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Mucocutaneous and Soft Tissue Infections Caused by Xanthomonas maltophilia: A New Spectrum

Shahe E. Vartivarian, MD; Konstantinos A. Papadakis, MD; Jose Antonio Palacios, MD; John T. Manning, MD; and Elias J. Anaissie, MD
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From The University of Texas M.D. Anderson Cancer Center, Houston, Texas. Requests for Reprints: Shahe E. Vartivarian, MD, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 47, Houston, TX 77030. Grant Support: In part by a grant from Merck, Sharp, & Dohme.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1994;121(12):969-973. doi:10.7326/0003-4819-121-12-199412150-00011
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Objective: To describe the mucocutaneous and soft tissue infections caused by Xanthomonas maltophilia in patients with cancer.

Design: A retrospective 15-month clinical study.

Setting: Academic, referral-based cancer center.

Patients: Of 237 patients with X. maltophilia isolated from all sites during the 15-month study period, 114 patients were judged to have true X. maltophilia infections. Only patients with mucocutaneous and soft tissue infections were included in the study.

Results: 17 (15%) of the 114 patients with X. maltophilia infection had mucocutaneous and soft tissue infections: Six patients had metastatic cellulitis, 5 had primary cellulitis usually associated with catheter use, and 6 had infected mucocutaneous ulcers. The metastatic cellulitis consisted of previously undescribed multiple, hard, tender nodules with surrounding and distant cellulitis (5 patients) or ecthyma gangrenosum (1 patient). Four of these patients died of the infection. Metastatic cellulitis and mucocutaneous infections occurred in hospitalized, neutropenic patients who received broad-spectrum antibiotics (β-lactams, quinolones), often with in vitro activity against the infecting organisms. Response usually correlated with recovery from myelosuppression and administration of trimethoprim-sulfamethoxazole with or without ticarcillin-clavulanate. Catheter removal contributed to response in the treatment of primary cellulitis.

Conclusions: Mucocutaneous and soft tissue infections caused by X. maltophilia are not uncommon, and X. maltophilia can cause metastatic nodular skin lesions that mimic disseminated fungal infections. It also causes serious morbidity and high mortality in patients with metastatic skin nodules and can cause superinfections in patients receiving broad-spectrum β-lactam or quinolone antibiotics to which the organisms are susceptible when the infections develop. Catheter removal contributes to a favorable outcome in patients with catheter-associated cellulitis without bacteremia. Xanthomonas maltophilia infection should be added to the differential diagnosis of mucocutaneous or soft tissue infection in patients with cancer. Trimethoprim-sulfamethoxazole with or without ticarcillin-clavulanate is the current treatment of choice for culture-proven infections, but early empiric therapy may improve outcome.


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Figure 1.
Metastatic Xanthomonas maltophilia cellulitis. Top.Bottom.X. maltophilia

Hard, nonfluctuant, warm, tender, erythematous nodule of the inner surface of the thigh of a patient with acute leukemia (central portion of figure). Another nodular lesion in the same patient in which black central necrosis developed. Cultures from biopsy specimens from these lesions grew .

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Figure 2.
Histopathologic changes of metastatic Xanthomonas maltophilia skin lesions in two patients with acute leukemia.Top left.Top right.Bottom left.Bottom right.

Nodular lesion: intense inflammatory cell infiltrate extending from the dermis to the subcutaneous tissue with minimal necrosis (hematoxylin and eosin; magnification, × 170). Nodular lesion: neutrophilic and lymphocytic infiltration with swelling of endothelial cells (hematoxylin and eosin; magnification, × 350). Ecthyma gangrenosum: coagulation necrosis of the dermis with fibrin thrombi within blood vessels and minimal or absent inflammatory infiltrate (hematoxylin and eosin; magnification, × 170). Ecthyma gangrenosum: numerous gram-negative rods within the blood vessel walls and perivascular connective tissue (Gram stain; magnification, × 560).

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