Disseminated Mycobacterium abscessus with bone and central nervous system (CNS) involvement − a case report and review of the literature

• Treatment of Mycobacterium Abscessus (M.abscessus) infection follows a complex course, with multiple antimicrobials required. There is a frequent need for changes due to adverse antimicrobial side-effects. • Most data cover the treatment of pulmonary disease; evidence for treating both vertebral osteomyelitis and CNS M.abscessus infection is therefore limited. • This case puts emphasis on the importance of source control in the management of disseminated M.abscessus infection. • Our patient is unusual in that he had auto-antibodies to only Granulocyte-macrophage-colony-stimulating-factor (GM-CSF); the literature describes only one other such patient. Mycobacterium abscessus (M.abscessus) is a rapidly growing mycobacterium with intrinsic multidrug resistance. Disseminated disease is usually diagnosed in those patients who are immunocompromised. There is currently limited data available that describe the optimal management of disseminated M.abscessus infection. M.abscessus is difficult to treat and involves a prolonged course of antibiotics in a combination regimen of at least four drugs, with many unwanted side effects. Surgical debridement and/or removal of prostheses/metalwork is essential in managing the infection in many cases. We describe a case of disseminated M. abscessus infection in a 64-year-old patient who initially presented with back pain, with spinal metalwork in situ. An MRI whole spine revealed infective spondylodiscitis at both T8-9 and L1-2 vertebral levels. M. abscessus was grown from two sets of blood cultures, and the patient was commenced on treatment for M. abscessus -associated vertebral osteomyelitis. He subsequently developed symptoms of a central nervous system (CNS) infection, and a lymphocytic meningitis was diagnosed, likely to also be caused by M. abscessus . His antibiotic regimen was revised for better CNS penetration, the patient clinically improved, and he was discharged. However, over the next year of follow-up, the patient developed a range of antibiotic-related side effects that eventually resulted in cessation of antibiotic therapy, and explantation of the spinal prosthesis. The patient made an excellent clinical recovery after this. A subsequent literature review includes 12 patients with vertebral osteomyelitis and 12 patients with CNS infection. Patient presentations, risk factors, treatment and outcomes are summarised. This case report and literature review enriches the knowledge regarding the appropriate management of disseminated M. abscessus infection (including prosthetic explantation when possible) and highlights key challenges likely to be encountered by clinicians.