A comparison of CFZ containing MDR-TB regimens against pyrazinamide (PZA) containing regimens found that CFZ regimens resulted in more hyperpigmentation and less arthralgia. Certain members of the M. abscessus complex such as M. abscessus subsp. An outbreak of cutaneous infection due to Mycobacterium abscessus associated to mesotherapy. Although outbreaks of Mycobacterium abscessus infection have been reported, none of these reports has identified the potential sources of infection and modes of transmission. Symptoms includes skin infection usually red, warm, tender to the touch, swollen and painful, fever, chills, muscle aches. This Mycobacterium includes pathogens known to cause serious diseases in mammals. This article reviews the dermatologic manifestations of Mycobacterium avium-intracellulare (MAI, or MAC) infection.. MAI is an opportunistic pathogen that usually causes disease in the weakened immune system. Insulin injection abscesses occur in patients with diabetes and are mainly due to Staphylococcus aureus . Mycobacterium abscessus is a rapidly growing mycobacterium that has been affecting people undergoing invasive procedures, such as videosurgery and mesotherapy. M. abscessus: Mycobacterium abscessus complex is a group of rapidly growing, multidrug-resistant, nontuberculous mycobacteria. Diagnosing skin and soft tissue infections due to rapidly growing mycobacteria (RGM) can often prove difficult, leading to delays in treatment. The risk factors leading to this increased prevalence may coincide with the increased use of azithromycin in CF patients. M.abscessus is a nontuberculous mycobacterium (NTM). bolletii contain an inducible erythromycin methylase erm gene that confers resistance to macrolides; therefore these drugs should always be given in a combination therapy (American Thoracic Society, 2007; Brown-Elliott et al., 2012). Other signs of mycobacterium abscessus infection are fever, chills, muscle aches, and a general feeling of illness. Persons infected with this bacterium are generally advised to inform the diagnosing physician of the nature and location of any recent procedures. Treatment of Mycobacterium abscessus Infection Side effects were common; 74 side effects were docu-mented among 34 (62%) of 55 patients who received treat-ment. These lesions may be asymptomatic or pruritic, tender, or both. Mycobacterium abscessus is a rapidly growing mycobacterium that has been affecting people undergoing invasive procedures, such as videosurgery and mesotherapy. Mycobacterium abscessus infections are challenging to treat because multidrug resistance necessitates prolonged intravenous (IV) therapy and side effects are perceived to be common. In severe cases, the mycobacterium can enter the bloodstream and lead to systemic infection. It is also one of the mycobacteria that are most often isolated from cystic fibrosis patients. Lesions present as firm, painless, subcutaneous nodules that gradually enlarge and suppurate, then form ulcers and sinus tracts in overlying skin. abscessus, M. abscessus subsp. Although M. abscessus complex most commonly causes chronic lung infection and skin and soft tissue infection (SSTI), the complex can also cause infection in almost all human organs, … In Meyler's Side Effects of Drugs (Sixteenth Edition), 2016. Cutaneous Mycobacterium abscessus Infection Associated with Mesotherapy Injection @article{Wongkitisophon2011CutaneousMA, title={Cutaneous Mycobacterium abscessus Infection Associated with Mesotherapy Injection}, author={Pranee Wongkitisophon and P. Rattanakaemakorn and Somsak Tanrattanakorn and V. … 1 2 The incidence of infections caused by nontuberculous mycobacteria has increased significantly, 3–5 while the incidence of M. chelonae remains unknown. Background. However, NTM infection is often wrongly diagnosed initially causing prolonged suffering. It is a well-documented cause of pulmonary infection in patients with structural lung disease such as cystic fibrosis, and can cause skin and soft tissue infections in hospitalised post-surgical … However, 55.6% were due to M. abscessus and associated with a sharper decline in FEV1. Bechara C, Macheras E, Heym B, Pages A, Auffret N. Mycobacterium abscessus skin infection after tattooing: first case report and review of the literature. Most common were nausea/vomiting (n = 17, 31%) and skin changes (n = 11, 20%) (Table 2). chelonae [3†]. The frequency of published reports of infection by rapidly growing mycobacteria associated with tattooing procedures has increased in recent years. A 6-year-old child treated for XDR-TB spondylodiscitis with moxifloxacin + CFZ + linezolid (LNZ) + isoniazid (INH) + amoxicillin-clavulanate + para-aminosalicylic acid + capreomycin reported no adverse drug events following 18 months of treatment [25A]. The discriminating clinical characteristic of RGM skin lesions is their appearance 1 to 2 weeks after exposure. 