapy courses and are at risk of

17 significant toxicities from antibiotic therapy. An anecdotal finding was that reduction of immunosuppression was required in a handful of cases for resolution of the infection as well as surgery and antimicrobial therapy, a finding reported previously (8, 14, 16, 19, 26).

18 CONCLUSIONS M. haemophilum causes a variety of clinical infections. In children, lymphadenitis involving multiple lymph nodes is the main clinical manifestation. A significant proportion of children had an antecedent history of conjunctivitis or tear duct obstruction. The main treatment for children is surgical excision. Adult infections with M. haemophilum affect both immunocompetent and immunocompromised individuals. In healthy adults the main manifestation is skin and soft tissue infections, whereas in immunosuppressed adults, more invasive infection with bacteraemia, disseminated disease or lung infection also occur. Combination medical and surgical therapy of adults achieves better cure rates than either therapy alone. In immunocompromised individuals with septic arthritis, osteomyelitis, soft tissue abscesses, or skin infection a combination of surgical debridement and a prolonged course of clarithromycin, rifampicin and ciprofloxacin (6-9 would provide the best chance of cure. If patients are bacteraemic or have a lung infection, additional intravenous amikacin should be considered. In healthy adults with skin infections, triple therapy as described above for at least 3 months is necessary. Children with lymphadenitis, which can be excised do not need further therapy, however if there are multiple lymph nodes involved, as it often is the case, adjuvant clarithromycin therapy for at least four weeks may be required to prevent relapse or fistulae formation.

19 A high index of suspicion is required for the diagnosis of M. haemophilum infection and it should be considered in the differential diagnosis of skin lesions of healthy and immunocompromised adults not responsive to therapy, in systemic diseases of immunocompromised adults and in children with lymphadenitis. Standardised methodologies for antimicrobial susceptibility testing for M. haemophilum are needed.

20 Appendix 1 Figure 1. Mycobacterium haemophilum infection by site. 8% 8% 4% 8% 41% 31% Skin (20/51) Lymph node (15/51) Skin and node (5/51) Disseminated (4/51) Septic arthritis (4/51) Other (3/51)

21 Appendix 2 Case history year-old woman with cellulitis of the forearm two weeks after an iron infusion. The forearm was diffusely erythematous and there were also multiple nodular lesions, see figures 2 and 3. A skin biopsy grew M. haemophilum. She received 15 months therapy (clarithromycin 500mg BD, rifampicin 300mg BD and ciprofloxacin 500mg BD) but the infection relapsed twice as antibiotics were stopped. She had difficulty tolerating ciprofloxacin due to nausea and vomiting. Therapy continued at the time of her death 3 years after first developing the infection. Figures 2 and 3. Cellulitis of the forearm due to M. haemophilum infection Figure 2. Figure 3. Case history year-old man with carcinoma of the appendix presented with a skin eruption of the abdomen. A biopsy grew M. haemophilum (figure 4). He was immunosuppressed on azathioprine and prednisolone for a renal transplant. He did not tolerate clarithromycin and ciprofloxacin therapy and rifampicin was ceased due to interaction with warfarin. The rash improved on azithromycin 500mg and moxifloxacin 400mg daily. He was still on therapy when he died, 9 months after developing the infection. Figure 4. M. haemophilum scaly abdominal rash, as indicated by the blue arrow. Figure 4A shows a close up of the scaly rash. Figure 4. Figure 4A. Case history year-old woman with poorly controlled diabetes and hepatitis C infection with papular skin eruption of the abdomen (figure 5). A skin biopsy grew M. haemophilum. The skin infection was slow to respond to therapy (ofloxacin, azithromycin and ethambutol) and she received a total of 18 months of antibiotics. Figure 5. M. haemophilum papular rash.

