Disseminated folliculitis by Mycobacterium fortuitum in an immunocompetent woman
A 32-year-old woman who worked as a nurse in hospitals in Maringá, Parana, Brazil, suffered from erythema nodule-type lesions with some cold abscesses. The lesions had diameters ranging from 5 to 30 mm, on the trunk and on the upper and lower members, with an evolution of approximately 60 days (). At first, the patient was treated with cephalexin 500 mg four times daily, for furunculosis, and later, with ciprofloxacin 500 mg orally twice daily for 14 days, with no improvement. Puncture and drainage of certain lesions were undertaken and specimens submitted to culture. Results were negative for aerobic bacteria and facultative anaerobic ones. The patient was then treated with rifampicin 600 mg orally twice daily and tetracycline 500 mg, four times daily, for 30 days, without any clinical improvement. The patient underwent biopsy for pathological test and culture for Acid-Fast Bacilli (AFB), fungi and pyogenic bacteria. Complementary tests, such as hemoculture, Hemogram, Aspartate Aminotranspherase (AST), Alanine-aminotranspherase (ALT), Urea, Createnin, Hemosedimentation speed, Antinuclear Antibodies (ANA), serology for HIV, Hepatitis C and B (HBs Ag, Anti-HBc, Anti-HBs), acid Alpha 1-glycoprotein, Immunoglobulins (IgE, IgA, IgG, IgM), Rheumatoid factor, Reactive Protein "C", Complement C3 and C4, CD4/CD8, were performed. The pathological test indicated deep perforating and suppurating folliculitis surrounded by a granulomatous and suppurating inflammatory process typifying a foreign body, coupled to a superficial and perivascular limphohistoplasmocytarian infiltrate and to a deep periadnexal infiltrate. Direct research for fungi and AFB showed negative results. Culture for AFB was positive in less than seven days at 30ºC and 35ºC. No growth of other bacteria occurred. Identification of AFB isolate was undertaken by Restriction Fragment Length Polymorphism Analysis (PCR-PRA) as Mycobacterium fortuitum complex. No complementary test produced any changes that would justify involvement of other infectious pathogens. The patient underwent treatment using intravenous amikacin 1 g, three times weekly, clarithromycin 500 mg orally twice daily, during 12 weeks. Afterward monotherapy was maintained with clarithromycin 500 mg twice daily for 12 months. The elapsed time from first medical appointment until the beginning of therapy that achieved regression of lesions was approximately two months. By the end of treatment the patient experienced total regression of skin lesions with no recurring factor up to the present.