6 The risk of tuberculosis infection with ustekinumab has been compared with anti-TNF agents [infliximab and golimumab] across … Termed “corneal lepromas,” they are composed of foamy histiocytes known as Virchow cells containing clusters of numerous acid-fast organisms (see Fig. The RGM make up Runyon's group IV: They produce colonies on subculture in 7 days or less. DOI: 10.1159/000324766 Corpus ID: 16105781. Background on this bacterium Mycobacterium abscessus is one of the rapidly growing mycobacteria (Runyon group IV), which are ubiquitous in the environment and also include Mycobacterium fortuitum and Mycobacterium chelonei. Nocardiaare weakly acid-fast bacteria and can be visualised by the modified Kinyoun acid-fast stain comparable to the Ziehl-Neelsen stain used to visualise mycobacteria. There are no case reports delineating the natural history of RGM-borne disease, nor are there any data regarding clinical presentation among immunocompromised patients. Recent reports cite the transmissibility of M. abscessus among CF patients at care centers in the United States and United Kingdom.132,133 Gross and colleagues134 at Tripler Army Medical Center Hospital (Hawaii) described an outbreak among a large portion of their CF cohort. Here we report a case of injection abscesses due to an atypical mycobacterium, Mycobacterium chelonae . Infectious involvement of the cornea by Mycobacterium leprae can manifest with nonspecific findings, such as fibrovascular pannus formation and interstitial keratitis. Mycobacterium abscessus (M. abscessus) is a non-tuberculous mycobacterium widely present in the natural environment and is now being increasingly identified as a cause of human disease. [] Although the prevalence of MAI infection has increased following the epidemic of acquired immunodeficiency syndrome (AIDS), MAI infection remains a rare cause of skin disease. More generalized symptoms can include feelings of malaise, chills, fever, and muscle aches. Overall, the CFZ containing regimens caused hyperpigmentation, arthralgia, and gastrointestinal intolerance; however, this was confounded by multiple other drugs within the regimen [24C]. 1. Skin biopsies of cutaneous lesions to identify acid-fast staining bacilli and cultures represent the cornerstone of … Infected areas can also develop boils or pus-filled vesicles. chelonae and M. abscessus were formerly considered the same organism, but in 1992 they were reclassified as independent species. Mycobacterial tenosynovitis is a rare condition. Infections with Mycobacterium abscessus can often cause serious symptoms. The most commonly implicated pathogens belong to Runyon Group IV and include Mycobacterium abscessus, Mycobacterium chelonae, Mycobacterium fortuitum, and Mycobacterium smegmatis, which are characterized by their rapid growth and lack of pigmentation. Certain slow-growing species of mycobacteria, namely Mycobacterium marinum, M. ulcerans, M. chimaera,andM. Mycobacterium abscessus infection control is important to protect the lungs. 4 Mycobacterium chelonae/abscessus skin infections are commonly associated with penetrating injury or surgery. It is commonly associated with contaminated traumatic skin wounds and with post‐surgical soft tissue infections. The results of environmental investigation suggest the most likely cause of the outbreak could have been the contamination of the products in the … Anna M. Stagner, ... Norman C. Charles, in Diagnostic Pathology of Infectious Disease (Second Edition), 2018, Isolated mycobacterium tuberculosis infections of the cornea are uncommon (the uvea is the most common site of ocular tuberculosis infection). Wikibuy Review: A Free Tool That Saves You Time and Money, 15 Creative Ways to Save Money That Actually Work. The rapidly growing mycobacteria (RGM)—Mycobacterium abscessus, Mycobacterium chelonae, and Mycobacterium fortuitum—are increasingly recognized causes of skin infections. Skin and soft tissue infections are the most common pre- sentation for the rapid-growing speciesMycobacterium fortuitum, M. abscessus,andM. Cutaneous Mycobacterium abscessus Infection Associated with Mesotherapy Injection @article{Wongkitisophon2011CutaneousMA, title={Cutaneous Mycobacterium abscessus Infection Associated with Mesotherapy Injection}, author={Pranee Wongkitisophon and P. Rattanakaemakorn and Somsak Tanrattanakorn and V. … Mycobacterium abscessus (M. abscessus) is a rapidly growing mycobacterium widely present in the natural environment, such as in the soil and water (1, 2). Because continuing linezolid therapy was required, oral vitamin B6 50 mg/day was administered in an attempt to mitigate the cytopenia. Mycobacterium abscessus subspecies