22 Appendix 3 Table 1. Summary of the characteristics, disease presentation, therapy, and outcomes for children who were infected with Mycobacterium haemophilum in Western Australia between 1980 and Case Age, years Se x Underlying disease Blocked tear duct Clinical presentation Culture source Therapy: surgery, antibiotics, (duration in Outcome 1 9 M None - Cervical lymphadenitis Lymph node Excision, Clm (1 Cure Figure 5. month) 2 3 M None 3 months Cervical lymphadenitis Lymph node Excision, Clm (1.5 Cure 3 2 M None - Skin Skin biopsy Excision Unknown 4 16 M None - Sub mandibular lymphadenitis Lymph node Excision, Clm (6 Cure 5 2 F None - Skin and lymphadenitis Skin biopsy Excision Cure 6 2 F None 1.5 Cervical lymphadenitis Lymph node Excision, Clm (1 Cure months Figure 5. month) 7 a 2 M None - Skin and lymphadenitis Skin & lymph node Excision, Rif, Inh, Cure Pas, Ery ( M None 2 months Cervical lymphadenitis Lymph node Excision Cure 9 2 M None 2 months Cervical lymphadenitis Lymph node Excision Cure 10 7 M None - Sub mandibular lymphadenitis Lymph node Excision, Clm (1.5 Cure 11 1 F None - Cervical lymphadenitis Lymph node Rif, Inh, Pza, Ery Cure ( M None 12 months Cervical lymphadenitis Lymph node Excision, Clm (3 Cure 13 1 M None 2 months Cervical lymphadenitis Lymph node Excision, Clm (2 Cure 14 4 F Diabetes - Skin abscess Skin biopsy Excision Cure 15 1 F None - Cervical lymphadenitis Lymph node Unknown Unknown 16 1 F None - Lymphadenitis Lymph node Unknown Unknown Note: Clm, clarithromycin; Rif, rifampicin; Inh, isoniazid; Pas, para-aminosalicylic acid; Ery, erythromycin; Pza, pyrazinamide. a Skin infection and axillary lymphadenitis associated with skin abrasion after cleaning a fish tank. Table 2. Summary of the characteristics, disease presentation, therapy, and outcomes for adults who were infected with Mycobacterium haemophilum in Western Australia between 1980 and 2005 Case Age, years Sex Underlying disease Clinical presentation Culture source Therapy: surgery, antibiotics, (duration) Outcome F None Cervical lymphadenitis Lymph node Clm, Eth (3 Cure 18 b 92 F None Forearm cellulitis Skin biopsy Clm, Rif, Cip (15 Relapse F Diabetes Thigh ulceration Skin biopsy Clm, Emb, Cip (15 Relapse F None Cervical lymphadenitis Lymph node Clm, Rib, Cip (7 Cure F Renal transplant Forearm cellulitis Skin biopsy Emb, Rif, Inh (8 Cure 22 c 62 M NHL, CD4 102 * Multiple nodular skin Skin biopsy Clm, Rib, Cip, Dox (2 Death lesions F None Forearm cellulitis Skin biopsy Clm, Rib (3 Cure F Diabetes, corticosteroids F Diabetes, haemodialysis Septic arthritis (R & L hips) Synovial fluidsurgical drainage & Clm, Rif, Amk, Cfx (10 IV line-related Skin biopsy Surgical debridement; Clm, Rif, Cip, Dox (9 Cure Cure

