Non-tuberculous cutaneous mycobacterioses

Nogueira, Lais Bastos; Garcia, Carina Nogueira; Costa, Marcela Santos Corrêa da; Moraes, Monica Brauner de; Kurizky, Patrícia Shu; Gomes, Ciro Martins

doi:10.1016/j.abd.2021.04.005

Lais Bastos Nogueira

Hospital Universitário de Brasília, Universidade de Brasília, Brasília, DF, Brazil

https://orcid.org/0000-0003-4240-2035

Carina Nogueira Garcia

Hospital Universitário de Brasília, Universidade de Brasília, Brasília, DF, Brazil

https://orcid.org/0000-0001-9092-5952

Marcela Santos Corrêa da Costa

Postgraduate Program in Tropical Medicine, Universidade de Brasília, Brasília, DF, Brazil

https://orcid.org/0000-0002-0636-7941

Monica Brauner de Moraes

Hospital da Criança de Brasília José Alencar, Brasília, DF, Brazil

https://orcid.org/0000-0001-6805-3334

Patrícia Shu Kurizky

Hospital Universitário de Brasília, Universidade de Brasília, Brasília, DF, Brazil

Postgraduate Program in Medical Sciences, Universidade de Brasília, Brasília, DF, Brazil

https://orcid.org/0000-0002-5759-2727

Ciro Martins Gomes ^** Corresponding author. E-mail: cirogomes@unb.br (C.M. Gomes).

Postgraduate Program in Tropical Medicine, Universidade de Brasília, Brasília, DF, Brazil

Postgraduate Program in Medical Sciences, Universidade de Brasília, Brasília, DF, Brazil

https://orcid.org/0000-0002-3069-6884

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How to cite this article: Nogueira LB, Garcia CN, Costa MSC, Moraes MB, Kurizky PS, Gomes CM. Non-tuberculous cutaneous mycobacterioses. An Bras Dermatol. 2021;96:527-38.

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Study conducted at the Dermatology Service, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, DF, Brazil.

* Corresponding author. E-mail: cirogomes@unb.br (C.M. Gomes).

Conflicts of interest

None declared.

Authors’ contributions

Lais Bastos Nogueira: Conceptualization, creation, editing and finalization.

Carina Nogueira Garcia: Conceptualization, creation, editing and finalization.

Marcela Santos Corrêa da Costa: Creation, editing and finalization.

Monica Brauner de Moraes: Creation, editing and finalization.

Patrícia Shu Kurizky: Conceptualization, creation, editing and finalization.

Ciro Martins Gomes: Conceptualization, creation, editing, review, finalization, coordination, supervision.

Adverse Event	Conduct
Local and Regional
Ulcer > 1 cm	Clinical observation In the absence of cure: isoniazid (10 mg/kg/day, maximum dose of 400 mg) until complete regression. Follow-up for up to three months after treatment
Cold subcutaneous abscesses	Clinical observation Isoniazid (10 mg/kg/day, maximum dose of 400 mg) until complete regression. Follow-up for up to three months after treatment
Hot subcutaneous abscesses	Clinical observation Consider the presence of secondary infection and treat with antibiotic therapy for pyodermitis
Granulomas	Clinical observation In the absence of cure: isoniazid (10 mg/kg/day, maximum dose of 400 mg) until complete regression. Follow-up for up to three months after treatment
Nonsuppurative regional lymphadenopathy	Clinical observation
Suppurative regional lymphadenopathy	Clinical observation Isoniazid (10 mg/kg/day, maximum dose 400 mg) until significant reduction. Follow-up for up to three months after treatment
Keloid	Clinical observation
Lupoid reaction	Clinical observation Triple regimen with: isoniazid: 10 mg/kg/day; rifampicin: 10 mg/kg/day; ethambutol: 25 mg/kg/day for 2 months, followed by: isoniazid: 10 mg/kg/day and rifampicin: 10 mg/kg/day for four months
Disseminated Skin	Clinical observation Triple regimen with: isoniazid: 10 mg/kg/day; rifampicin: 10 mg/kg/day; ethambutol: 25 mg/kg/day for 2 months, followed by: isoniazid: 10 mg/kg/day and rifampicin: 10 mg/kg/day for four months
Osteoarticular	Clinical observation Triple regimen with: isoniazid: 10 mg/kg/day; rifampicin: 10 mg/kg/day; ethambutol: 25 mg/kg/day for 2 months, followed by: isoniazid: 10 mg/kg/day and rifampicin: 10 mg/kg/day for four months
Lymph nodes and single-organ involvement	Clinical observation Triple regimen with: isoniazid: 10 mg/kg/day; rifampicin: 10 mg/kg/day; ethambutol: 25 mg/kg/day for 2 months, followed by: isoniazid: 10 mg/kg/day and rifampicin: 10 mg/kg/day for four months
Generalized lesions affecting more than one organ	Clinical observation Triple regimen with: isoniazid: 10 mg/kg/day; rifampicin: 10 mg/kg/day; ethambutol: 25 mg/kg/day for two months, followed by: isoniazid: 10 mg/kg/day and rifampicin: 10 mg/kg/day for at least four months.