massiliense infection after skin graft and cholecystectomy in a burn patient. Mycobacterium abscessus is a nonchromogenic and rapidly growing mycobacteria that is found in the environment. We report a case of a skin ulcer associated with M. abscessus in a spa worker. Mycobacterium chelonae is a rapid growing, nontuberculous mycobacterium.M. The typical treatment regimen for MABSC involves an intensive phase followed by a continuation phase. It is increasingly being identified as a cause of human disease, particularly as an agent of cutaneous and soft-tissue infections, pulmonary infections, and disseminated disease associated with … 2. In April 2008, we identified and investigated an outbreak of M. abscessus skin and soft tissue This article reviews the dermatologic manifestations of Mycobacterium avium-intracellulare (MAI, or MAC) infection.. MAI is an opportunistic pathogen that usually causes disease in the weakened immune system. Objective To compare the demographics, clinical features, susceptibility patterns, and treatment for skin and soft tissue infections due to Mycobacterium fortuitum and Mycobacterium chelonae or Mycobacterium abscessus.. Design Retrospective medical record review.. Human diseases include pulmonary infections and skin, soft tissue, and bone infections that usually develop following trauma, surgery, or postinjection. A 43-year-old woman with diabetes … Skin infected with mycobacterium abscessus is usually red, warm, tender to the touch, swollen, and/or painful. Mycobacterium Abscessus One such infection, which is becoming more common worldwide among those with cystic fibrosis, is Mycobacterium abscessus, a bacterium found in soil and water which is distantly related to Mycobacterium tuberculosis, which causes tuberculosis. The first, Washington cluster 1, had three confirmed Mycobacterium abscessus cases and 24 possible cases in persons tattooed with black ink from company B. Patients with these predisposing factors are usually younger than 40 years. When the specific medication causing a side effect was known, it was most com- If one of these organisms is recovered on routine culture, and the Gram stain shows Gram-positive bacilli, the organism may be incorrectly reported as diphtheroids, with no further workup. As noted previously, azithromycin is preferred over clarithromycin and there is some evidence to suggest it is associated with better treatment outcomes in non-CF adults.101 The duration of the intensive phase will be determined by the severity of disease, the response to therapy, and the tolerability of the regimen. DOI: 10.1159/000324766 Corpus ID: 16105781. Current therapeutic guidelines for the infection … Patients All patients seen at our institution with a positive culture for M … 13, 14 We postulate that our patient may have acquired M. abscessus skin infection through direct inoculation from soil exposure during gardening. Stacey L. Martiniano MD, ... Charles L. Daley MD, in Kendig's Disorders of the Respiratory Tract in Children (Ninth Edition), 2019, Treatment of pulmonary disease due to MABSC is complicated because of significant levels of in vitro resistance, the need for intravenous antibiotics, common adverse reactions, and generally poor treatment outcomes. We use cookies to help provide and enhance our service and tailor content and ads. Patients with lung disease due to M. abscessus are usually white, female nonsmokers, older than 60 years without particular predisposing factors. Mycobacterium abscessus is the most pathogenic and chemotherapy‐resistant rapid‐growing mycobacterium. The intensive phase should include 3–12 weeks of intravenous amikacin, plus one or more of the following agents: intravenous tigecycline, imipenem, or cefoxitin.19,20 This regimen should also include oral drugs for which some degree of in vitro activity has been demonstrated. Mycobacterium abscessus Skin infected with M. abscessus is usually red, warm, tender to the touch, swollen, and/or painful. As described previously, MABSC can be divided into three subspecies: M. abscessus, M. massiliense, and M. bolletii. CFZ therapy often results in gastrointestinal AEs along with skin and fluid discoloration. The infected area may be warm. These patients should generally be managed in collaboration with an expert in the treatment of NTM disease. A curative therapy may include surgical resection of focal (lung) involvements and/or a combined multidrug therapy with macrolides and amikacin, cefoxitin, or imipenem. Mycobacterium abscessus, Mycobacterium fortuitum, and Mycobacterium chelonae are the most prevalent RGM causing human disease, and almost all RGM-related diseases are caused by one of these three species. The frequency of published reports of infection by rapidly growing mycobacteria associated with tattooing