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Botryomycosis

Botryomycosis
Literature review current through: Jan 2024.
This topic last updated: Nov 29, 2023.

INTRODUCTION — Botryomycosis is a chronic suppurative infection characterized by a granulomatous inflammatory response to bacterial pathogens; it may present with cutaneous or, less commonly, visceral involvement [1]. Botryomycosis was first described in a horse in 1870 by a German pathologist. The name "botryomycosis" was coined in 1884, but its bacterial nature was not discovered until 1919 [2]. The term "botryomycosis" is derived from the Greek word "botrys" (meaning "bunch of grapes") and "mycosis" (a misnomer, due to the presumed fungal etiology in early descriptions). Other terms used to describe botryomycosis include bacterial pseudomycosis, staphylococcal actinophytosis, granular bacteriosis, and actinobacillosis.

EPIDEMIOLOGY — Botryomycosis is a relatively uncommon disease, and its description is limited to case reports in children and adults. It occurs more commonly among immunocompromised patients, although infection in immunocompetent patients has also been described [3-5]. The specific role of the host immune response is not fully understood [6-8].

Risk factors associated with botryomycosis include [6,7,9-13]:

Alcoholism

Diabetes mellitus

HIV infection

Cystic fibrosis

Chronic granulomatous disease

Trauma

Surgery

MICROBIOLOGY AND PATHOGENESIS — The most common organism causing botryomycosis is Staphylococcus aureus. Less common pathogens include gram-negative bacteria (Pseudomonas aeruginosa, Escherichia coli, Serratia, and Proteus), gram-positive cocci (coagulase-negative staphylococci, streptococci, micrococci), and anaerobes (Actinobacillus, Peptostreptococcus, and Cutibacterium [formerly Propionibacterium] acnes) [3,14].

The pathogenesis of botryomycosis is not fully understood; it is thought to involve a combination of potential factors including an inciting event (such as trauma), the number of organisms inoculated, the virulence of the infecting pathogen, and host susceptibility to infection [1,6,15,16]. Visceral botryomycosis is more likely to occur in patients who are immunosuppressed [2].

CLINICAL MANIFESTATIONS — Botryomycosis may present as cutaneous or visceral disease. Cutaneous botryomycosis involves the skin and subcutaneous tissue; visceral botryomycosis involves internal organs such as lungs, liver, or brain.

Cutaneous disease — Cutaneous botryomycosis is the most common form of botryomycosis and usually occurs following cutaneous inoculation of bacteria due to trauma, surgery, or the presence of a foreign body [17-19]. Lesions characteristically develop slowly and may evolve and enlarge for several months and, rarely, even years.

Most patients present with subcutaneous nodules, but others may develop verrucous lesions or nonhealing ulcers associated with draining sinuses or fistulae (picture 1). Drainage from these lesions is usually purulent and may contain small yellowish "grains" resembling the sulfur granules seen in actinomycosis. (See "Cervicofacial actinomycosis".)

Occasionally, infection may involve contiguous soft tissues such as the subcutaneous tissue, muscles, tendons, and bone. Mucosal involvement of areas such as the tongue and nasal septum, lymph nodes or visceral involvement has also been described [5,20,21]. Disseminated infection can follow cutaneous disease in the setting of severe immunosuppression [22].

Patients infected with HIV may present with atypical lesions resembling conditions such as prurigo nodularis, lichen simplex chronicus, or sporotrichosis [7,23]. No correlation between CD4 count and susceptibility to botryomycosis has been described. (See "Fever and rash in patients with HIV".)

Visceral disease — Visceral botryomycosis occurs most commonly in the lung, although involvement of other organs including liver, spleen, kidney, and brain has also been described [2]. Systemic symptoms such as fever, fatigue, or weight loss may or may not be present.

Symptoms associated with pulmonary botryomycosis include chronic cough, dyspnea, hemoptysis, and chest wall pain [14,24]. Clinical examination may be normal or demonstrate diminished breath sounds or rhonchi over the consolidated lung. Given the prolonged duration and nature of the symptoms, pulmonary botryomycosis may be mistaken for malignancy [24].

Botryomycosis involving the liver, spleen, or kidney tends to present with chronic abdominal pain and local tenderness to palpation [9,25]. Ultrasonography or computerized tomography reveals a mass lesion of the abdomen suspicious for an abscess or malignancy.

Cerebral botryomycosis has been described in association with dental caries or after oral surgery [25-27]. Focal neurological deficits, seizures, or signs of meningitis may occur, and some patients develop a fulminant course [25].

DIFFERENTIAL DIAGNOSIS — Conditions that mimic botryomycosis are summarized below; in general, the diagnoses are distinguished by histopathology and culture.