Clinical Aspects	Culture^a a The combination of liquid media, which allows faster and more solid growth, also allowing the growth of rarer mycobacteria, which should be used for the diagnosis of mycobacteriosis. The precise identification of mycobacteria can be achieved using molecular biology strategies.	Treatment^b b Monotherapy should be avoided to prevent the appearance of bacterial resistance. Treatment should follow a sensitivity test for mycobacteria whenever possible.
Mycobacterium marinum
Infection after contact with aquatic environments. Most cases have localized, papular-nodular lesions in the extremities, and there may be dissemination in immunosuppressed individuals.	Slow growing (Photochromogenic)	For limited infections, monotherapy with clarithromycin (500-1000 mg/day), doxycycline (100 mg/day), minocycline (100 mg 2× a day), and sulfamethoxazole 400 mg + trimethoprim 80 mg 2× a day can be used for at least three months. For severe infections, rifampicin (450-600 mg/day) and ethambutol (15 mg/kg/day) can be used.
Mycobacterium ulcerans
There is no confirmation of persistent sources of transmission in Brazil. Initial lesions appear as papules or nodules, progressing to relatively painless ulcers, despite evident and visible tissue destruction.	Slow growing (Achromogenic)	Combination of rifampicin (450-600 mg/day) and another active antibiotic such as clarithromycin (500-1000 mg/day), streptomycin (15 mg/kg/day) or quinolones for eight weeks (see current local or World Health Organization guidelines). Surgical intervention.
*Mycobacterium kansasii*
Immunosuppressed patients. Operative wounds, including the involvement of deep tissues and bone.	Slow growing (Photochromogenic)	Traditional antibiotics at the doses used against tuberculosis has shown to be effective. Rifampicin (450-600 g/day), isoniazid (300 mg/day), ethambutol (15 mg/kg/day).
Mycobacterium haemophilum
It rarely affects humans. It occurs after surgical procedures and in immunosuppressed patients.	Slow growing (Achromogenic)	Polychemotherapy containing clarithromycin (500-1000 mg/day), ciprofloxacin (500 mg 2× daily), and rifabutin (150-300 mg/day) are suggested.
Mycobacterium fortuitum, Mycobacterium abscessus, Mycobacterium chelonae
Papules, nodules, plaques and abscesses. Disseminated infections can occur, especially in immunosuppressed individuals.	Fast-growing	For localized infections, polychemotherapy with clarithromycin (500-1000 mg/day), azithromycin (250-500 mg/day), ciprofloxacin (500 mg 2× a day), levofloxacin (500 mg/day), doxycycline (100 mg/day), minocycline (100 mg 2× a day) or sulfamethoxazole 400 mg + trimethoprim 80 mg 2× a day is recommended for severe infections. Initial parenteral treatment followed by oral treatment for six months to one year may be necessary with polychemotherapy.

[1] ☆
How to cite this article: Nogueira LB, Garcia CN, Costa MSC, Moraes MB, Kurizky PS, Gomes CM. Non-tuberculous cutaneous mycobacterioses. An Bras Dermatol. 2021;96:527-38.

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