23 26 27 F HSCT, corticosteroids F HSCT, corticosteroids 28 d 61 M Melanoma, corticosteroids M Scleroderma, polymyositis *IV line-related bacteraemia Skin & lymphadenitis, IV line Blood cultures & skin biopsy Surgical debridement, Clm, Rif, Cip, Amk, Cfx (3 Lymph node Excision lymph nodes, Clm, Rif, Cip, Amk, Cfx (6 Cure Cure Skin nodules Skin biopsy Clm, Rif (7 Death *Pneumonia Blood cultures & sputum Sputum None (died prior to diagnosis) Death M AML Lung cavitation & haemorrhage None (died prior to diagnosis) Death M HIV CD4<5 *Septic arthritis & skin Synovial Clm, Rib, Cip, Dox (14 Death lesions tissue, skin months, ongoing at time biopsy of death) M CLL Olecranon bursitis Bursa fluid None Death F Renal transplant Soft tissue abscess Abscess pus Surgical debridement, Emb, Rif, Inh, Cip, Dox (3 Relapse M NHL Multiple nodular skin Skin biopsy Clm, Cip, Tet (unknown) Unknown lesions F Renal transplant Multiple nodular skin lesions Skin biopsy Emb, Rif, Inh (12 & reduction of corticosteroids Cure Skin biopsy Itra, Min (4 Cure F None Multiple nodular skin lesions M None Septic arthritis Synovial fluidsurgical drainage & Clm, Cure Ofl, Emb ( F Renal transplant Multiple nodular skin Skin biopsy Inh, Rif, Cip (24 Cure lesions M None Septic arthritis Synovial fluidsurgical drainage; Clm, Cure Ofl, Cip, Emb ( F Diabetes mellitus, Multiple nodular skin Skin biopsy Ofl, Azy, Rib, Emb (18 Cure HCV lesions 41 e 53 F Renal transplant Lower leg cellulitis Skin biopsy Clm, Mox (6 Cure F None Lymphadenitis and tear duct obstruction Skin & lymphsurgical debridement; Cure node biopsy Clm, Rif, Emb (6 Skin biopsy Mox, Azy (9 months, Death ongoing at time of death) Skin biopsy Clm, Cip (10 Cure 43 f 65 M Renal transplant Multiple nodular skin lesions F CAL, Multiple nodular skin corticosteroids lesions M None Multiple skin lesions Skin biopsy Unknown Unknown F None Cervical lymphadenitis Lymph node Unknown Unknown F None Multiple nodular skin Skin biopsy Unknown Unknown lesions F None Multiple nodular skin lesions Skin biopsy Unknown Unknown F None Lymphadenitis and Skin & lymphunknown Unknown cellulitis node biopsy F None Septic arthritis Synovial fluidunknown Unknown F SLE, corticosteroids Multiple nodular skin lesions Skin biopsy Unknown Unknown Note: Clm, clarithromycin; Rif, rifampicin; Rib, rifabutin; Inh, isoniazid; Pas, para-aminosalicylic acid; Ery, erythromycin; Pza, pyrazinamide; Cip, ciprofloxacin; Ofl, ofloxacin; Mox, moxifloxacin; Dox, doxycycline; Amk, amikacin; Cfx, cefoxitin; Tet, tetracycline; Itra, itraconazole; Min, minocycline; Azi, azithromycin. * Asterisk indicates systemic disseminated disease. b Forearm cellulitis associated with intravenous iron infusion for treatment of iron deficiency anaemia. c This man had many nodular skin lesions involving the limbs, trunk and face. He was on antibiotic therapy at the time of death due to the underlying lymphoma. d This man died of metastatic melanoma. M. haemophilum skin lesions had resolved. e Skin infection slow to improve on antibiotics. Finally resolved with reduction of immunosuppression. f This man died of an unrelated adenocarcinoma of the appendix.

24 Appendix 4 Table 3. Variables and their associations with outcome. Variable Outcome (%) Cured Not cured p value Age (years) <75 14 (67) 7 (33) 0.6 >75 3 (50) 3 (50) Multiple sites Yes 4 (57) 3 (43) 1.0 No 13 (65) 7 (35) Co-morbidity Yes 7 (41) 10 (58) No 10 (100) 0 Medical therapy Yes 17 (71) 7 (29) No 0 3 (100) Medical surgical Therapy Length therapy ( and Yes 9 (100) No 8 (44) 10 (55) of <3 4 (50) 4 (50) 0.4 >3 13 (63) 10 (37)