38 • CID 2004:38 (1 January) • Winthrop et al.
M A J O R A R T I C L E
The Clinical Management and Outcome of
Nail Salon–Acquired Mycobacterium fortuitum
Kevin L. Winthrop,1,2Kim Albridge,aDavid South,aPeggy Albrecht,4Marcy Abrams,3Michael C. Samuel,2
Wendy Leonard,3Joanna Wagner,2and Duc J. Vugia2
1Epidemic Intelligence Service, Epidemiology Program Office, Centers for Disease Control and Prevention and
Disease Control, California Department of Health Services, Berkeley, and
Santa Cruz, California
2Division of Communicable
4Santa Cruz Medical Clinic,
3Santa Cruz County Health Agency and
Nontuberculous mycobacterial infections are becoming more common. Recently, Mycobacterium fortuitum
and other rapidly growing mycobacteria have been found to cause severe skin and soft-tissue infections in
association with nail salon whirlpool footbaths. We recently investigated a large outbreak of M. fortuitum
furunculosis among women who received pedicures at a single nail salon. To better define the clinical course
of such infections, we collected clinical details from physicians who were treating outbreak patients. We
constructed multivariable linear models to evaluate the effect of antibiotic treatment on disease duration.
Sixty-one patients were included in the investigation. The mean disease duration was 170 days (range, 41–
336 days). Forty-eight persons received antibiotic therapy for a median periodof4months(range,1–6months),
and 13 persons were untreated. Isolates were most susceptible to ciprofloxacin and minocycline. Early ad-
ministration of therapy was associated with shorter duration of disease only in persons with multiple boils
(). One untreated, healthy patient had lymphatic disease dissemination.
P ! .01
Mycobacterium fortuitum is one of several rapidlygrow-
ing mycobacteria that are ubiquitous in soil and water
habitats [1–5]. These mycobacteria are known to cause
cutaneous infection, typically in association with trau-
ma or clinical procedures . In 2002, however, Win-
throp et al.  documented a large outbreak of com-
munity-acquired infection with rapidly growing my-
cobacteria. In this outbreak, 1115 patrons from a single
Received 19 June 2003; accepted 18 August 2003; electronically published 8
Presented in part: 40th Annual Meeting of the Infectious Diseases Society of
America, Chicago, IL, 25 October 2002 (abstract 686).
aPrivate practice, Watsonville, California.
Reprints or correspondence: Dr. Kevin L. Winthrop, Div. of Tuberculosis
Elimination/Field Services, Centers for Disease Control and Prevention at the
California Dept. of Health Services, Rm. 608, 2151 Berkeley Way, Berkeley, CA
Clinical Infectious Diseases2004;38:38–44
This article is in the public domain, and no copyright is claimed.
nail salon contracted severe, lower-extremity M. for-
tuitum furunculosis fromcontaminatedwhirlpoolfoot-
baths used in the salon. Since this time, additional out-
breaks and similar sporadic cases of disease have been
reported [7–9], and it has become clear that whirlpool
footbath–associated mycobacterial infections are more
widespread than was previously appreciated. Because
such infections have only recently been recognized,
their natural history and optimal clinical management
have not yet been elucidated. To document the clinical
and diagnostic features of these infections, we observed
the clinical course of a subset of persons affected by
the outbreak of M. fortuitum furunculosis reported by
Winthrop et al. .
PATIENTS AND METHODS
In this observational study, we followed a subset of case
patients previously identified by Winthrop et al. 
during an initial outbreak investigation conducted
by guest on November 5, 2015
44 • CID 2004:38 (1 January) • Winthrop et al.
Leslie Christie, Dr. Thomas Deetz, Dr. Barbara Drucker, Dr.
ard Moore, Dr. Daryl Nounnan, Dr. William Richards, Dr. Vaal
Rothman, Dr. Molly Shields, and Dr. Michelle Violich, for their
collaboration in this study; and Dr. Andrea Winquist (Centers
for Disease Control and Prevention; Atlanta, GA), for her
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