procedures has increased in recent years. Mycobacterium abscessus (MAB) is a rapidly growing mycobacterial species that causes a wide spectrum of human infections,91 including lung, skin and soft tissue infection, disseminated infection, lymphadenitis, postoperative catheter-related infection, and bone and joint infection. The safety of CFZ was reviewed in a cohort of 112 adult and pediatric patients, including cystic fibrosis patients. The patient had significant improvement of symptoms with the use of clarithromycin monotherapy. Key words: botulinum toxin; Mycobacterium abscessus; nontuberculous mycobacterium. Treatment of Mycobacterium abscessus Infection Side effects were common; 74 side effects were docu-mented among 34 (62%) of 55 patients who received treat-ment. In April 2008, we identified and investigated an outbreak of M. abscessus skin and soft tissue infections following acupuncture among the patients who visited an oriental medical clinic. Other signs of mycobacterium abscessus infection are fever, chills, muscle aches, and a general feeling of illness. Mycobacterium is a genus of Actinobacteria, the Mycobacteriaceae. Predisposing conditions that are commonly associated with M. abscessus pulmonary infections are bronchiectasis with reticulonodular lung infiltration, cystic fibrosis, lipoid pneumonia, gastrointestinal disorders with chronic vomiting. Mycobacterium abscessus is not considered contagious from person to person, and usually enters the body through a break in the skin. Whether a macrolide should be included in the regimen for M. abscessus or M. bolletii is debatable given the presence of an erm41 gene in most strains. Kevin L. Winthrop, Emilie Emilie Roy, in Handbook of Systemic Autoimmune Diseases, 2020. Outbreaks of cutaneous infections secondary to M. abscessus have been well-described, following surgical procedures or environmental exposures. In April 2008, we identified and investigated an outbreak of M. abscessus skin and soft tissue infections following acupuncture among the patients who visited an oriental medical clinic. All but two cases involved exit-site infections, however the remaining two cases developed peritonitis with M. abscessus as the causative organism [15c]. These organisms can grow rapidly enough that they are recovered in routine culture. However, specific to the disease is the appearance of enlarged and opacified corneal nerves, resulting in corneal anesthesia and neurotrophic keratopathy, as also seen in herpetic disease.40 Finally, limbal masses can form, resembling fibrous histiocytoma. Two patients with disseminated Mycobacterium abscessus infections who took linezolid for at least 9 months developed cytopenias and one also developed a peripheral neuropathy [102]. In most case reports, the lesions are restricted to a small region of skin, but in some cases the lesions coalesce and affect large swathes of skin. M. abscessus infection is commonly found to cause pulmonary disease, but M. abscessus can also cause skin, soft tissue, and central nervous system infection (Lee, 2015). Mycobacterium abscessus infection control is important to protect the lungs. Abstract. However, it can cause skin and soft tissue infection following trauma or surgery. It is also one of the mycobacteria that are most often isolated from cystic fibrosis patients. These species may grow in routine media such as liquid broth blood culture media or on solid agars used for routine bacteriology. The bacterial infection caused by Mycobacterium abscessus usually causes skin symptoms, including redness, swelling, and pain. Mycobacterium Abscessus Infection is known commonly to be the cause of chronic lung infection and skin and soft tissue infections (SSTI), but can also cause infection to most human organs when one’s immune system does not have the ability to combat the bacteria/virus (immunodeficiency). The top three reported events were skin discoloration (61%), nausea (33%), and fatigue (30%) [23C]. Dermatology 2010;221: 1 … haemophilum, are also more frequently associated with skin disease [3†, 21.17B).41,42, Ahmet Uluer, Francisco M. Marty, in Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases (Eighth Edition), 2015, During the mid-1990s, the prevalence of nontuberculous mycobacteria (NTM) infection among CF patients was 13%. Background. Drage LA, Ecker PM, Orenstein R, et al. Mycobacterim abscessus infection is generally spread through contact with contaminated soil, water, or objects. Changes to the drug regime are common, due to drug intolerance, side-effects, and lack of efficacy. The frequency of published reports of infection by rapidly growing mycobacteria associated with tattooing procedures has increased … Mycobacterium abscessus (M. abscessus) is a rapidly growing mycobacterium widely present