Actinomycosis – Both actinomycosis and botryomycosis can present with cutaneous or visceral involvement. Cutaneous disease due to both actinomycosis and botryomycosis can be associated with drainage containing small "grains." (See "Nonresolving pneumonia", section on 'Nocardia and Actinomyces'.)

Nocardia – Like botryomycosis, nocardiosis may present with cutaneous or visceral involvement; it is generally observed in immunocompromised patients. (See "Nocardia infections: Epidemiology, clinical manifestations, and diagnosis".)

Fungal infection – A number of fungal infections present with cutaneous lesions resembling botryomycosis; these include eumycetoma, chromoblastomycosis, and phaeohyphomycosis. (See "Eumycetoma".)

Mycobacterial infection – Cutaneous tuberculosis, tuberculous lymphadenitis, and atypical mycobacterial infection may present with skin lesions and draining sinus tracts resembling botryomycosis. (See "Cutaneous manifestations of tuberculosis" and "Overview of nontuberculous mycobacterial infections".)

Sporotrichosis – Sporotrichosis occurs following cutaneous inoculation and presents with lymphocutaneous spread; in rare cases, pulmonary involvement may be observed. (See "Clinical features and diagnosis of sporotrichosis".)

Cutaneous leishmaniasis – Cutaneous leishmaniasis causes a spectrum of cutaneous disease and can resemble botryomycosis. Epidemiologic exposure is an important component of the clinical history. (See "Cutaneous leishmaniasis: Clinical manifestations and diagnosis".)

Skin cancer – Botryomycosis can mimic the appearance of squamous cell carcinoma or the violaceous lesions of Kaposi sarcoma; these are distinguished by histopathology. (See "Cutaneous squamous cell carcinoma (cSCC): Clinical features and diagnosis" and "Classic Kaposi sarcoma: Clinical features, staging, diagnosis, and treatment".)

DIAGNOSIS — Laboratory evaluation including biopsy for histopathology and culture are needed to differentiate botryomycosis from other diagnoses listed above [20]:

Evaluation of drainage for grains – Pus from draining sinuses should be collected on sterile gauze or aspirated and transferred to a sterile container. Granules should be picked up using a needle or forceps and crushed between two slides. Anecdotal reports associate certain pathogens with a characteristic grain color. S. aureus is classically associated with pale yellow or white granules.

The presence of granules itself does not establish diagnosis of botryomycosis since they can be present in actinomycosis and nocardiosis.

Botryomycosis may be distinguished from actinomycosis and mycetoma in that botryomycosis granules are of variable size and shape up to 500 microns in diameter.

Gram staining (using traditional methods or the Brown-Brenn stain) or silver nitrate staining (using the Grocott-Gomori method) of crushed granules or biopsy specimens to identify nonfilamentous bacteria – Rarely, gram-positive cocci ≤1 micron in diameter are present in the exudate surrounding the granule and occur singly, in pairs, or in small clumps. In contrast, actinomycetes are branching filamentous bacteria ≤1 micron in diameter, while fungi causing mycetoma have hyphae that are at least 2 microns wide. These distinctions are important for guiding clinical management.

Routine bacterial, fungal, and mycobacterial cultures – Growth of bacterial pathogens would support diagnosis of botryomycosis.

The histopathologic appearance of botryomycosis is characterized by a central focus of necrosis surrounded by a chronic inflammatory reaction containing histiocytes, epithelioid cells, multinucleated giant cells, and fibrosis [25]. Unlike the sulfur granules seen in actinomycosis (which contain filamentous branching organisms), the granules seen in botryomycosis (Bollinger granules) contain bacteria surrounded by an eosinophilic matrix containing club-like projections. This histologic appearance is commonly referred to as the Splendore-Hoeppli phenomenon, although it may not always be present (picture 2) [22,28,29].

Radiographic studies may be useful to evaluate the size and extent of involvement. Pulmonary lesions may be present as a consolidation or mass lesion (picture 3), while other forms of visceral botryomycosis usually present as a mass lesion.

TREATMENT — In general, patients should receive antibiotic therapy until signs and symptoms of infection have resolved. A few weeks of therapy may be sufficient for those with superficial infection; patients with deep infections and/or those with underlying immunodeficiency may require months of therapy. Prolonged antibiotic therapy may be necessary in cases for which debridement is incomplete or not feasible. In such situations, antibiotic penetration to the organisms sequestered in the granules may be poor or limited [20].

Selection of antibiotics should be tailored to culture and susceptibility results. There is no conclusive evidence regarding the appropriate duration of therapy; most information on the duration of treatment of botryomycosis is anecdotal [20]. The duration of therapy described in case reports has ranged from weeks to months. In general, antibiotic therapy is continued until the clinical and radiographic (if applicable) signs of infection have resolved.

