In November 2009, two cases of mycobacterium haemophilum – one confirmed, one suspected – were reported in Seattle. Both cases resulted after the individuals, who were otherwise immunocompetent, had gotten tattoos at the same tattoo parlor. Now, a new report in the Journal of Emerging Infectious Diseases analyzes the two cases, providing findings that can serve as guidelines for dermatologists.
The patient with the confirmed case of M. haemophilum first went to his physician 12 days after a rash appeared at the site of his new tattoo and after application of antibacterial ointment did not resolve the problem. When courses of ceftriaxone and trimethoprim/sulfamethoxazole did not improve the patient’s rash, clindamycin was prescribed, but this next course of medication was still not effective in treating the rash. Finally, treatment with rifampin, ciprofloxacin and clarithromycin led to improvement of the rash, although healing papules and erythema were still present. The regimen of three prescriptions was eventually discontinued because of nausea, but the rash still healed entirely. In all, it took a total of 9 months for the patient’s rash to heal completely.
The suspect case of M. haemophilum actually occurred before the patient with the confirmed case. The suspect case also occurred in an immunocompetent male patient who received a tattoo from the same parlor. This second patient suffered from a pustulo-nodular skin infection that was confined to shaded areas of the tattoo, but standard aerobic bacterial or mycobacterial cultures did not recover any organisms, leading this case to be classified as suspected, not confirmed.
The researchers issued a number of recommendations in their review. The primary suggestion in the review directs dermatologists to consider M. haemophilum in the differential diagnosis of skin infections that occur at the site of a tattoo shortly after the tattoo is completed, particularly in patients who do not respond to antimicrobial drugs and regardless of the patient’s immune status. Physicians who treat M. haemophilum patients with healthy immune systems are also advised to use multi-drug regimens, including clarithromycin, rifampin, rifabutin and ciprofloxacin; the authors add that amikacin seems to be active in vitro.
The review is available online for dermatologists interested in reading the review in full.
