Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ.
Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ.
J Hand Surg Am. 2023 Nov;48(11):1159.e1-1159.e10. doi: 10.1016/j.jhsa.2022.03.019. Epub 2022 May 28.
We analyzed patient demographic factors involved in the development of nonmarinum, nontuberculous mycobacterial infections (NTMI) involving the upper extremity, and assessed diagnostic and prognostic values of commonly used preoperative laboratory and imaging studies, as well as factors related to recurrence of disease and patient outcomes.
Patients from 2 academic, tertiary facilities with culture-proven, nonmarinum NTMI involving the upper extremity were reviewed. Patient-related factors and clinical outcomes were extracted. The analysis was based on pathogen identification (rapid- vs slow-growing subspecies) and immune status.
Our 76 patients had a mean age of 59 years, and 65% were male. Forty-eight percent reported an injury, and hands were frequently involved (58%). Forty-one percent were immunosuppressed (19% organ transplant recipients). The mean symptom duration prior to presentation was 203 days. The culture identification took a mean of 33 days, with 25 different species identified (subcategorized as rapid or slow growers). Seventy-seven percent had solitary lesions, with a cutaneous or subcutaneous location most common. Immunosuppressed patients were treated longer with antibiotics (243 vs 155 days in immunocompetent patients) and experienced higher rates of side effects, complications, and recurrence. All patients underwent debridement to control infection, including 4 individuals who required amputations. One-third experienced complications and/or recurrence, regardless of the organism type.
Upper-extremity nonmarinum NTMI is often misdiagnosed, causing management delays. Early consideration in differential diagnoses of chronic, painful swelling, nodular or inflammatory lesions, or septic arthritis is crucial. Tissue biopsy with specimens for histopathology and microbiological analysis (mycobacterial smear, cultures, and broad range polymerase chain reaction) and early involvement with an infectious disease specialist are recommended. Empiric antibiotic therapy is not standard. Debridement and prolonged, directed combination antimicrobial therapy is required; however, adverse reactions are commonly encountered.
TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.
我们分析了导致上肢非结核分枝杆菌感染（NTMI）的患者人口统计学因素，并评估了常用术前实验室和影像学研究的诊断和预后价值，以及与疾病复发和患者结局相关的因素。
我们对来自 2 家学术性三级医疗机构的经培养证实的上肢非结核分枝杆菌感染患者进行了回顾性分析。提取患者相关因素和临床结局。分析基于病原体鉴定（快速生长亚种与缓慢生长亚种）和免疫状态。
我们的 76 例患者平均年龄为 59 岁，65%为男性。48%有外伤史，手部经常受累（58%）。41%为免疫抑制者（19%为器官移植受者）。就诊前症状持续时间的平均值为 203 天。培养鉴定平均需要 33 天，共鉴定出 25 种不同的菌种（分为快速生长和缓慢生长亚种）。77%为单发病变，最常见的部位是皮肤或皮下组织。免疫抑制患者接受抗生素治疗的时间更长（免疫功能正常患者为 243 天，免疫抑制患者为 155 天），并且副作用、并发症和复发的发生率更高。所有患者均接受清创术以控制感染，其中 4 例患者需要截肢。三分之一的患者发生了并发症和/或复发，无论病原体类型如何。
上肢非结核分枝杆菌 NTMI 常被误诊，导致治疗延误。在慢性、疼痛性肿胀、结节或炎症性病变或化脓性关节炎的鉴别诊断中，应及早考虑。建议进行组织活检，包括组织病理学和微生物学分析（分枝杆菌涂片、培养和广泛聚合酶链反应），并尽早与传染病专家合作。经验性抗生素治疗并不标准。需要清创和长期、针对性的联合抗菌治疗，但常发生不良反应。
研究类型/证据水平：预后 IV 级。