Cutaneous disease — Treatment of cutaneous disease requires antibiotic therapy and, in most cases, surgical debridement. Antibiotic therapy alone may be sufficient for patients with superficial disease if a bacterial pathogen has been identified and malignancy has been excluded. For gram-positive infections, including S. aureus, oral trimethoprim-sulfamethoxazole (two double-strength tablets twice daily) can be used. Depending on culture and susceptibility data, other alternative agents include doxycycline (100 mg twice daily), minocycline (100 mg twice daily), erythromycin (500 mg four times daily), cephalexin (500 mg four times daily), dicloxacillin (500 mg every six hours), flucloxacillin (500 mg every six hours), or linezolid (600 mg every 12 hours). Linezolid should be avoided for durations longer than two weeks due to increased risk of adverse events, such a cytopenia and peripheral neuropathy.

For pseudomonal infections, we recommend initiating therapy with ceftazidime (2 g intravenously [IV] every 8 hours), cefepime (2 g IV every 8 hours), aztreonam (2 g IV every 8 hours), or imipenem (500 mg IV every 6 hours). If the isolate is fluoroquinolone sensitive, therapy may be switched to oral ciprofloxacin (750 mg twice daily).

For infections due to other gram-negative organisms (E. coli, Serratia, Proteus), ceftriaxone (1 to 2 g once daily), cefepime (2 g IV every 8 hours), imipenem (500 mg IV every 6 hours), or ertapenem 1 gm IV every 24 hours can be used initially until susceptibility data is available; oral ciprofloxacin (500 mg twice daily) can be used if the isolate is susceptible.

In patients with superficial infection, antibiotic therapy is usually continued for one to two months or until all signs of infection have resolved. Surgical debridement together with antibiotic therapy is appropriate for lesions that extend into deep tissues such as muscle or bone, for lesions that do not improve with antibiotics alone, and for immunocompromised patients.

Visceral disease — Treatment of visceral disease requires a combination of surgical and antimicrobial therapy. Resection of the mass often occurs prior to diagnosis given concern for malignancy in most cases of visceral disease.

For S. aureus and other gram-positive infections, we recommend initiating therapy with IV vancomycin (table 1). For S. aureus isolates sensitive to methicillin, a beta-lactam agent such as nafcillin or flucloxacillin (2 g IV every four to six hours), or cefazolin (2 g IV every eight hours), should be used. Patients can be switched to oral antibiotics once the infection is debrided surgically and susceptibility data are available.

Antibiotic selection for pseudomonal and other gram-negative infections is similar to the recommendations for cutaneous infections. Therapy is usually continued for several months until all signs of infection have resolved.

SUMMARY AND RECOMMENDATIONS

Epidemiology – Botryomycosis is a chronic suppurative infection characterized by a granulomatous inflammatory response to bacterial pathogens that is observed most commonly among immunocompromised patients. (See 'Introduction' above and 'Epidemiology' above.)

Microbiology – The most common pathogen is Staphylococcus aureus; other pathogens have also been implicated. The pathogenesis of botryomycosis is not fully understood; it is thought to involve a combination of factors including an inciting event (such as trauma), the number of organisms inoculated, the virulence of the infecting pathogen, and host susceptibility to infection. (See 'Microbiology and pathogenesis' above.)

Cutaneous disease – Cutaneous botryomycosis may present with subcutaneous nodules, verrucous lesions, or nonhealing ulcers associated with draining sinuses or fistulae. Drainage from the lesion is usually purulent and contains small yellowish grains resembling the sulfur granules seen in actinomycosis. (See 'Cutaneous disease' above.)

Visceral disease – Visceral botryomycosis occurs most commonly in the lung, although involvement of other organs including liver, spleen, kidney, and brain has also been described. (See 'Visceral disease' above.)

Differential diagnosis – Botryomycosis may be difficult to distinguish from mycetoma, actinomycosis, malignancy, and other conditions. (See 'Differential diagnosis' above.)

Diagnosis – The diagnosis of botryomycosis may be established by identifying nonfilamentous bacteria in granules in pus from draining sinuses, identifying nonfilamentous bacteria in granules in biopsy specimens, or culturing bacteria from ulcers or exudates in patients with clinical findings of botryomycosis. (See 'Diagnosis' above.)

Treatment – Treatment of cutaneous disease requires antibiotic therapy and may also require surgical debridement, while treatment of visceral disease requires both surgical and antimicrobial therapy. (See 'Treatment' above.)

Duration of therapy – There is no conclusive evidence regarding the appropriate duration of therapy. In general, patients should receive antibiotic therapy until signs and symptoms of infection have resolved. For superficial infection, a few weeks may be sufficient, while patients with deep infection and/or immunodeficiency may require a prolonged course of therapy. (See 'Treatment' above.)

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