in the natural environment, such as in the soil and water (1, 2). For instance, cutaneous NTM infections from M. abscessus have resulted from some skin procedures such as mesotherapy and acupuncture. Dermatology 2010;221: 1-4. Mycobacterium abscessus. A definitive diagnosis of Mycobacterium abscesses can often be made by culturing pus from an infected boil, or by examining a biopsy sample of infected skin. In this manner, hospitals and clinics can be warned of the possibility that their equipment may be contaminated with Mycobacterium abscessus. Although outbreaks of Mycobacterium abscessus infection have been reported, none of these reports has identified the potential sources of infection and modes of transmission. Subspecies of M. chelonae; Found in water, soil, dust, animals; Rarely causes illness in humans but can be difficult to diagnose and treat; Can cause skin infection after puncture wounds, tattoos, skin trauma or surgery; May cause lung infection and disseminated infection in immunosuppressed people; Mycobacterium abscessus Its presence in pulmonary specimens usually represents either laboratory contamination or nonpathogenic colonization. Although outbreaks of Mycobacterium abscessus infection have been reported, none of these reports has identified the potential sources of infection and modes of transmission. Active NTM infection should be considered in patients with repeatedly smear-positive respiratory cultures, compatible radiographic findings, and lack of clinical response despite appropriate antibacterial therapy.135. Examples of RGM include M. abscessus, M. fortuitum and M. chelonae. Scrofuloderma results from breakdown of skin overlying a tuberculous focus, usually at a lymph node but also at the skin over infected bones or joints. Lucy Burr, ... David Serisier, in Side Effects of Drugs Annual, 2014. Their geographic distribution has not been completely described; RGM-borne cutaneous disease has been reported throughout the world. Mycobacterium abscessus is closely related to the bacteria that causes tuberculosis. Cutaneous infections by this complex show a heterogeneous clinical presentation with varied histopathologic findings. massiliense. Abstract. M. fortuitum is the most common RGM causing extrapulmonary infections. DOI: 10.1159/000324766 Corpus ID: 16105781. Dermatology 2010; 221:1. Most common were nausea/vomiting (n = 17, 31%) and skin changes (n = 11, 20%) (Table 2). Their geographic distribution has not been completely described; RGM-borne cutaneous disease has been reported throughout the world. Laura Chandler, in Accurate Results in the Clinical Laboratory, 2013. As with all long-term antimicrobial use, overgrowth with resistant organisms is a consideration. It usually causes nosocomial infection of the skin and soft tissues. Mycobacterium abscessus skin infection after tattooing: first case report and review of the literature. In April 2008, we identified and investigated an outbreak of M. abscessus skin and soft tissue Meenakshi R. Ramanathan, ... James M. Sanders, in Side Effects of Drugs Annual, 2018. The M abscessus complex is most pathogenic and comprises 3 subspecies, M abscessus subsp abscessus, M abscessus subsp bolletii, and M abscessus subsp massiliense. Studies in CF98 and non-CF99–101 patients have clearly demonstrated that culture conversion is much more likely to occur in patients infected with M. massiliense compared with M. abscessus.98 These differences are presumably related to the presence of a functional erm41 gene in M. abscessus that results in inducible macrolide resistance, whereas in M. massiliense the gene is nonfunctional.99. Mycobacterium abscessus is not considered contagious from person to person, and usually enters the body through a break in the skin. An outbreak of cutaneous infection due to Mycobacterium abscessus associated to mesotherapy The results of environmental investigation suggest the most likely cause of the outbreak could have been the contamination of the products in the factory, although there was no laboratory confirmation. Mycobacterium abscessus (M. abscessus) is a non-tuberculous mycobacterium widely present in the natural environment and is now being increasingly identified as a cause of human disease. Patients that already have a respiratory disease, such as cystic fibrosis or tuberculosis, are more susceptible to infection. M. chelonae causes mostly skin and soft tissue disease in immunocompromised persons or in nosocomial infection of surgical wounds. The American Thoracic Society (ATS), Infectious Diseases Society of America (IDSA), and several case reports imply that like M. marinum, RGM may be ubiquitous, perhaps particularly in water, and may be transmitted to the host through breaks in colonized or contaminated skin. Mycobacterium abscessus