Mycobacterial skin infections

404 Pages·2017·17.295 MB·English

by  Angelini, Gianni, Bonamonte, Domenico

Mycobacterial
Skin Infections
Domenico Bonamonte
Gianni Angelini
Editors
123
Mycobacterial Skin Infections
Domenico Bonamonte • Gianni Angelini
Editors
Mycobacterial Skin
Infections
Editors
Domenico Bonamonte Gianni Angelini
University of Bari “Aldo Moro” University of Bari “Aldo Moro”
Department of Biomedical Science and Dermatology
Human Oncology Bari
Bari Italy
Italy
English editing by Mary VC. Pragnell, B.A. (HONS).
ISBN 978-3-319-48537-9 ISBN 978-3-319-48538-6 (eBook)
DOI 10.1007/978-3-319-48538-6
Library of Congress Control Number: 2017951315
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To Davide
Elizabeth
Gianmarco
Preface
The overview of mycobacterial skin infections presented in this work is justified by
the current worldwide increase in diseases induced by both old and new mycobac-
teria. Until the late 1980s, such diseases had been notably declining, but after that
period, the trend reversed, and an exponential increase began to be observed. There
are various reasons for this rise not only in developing countries but even in urban
areas in the most developed nations.
Being the cause of tuberculosis and leprosy, the Mycobacterium genus has prob-
ably caused mankind more suffering than all the other bacterial genera combined.
Moreover, in addition to the obligate pathogens, namely, the Mycobacterium tuber-
culosis complex and M. leprae, this genus is continually being enriched by the addi-
tion of many other species. Although usually encountered as environmental
saprophytes, in some conditions that depend on the host immune status, they can
induce extremely severe, sometimes fatal, clinical pictures.
It is well known that tuberculosis (TB) is one of the oldest diseases ever to affect
mankind, but nowadays, it is emerging once more as an enormous and growing
global health problem.
According to the World Health Organization (WHO) (Global Tuberculosis
Report 2016, World Health Organization), in 2015 there were an estimated 10.4
million new (incident) TB cases worldwide, of which 5.9 million (56%) were among
men, 3.5 million (34%) among women, and 1.0 million (10%) among children.
HIV-infected people accounted for 11% of all new TB cases. Six countries accounted
for 60% of the new cases: in descending order, India, Indonesia, China, Nigeria,
Pakistan, and South Africa.
The rate of decline in TB incidence remained worldwide at only 1.5% from 2014
to 2015. This need to accelerate to a 4–5% annual decline by 2020 to reach the first
milestones of the End TB Strategy. The WHO End TB Strategy (approved by the
World Health Assembly in 2014), in fact, calls for a 90% reduction in TB deaths and
an 80% reduction in the TB incidence rate by 2030, compared with 2015.
According to many authors, the high present TB incidence is attributable to
increased levels of poverty in our overpopulated world, to the breakdown of health-
care systems and to the impact of the HIV/AIDS pandemic. Further complicating
the situation, there has been a worrying rise in multidrug-resistant TB (MDR-TB)
(defined as resistance to isoniazid and rifampicin), and now we also face the recent
emergence of extensively drug-resistant TB (defined as resistance to many other
vii
viii Preface
drugs). In 2015, there were an estimated 580,000 new cases of MDR-TB. India,
China, and the Russian Federation accounted for 45% of the combined total of
580,000 cases. The WHO estimated that in 2015 there has been 1.4 million TB
deaths and an additional 0.4 million deaths resulting from TB infection among HIV-
infected people. Although the number of TB deaths fell by 22% between 2000 and
2015, TB remained one of the top 10 causes of death worldwide in 2015.
Extrapulmonary TB manifests only in 8.4–13.7% of cases, while cutaneous TB
comprises only a small proportion (<1–2%) of all cases of TB. All the same, in view
of the current high prevalence of TB worldwide, these numbers become significant.
Assuming that 1% of all cases of TB will have cutaneous involvement, dermatolo-
gists in countries such as India, where 1,847,000 new cases of TB were reported in
1999, must expect to see an annual incidence of about 18,000 cases of cutaneous
TB. In any event, factors such as HIV infection and migration are ensuring that
cutaneous TB will necessarily have to be included in differential diagnosis made by
dermatologists all over the world.
Apart from M. tuberculosis, TB in man is induced also by M. bovis, which has a
greater number of potential hosts than the tubercle bacillus. Various studies have
shown that 0.3–1.5% of TB in humans is due to M. bovis in developed countries.
Due to inappropriate methods for identifying the pathogen, in developing countries
the incidence is unknown, but is most likely higher than in industrialized countries.
In 1992, the European Union declared infection by M. bovis one of the four most
important zoonoses (European Union. Council Directive 29/117/EEC, 1992. Off J
Eur Comm 1993; L62:38), and in 1995, the WHO labeled the infection a global
emergency (Guidelines for speciation within the Mycobacterium tuberculosis com-
plex. Geneva: World Health Organization, 1995). Among the various modes of
transmission of this organism to man (respiratory, gastrointestinal), we must include
direct skin contact that occurs mainly in some occupational fields.
Meanwhile, the modes of transmission of M. leprae are still not fully understood.
There is solid evidence of transmission among contacts, as well as of zoonotic lep-
rosy in southern states in the USA. Current findings suggest that aerosols/droplets
and shedding of bacteria in the environment, as well as skin-to-skin contact, are
possible culprits. Globally, the number of leprosy cases is now below the elimina-
tion threshold of 1 case/10,000 people, as defined by the WHO. In various countries
