散发性皮肤非结核分枝杆菌感染37例回顾研究

Sporadic cutaneous infections due to nontuberculous mycobacteria: a retrospective study of 37 cases

目的:通过分析散发性皮肤非结核分枝杆菌(nontuberculous mycobacteria,NTM)感染的临床及病理特点,探讨皮肤NTM感染诊断方法的准确性及药物治疗原则。方法:回顾分析北京大学人民医院皮肤科门诊自2000年1月至2014年3月诊治的散发性皮肤NTM感染患者,病原学检查方法主要包括细菌培养鉴定及PCR扩增病损组织DNA分枝杆菌hsp65基因并鉴定。结果:共37例患者,30例为海分枝杆菌感染,6例为脓肿分枝杆菌感染,1例为龟分枝杆菌和偶发分枝杆菌感染,PCR法较细菌培养更为敏感;21例有外伤史,21例有养鱼史或海产相关工作史,1例有美容手术史。海分枝杆菌感染皮疹多表现为结节和浸润性斑块,沿淋巴管播散常见,脓肿分枝杆菌感染临床缺乏特异性,组织病理上常表现为感染性肉芽肿。海分枝杆菌感染患者多采用利福平、乙胺丁醇、克拉霉素二联或三联治疗,治愈率90.00%;6例脓肿分枝杆菌感染患者中4例治愈,1例死亡。结论:散发性皮肤NTM感染以海分枝杆菌感染最常见,外伤(包括美容或手术)及鱼类或海产接触为常见诱因;组织病理改变无致病菌特异性,确诊需有病原学诊断依据。海分枝杆菌感染的治疗可选用利福平、乙胺丁醇、克拉霉素中任两种联合治疗,脓肿分枝杆菌感染的治疗应依据药物敏感试验结果制定方案。

Objective： To study the clinical and pathological characteristics of sporadic cutaneous infections due to nontuberculous mycobacteria（ NTM）,and investigate the diagnostic criteria and therapeutic principal. Methods： Totally 37 cases of sporadic cutaneous infections due to NTM were confirmed in the Department of Dermatology,Peking University People＇s Hospital from January 2000 to March 2014.The microbiologic and clinical data were reviewed,and their skin biopsy specimens were reassessed. Results： Of all the 37 patients,30 cases were Mycobacterium marinum infection,6 were Mycobacterium abscessus infection,and one was Mycobacterium chelonea and Mycobacterium fortuitum infection. Identification of mycobacterial species by analysis of hsp65 gene in tissue DNA was more sensitive than traditional bacterial culture. The most common risk factors were traumatic injuries（ 21 of 37） and aquarium or fish-related job（ 21 of 37）. One case of Mycobacterium abscessus infection occurred after autologous fat filling. Nodule and plaque were most common lesions in Mycobacterium marinum infection. Twenty-four of the 30 cases of Mycobacterium marinum infection presented with multiple lesions or sporotrichoid spread lesions. Ulceration,papules,abscess,and purulent discharge were observed in cases of Mycobacterium abscessus infection. Infective granuloma was most common histopathological appearance. For the treatment of Mycobacterium marinum infection,rifampin,ethambutol,and clarithromycin were commonly used（ combination of two antibiotics,or three antibiotics）,with the cure rate 90. 00%. Four of the six Mycobacterium abscessus infections cases were cured,and one patient died. Conclusion： The most common species of sporadic cutaneous infections due to NTM is Mycobacterium marinum. Traumatic injuries,aquarium or fish-related job,and cosmetic surgeries are common risk factors. Mycobacterium marinum infection often presents with nodules,plaques,and sometimes sporotrichoid spread lesions. Lesions of Mycobacterium abscessus infection may vary. Pathological changes were not species specific,final diagnosis must be made depending on the identification of the microorganism. For the treatment of Mycobacterium marinum infection,excellent outcomes can be achieved by the combination of rifampin and ethambutol,and the combination of clarithromycin and rifampin or ethambutoland. Treatment regimens of Mycobacterium abscessus infection should be decided according to the results of antibiotic susceptibility testing.