is the third most frequently isolated respiratory NTM after MAC and gives more than 80% of all rapidly growing mycobacterial respiratory infections. Setting Mayo Clinic, Rochester, Minn.. Mycobacterium abscessus comprises three subspecies: M. abscessus subsp. These are aerobic and non-motile bacteria which are acid fast. However, it can cause skin and soft tissue infection following trauma or surgery. After intravenous therapy, patients typically continue a combination of oral and inhaled treatments with adjustments of therapy based on culture conversion as well as clinical and radiographic response. Although outbreaks of Mycobacterium abscessus infection have been reported, none of these reports has identified the potential sources of infection and modes of transmission. Mycobacterium abscessus symptoms. Mycobacterium abscessus symptoms. Rapidly growing mycobacteria, including the Mycobacterium abscessus group, Mycobacterium chelonei, and Mycobacterium fortuitum, are increasingly recognized pathogens in cutaneous infections associated particularly with plastic surgery and cosmetic procedures. Most were identified as Mycobacterium avium complex (MAC, 72%) followed by Mycobacterium abscessus (16%).129 Risk factors associated with NTM included older age, geographic location (higher incidence in Southwest compared with Northeast), and milder lung disease based on FEV1, as well as a relatively higher association in those patients infected with S. aureus as compared with those infected with PA. Esther and colleagues130 reviewed 4862 CF culture data from patients older than 8 years and also found an 11% NTM prevalence rate. They are primarily abscesses, nodules, papules, or plaques; the nodules, papules, or plaques may be erythematous or violaceous in color, and some may be scaling or draining purulent material (Figure 24-4). [] Although the prevalence of MAI infection has increased following the epidemic of acquired immunodeficiency syndrome (AIDS), MAI infection remains a rare cause of skin … Mycobacterium abscessus is a rapidly growing mycobacterium that has been affecting people undergoing invasive procedures, such as videosurgery and mesotherapy. It is responsible for nearly 10% of pulmonary NTM infections [34], which is its most frequent clinical manifestation. This bacterium can contaminate medical implements, including hypodermic syringes, so that it often infects those who receive injections or surgical procedures in improperly sanitized surroundings. Mycobacterium abscessus is a rapidly growing mycobacterium that has been affecting people undergoing invasive procedures, such as videosurgery and mesotherapy. Copyright © 2021 Elsevier B.V. or its licensors or contributors. The continuation phase should include inhaled amikacin in conjunction with 2–3 of the following daily oral antibiotics: minocycline, moxifloxacin, linezolid, and clofazimine.19,20 If macrolides are used, they should be continued throughout the continuation phase. While antibiotics are usually necessary to combat Mycobacterium abscessus infection, treatment can also involve cleaning pus from infected boils and even surgically excising infected tissue. In both patients the cytopenia resolved after administration of vitamin B6 and stabilized during prolonged linezolid therapy, although the peripheral neuropathy did not. In addition, it has the potential to prolong the QTc interval [14R, 22R]. The frequency of published reports of infection by rapidly growing mycobacteria associated with tattooing procedures has increased … Luis G. Tulloch, in Netter’s Infectious Diseases, 2012. Mycobacterium abscessus complex (MABSC) is a group of rapidly growing, multidrug-resistant, nontuberculous mycobacteria (NTM) species that are common soil and water contaminants. Interestingly, a study that included more than 27,000 patients detected NTM in 20% of cases (64% MAC and 36% M. abscessus), and chronic azithromycin use was less likely to be associated with NTM culture positivity.131 Despite this, it is still important to screen patients for NTM to help avoid drug resistance to azithromycin. Human infections are relatively uncommon, but an increase in the number of reported cases has been identified among immunocompromised persons. Here is … It can be commonly recovered from drinking water or soil and is the most pathogenic and chemotherapy-resistant rapidly growing mycobacterium. bolletii, and M. abscessus subsp. Mycobacterium abscessus and M.chelonae belong to the rapid‐growing nontuberculous mycobacteria (NTM) group, which are defined by their ability to form visible colonies on agar within 7 days of subculture. Symptoms of Nocardiainfection include skin infection, ulcerations, cellulitis and subcutaneous abscesses making it difficult to distinguish from other pyogenic bacteria.