and subnational regions, however, the number of leprosy patients is still above this
threshold. Moreover, despite the near-universal use and efficacy of multidrug ther-
apy, the annual number of newly detected cases has remained fairly constant at
around 200,000–300,000 cases in the last years. This demonstrates that the current
control measures are insufficient to arrest the process of leprosy transmission.
The experience we gained over several years of assiduous attendance of the
Hansenian Colony in Gioia del Colle (Bari, Italy), one of the largest in Europe, vali-
dated by clinical-therapeutic studies of the disease, has been of inestimable aid in
writing the relative chapter about leprosy.
To compound the issue, nontuberculous mycobacteria (NTM) are common in
nature, and, except perhaps in extreme environments such as deserts and polar
regions, humans are regularly exposed to them. Unlike the obligate pathogens,
Preface ix
NTM may occur as transient commensals on the skin and in various other organs
(the pharynx, lower urethra, gastrointestinal tract), so their isolation does not neces-
sarily indicate the presence of disease. The pathogenicity of NTM is directly cor-
related to the host immune system, and in fact since the 1930s, many species have
been strongly associated with some human diseases. The development of new diag-
nostic tools has resulted in a huge increase in the number of infections associated
with specific species, as well as the number of new species identified as causal
agents. NTM can cause a vast spectrum of diseases that are often quite difficult to
diagnose. A high suspicion index is important, and the diagnostic conclusions must
be based on a number of microbiological and radiological investigations. It must
also be borne in mind that the search for bacilli in various clinical specimens may
not always be positive. Even histopathology is not definitive because granulomatous
tubercle findings are rare, whereas nonspecific inflammatory aspects are common.
The aim of this work is, therefore, to offer dermatologists a tool to help them
recognize the different clinical mycobacterial manifestations, make a prompt diag-
nosis, and institute effective treatment. Unfortunately, older dermatologists tend to
have become less familiar with these very important diseases in recent decades,
while younger dermatologists have perhaps never encountered them before. By
contrast, the current globalization process, and all its accompanying implications as
regards infectious diseases that may be more or less widespread in the different
countries, “demands” as wide as possible a knowledge of these among clinicians.
Bari, Italy Gianni Angelini, MD
May 2017 Domenico Bonamonte, MD, PhD
Acknowledgments
This book has been produced thanks also to the valuable contributions of various
colleagues, to whom go our most grateful thanks.
Professor Roger Pradinaud, chairman of the Dermatology Service of the Andrée
Rosemon Hospital, Cayenne (French Guyana), a great expert on tropical dermatol-
ogy, offered valuable information about Mycobacterium ulcerans infection: his
wise suggestions and in-depth knowledge of the subject, illustrated in numerous
publications, provided us with inestimable guidance. We are also grateful to
Professor Roger Pradinaud for clinical images of this disease.
Professor Giorgio Leigheb, former chairman of the Dermatological Clinic of the
University of Novara (Italy), famous entomological dermatologist and great friend,
kindly provided us with various clinical images of Mycobacterium ulcerans infec-
tion, a topic that he has studied widely in the nations with the highest incidence of
this infection.
Doctors Angela Filoni, Paolo Romita, Pietro Verni, and Michelangelo Vestita, of
the Dermatological Clinic of Bari University Hospital (Italy), contributed enor-
mously with their enthusiasm and skill to the completion of this work.
We would like to thank the publishers Springer-Verlag (Berlin), Cambridge
University Press (Cambridge, UK), and Piccin (Padova, Italy) and John Libbey
Eurotest, editor of the European Journal of Dermatology (Montrouge, France), for
having kindly authorized the reproduction of various figures.
Finally, we are very grateful to Springer-Verlag for their assiduous commitment
to producing this volume.
Gianni Angelini
Domenico Bonamonte
xi
Contents
1 Mycobacteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Domenico Bonamonte, Paolo Romita, Pietro Verni,
and Gianni Angelini
2 Cutaneous Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Domenico Bonamonte, Angela Filoni, Pietro Verni,
and Gianni Angelini
3 Mycobacterium bovis Skin Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Domenico Bonamonte, Angela Filoni, and Gianni Angelini
4 Bacillus Calmette-Guérin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Domenico Bonamonte, Angela Filoni, and Gianni Angelini
5 Leprosy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Domenico Bonamonte, Angela Filoni, Pietro Verni, Paolo Romita,
and Gianni Angelini
6 Nontuberculous Mycobacteria and Skin Infection . . . . . . . . . . . . . . . 277
Domenico Bonamonte, Pietro Verni, and Gianni Angelini
7 M ycobacterium scrofulaceum Infection . . . . . . . . . . . . . . . . . . . . . . . . . 297
Domenico Bonamonte, Pietro Verni, and Gianni Angelini
8 R apidly Growing Mycobacteria and Skin Infection . . . . . . . . . . . . . . 305
Domenico Bonamonte, Angela Filoni, Pietro Verni,
and Gianni Angelini
9 Mycobacterium marinum Skin Infection . . . . . . . . . . . . . . . . . . . . . . . . 325
Domenico Bonamonte, Angela Filoni, Michelangelo Vestita,
and Gianni Angelini
10 Mycobacterium ulcerans Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Domenico Bonamonte, Angela Filoni, and Gianni Angelini
11 Other Nontuberculous Mycobacteria and Skin Infection . . . . . . . . . . 389
Domenico Bonamonte, Pietro Verni, and Gianni Angelini
xiii