P-005 YI Mycobacterium Marinum Infection in an Immunosuppressed Patient with Crohnʼs Disease

Abstract

Background: Crohn's disease is associated with several dermatologic manifestations, some of which may include facial involvement. While on immunosuppressant therapy, opportunistic infections may also manifest as facial lesions in some patients. We present a case of Mycobacterium marinum infection presenting as facial lesions in an immunosuppressed patient with Crohn's disease. Case Report: A 27-year-old Caucasian male with a history of inflammatory ileocolonic Crohn's disease with oropharyngeal involvement, presented to the emergency room with complaints of progressive facial swelling for 2 weeks. He received a diagnosis of Crohn's disease 7 years prior, and his course had been complicated with waxing and waning luminal symptoms along with refractory pyoderma gangrenosum of the lower extremities. He also was diagnosed with pyoderma faciale involving the nose, treated successfully with injected steroids and antibiotics. He was noted to have a positive tuberculin skin test in the past, and was treated for latent tuberculosis prior to starting immunosuppressive therapy. He was doing well while on infliximab and cyclosporine until he began noticing a rash and gradual swelling of his nose, lips and cheeks followed by erythema and slight ulcerations of these areas. He also developed recurrent oropharyngeal pain that was treated with short bursts of methylprednisolone. He subsequently developed progressive facial edema and low-grade fevers prompting an emergency room visit. Physical examination was remarkable for facial edema along with crusted, erythematous, fungating nodules with central umbilication along his bilateral cheeks, nose and upper lips. His temperature was 101.38F. He was admitted to the medical floor where an extensive infectious work-up was performed. The infliximab and cyclosporine were held and he received intravenous immune globulin. His facial lesions were thought to be secondary to recurrent pyoderma faciale, metastatic Crohn's disease, or an opportunistic infection secondary to immunosuppressant therapy. A shave biopsy of the left cheek was performed revealing pseudoepitheliomatous hyperplasia with parakeratosis and heavy mixed inflammatory infiltrate and exocytosis of inflammatory cells. Special stains for acid-fast bacilli were positive, and Mycobacterium marinum bacterium was isolated. The patient was started on therapy with minocycline followed by clarithromycin with marked clinical improvement. The infliximab was restarted after he developed migratory inflammatory arthritis, however the cyclosporine was discontinued. Discussion: There are several reports of atypical mycobacterial infections developing in patients receiving immunosuppressant therapy with infliximab and cyclosporine. Although the prevalence of Mycobacterium marinum is exceedingly rare, clinicians should be cognizant of this bacterium, especially in those immunosuppressed patients with a history of pyoderma faciale. Patients with Mycobacterium marinum infection can often be misdiagnosed with pyoderma faciale if appropriate cultures and stains for acid-fast bacilli are not requested. Misdiagnosis can lead to further continuation of immunosuppressive therapy with failure to initiate appropriate antibiotic treatment. Although it may be intuitive to stop immunosuppressive therapy in patients with opportunistic infections, the decision to stop therapy in patients with Mycobacterium marinum infection largely depends on whether there is clinical improvement of the lesions while on antibiotic therapy.