Disseminated Mycobacterium chelonae infection: Complicating a case of hidradenitis suppurativa
A 28-year-old, married, male presented with complains of pain, discomfort and purulent discharge from both axilla and inguinal regions since 4 years duration with intermittent partial regression and relapse. He had been treated by general practitioners for all these years with systemic and local antibiotics without much relief. He also complained of low-grade intermittent fever, weight loss and weakness since 6 months.\nOn examination, suppurative nodules, plaques, and discharging sinuses were seen over both the axilla and inguinal region with involvement of the scrotum [Figures –]. The discharge consisted of cream colored pus without granules or any specific odour. In some areas there were healed lesions with scarring and fibrosis. Axillary and inguinal group of lymph nodes were palpable and non-tender. He had normal pulse rate, blood pressure, chest was clear and no organomegaly was seen. Laboratory investigations revealed hemoglobin 11.6 g%, TLC 9,000/mm3, Differential count showed N 64%; L 32%; E 3%; M 1%; ESR 60 mm in 1st hour and fasting blood sugar 230 mg/dl. Mantoux test was negative. Serum for VDRL and HIV tests was non-reactive. Chest X-ray was normal. Gram staining of the purulent discharge from the axilla and inguinal region showed the presence of Gram positive cocci in clusters []. Zeihl Neelsen (ZN) staining revealed the presence of acid fast bacilli []. The pus sample from all the four sites were inoculated separately in blood agar, MacConkey agar, Lowenstein-Jensen (LJ) media in duplicate, one covered with black paper to rule out scotochromogens and in SDA slants. After 48 h of incubation two types of colonies were seen on MacConkey agar media, which was found to be Gram positive cocci in clusters and acid fast bacilli. On the 6th day non-pigmented colonies were seen in LJ media which were found to be acid fast [] No growth was seen in SDA slants after 4 weeks of incubation. Both the organisms were identified as S. aurues and M. chleonae based on preliminary staining, growth characteristics and biochemical findings. M. chelonae and S. aureus were isolated from all the four sites from where samples were collected. Biopsy of the lesion showed foreign body type granulomas around the hair follicle with inflammatory cell infiltrate, fibrosis and destruction of appendageal structures suggestive of HS. Differential diagnosis of furnculosis, scrofuloderma, actinomycosis, lymphogranuloma venereum and granuloma inguinale were ruled based on microscopic findings of the pus, absence of genital ulcer as well as history of contact, no spread from bone or lymph node, or on any bony prominence, chronicity and bilateral nature of the lesions.\nThe lesions were drained after excision to provide local relief to the patient. The infection was treated with clarithromycin (500 mg) twice daily for 12 weeks, injection tobramycin (16 mg) twice daily for 2 weeks along with local application of mupirocin. The discharge was sterile on culture after 2 weeks of treatment. Isotretinoin (40 mg daily in two divided doses), dapsone (100 mg daily) and zinc gluconate (200 mg daily) were given for 6 months. He was also given insulin as his fasting blood sugar was high. The lesions showed signs of regression with disappearance of the distressing symptoms like tenderness, swelling and discharge.