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Outbreaks of Non-tuberculous Mycobacterium Infection in the United States

To date, 114 known outbreaks of human infection by non-tuberculous mycobacteria (NTM) have been associated with medical / other invasive procedures.  37 of these (32%) have reported from the United States.  The following chronology is abstracted from the Gideon e-book series. [1]   Primary references are available from the author.

 1987     17 cases of Mycobacterium chelonae otitis media in Louisiana caused by contaminated water used by an ENT practice

 1988    8 cases of Mycobacterium chelonae infection associated with a contaminated jet injector used in a Podiatry office.

 1989 – 1990   16 cases of  Mycobacterium fortuitum respiratory tract colonization in Washington, D.C. among patients on an alcoholism rehabilitation ward

 1991 *     6 cases of Mycobacterium fortuitum infection in Washington, related to contaminated electromyography needles

 1995 – 1996    87 cases (in 16 states) of Mycobacterium abscessus soft tissue infection associated with use of a contaminated adrenal cortex extract

 1998     6 cases of Mycobacterium mucogenicum  bacteremia among bone marrow transplant and oncology patients in Minnesota, related to use of  contaminated water in a hematology-oncology unit.

 1999     10 cases of Mycobacterium abscessus arthritis  in Texas associated with  contaminated benzalkonium chloride used in injections.

 2000 – 2001     110 cases of Mycobacterium fortuitum skin infection in California,  associated with contaminated footbaths at a nail salon.   

 2001  Outbreak of Mycobacterium chelonae keratitis in California, associated with laser in situ keratomileusis (LASIK) performed in an Ophthalmology clinic.

 2001 – 2002   Outbreak of Mycobacterium simiae infections in a Texas hospital was associated with contaminated tap water.

 2002 *     34 cases of Mycobacterium chelonae soft tissue infection in California,  associated with liposuction procedures.

 2002    115 cases of Mycobacterium fortuitum  infection in California, associated with contaminated footbaths at a nail salon.

 2002     11 cases of Mycobacterium abscessus soft tissue infections in New York City, associated with injection of cosmetic substances by unlicensed practitioners

 2002 – 2003     4 cases of Mycobacterium chelonae infection in New Jersey,  associated with injection of contaminated methylene blue solution into patients undergoing rhytidectomies.

 2003     3 cases of Mycobacterium goodii infections at a hospital in Colorado,  associated with contaminated surgical implants

 2004     12 cases of Mycobacterium abscessus soft tissue infection, among Americans undergoing cosmetic surgery at various clinics in the Dominican Republic

 2004     143 cases of Mycobacterium fortuitum                skin and soft tissue infections in California,  associated with a nail salon  

 2008     4 cases of Mycobacterium mucogenicum bacteremia in North Carolina,  among sickle-cell anemia patients     

 2008 – 2011     6 cases of Mycobacterium wolinskyi infection among patients on a cardiothoracic surgery unit in Minnesota.

 2009 *     6 cases of Mycobacterium chelonae infection related to contaminated needles used in a tattoo parlor.

 2009     2 cases of Mycobacterium haemophilum infection in Washington,  associated with a tattoo parlor.

 2009     5 cases of Mycobacterium abscessus infection reported at a cystic fibrosis center in Washington.

 2011 *     11 cases of Mycobacterium porcinum infection in Texas,  related to contaminated drinking water.                   

2011 *      3 cases of Mycobacterium bolletii/M. massiliense furunculosis in North Carolina,  associated with a nail salon.

2011 *     Outbreak of Mycobacterium abscessus infections in Florida,  associated with outpatient rhytidectomies.

2011 – 2012     19 cases of Mycobacterium chelonae involving multiple states, associated with contaminated needles used in tattoo parlors.

2011 – 2012     15 cases of infection due to rapidly-growing Mycobacterium species, among transplant recipients on a hematopoietic stem cell transplantation unit in Minnesota.

2012     19 cases of Mycobacterium abscessus infection, among cystic fibrosis patients at a hospital in Hawaii             

2013     2 cases among patients at a North Carolina cosmetic surgery clinic, associated with fractionated CO2 laser resurfacing procedures

2013 – 2014     19 cases of Mycobacterium abscessus and Mycobacterium fortuitum infections among Americans who traveled to the Dominican Republic of cosmetic surgery.             

 2013 – 2015     95 cases of  Mycobacterium abscessus infection at a hospital in North Carolina, associated with contaminated tap water.

 2013 – 2014     39 cases of  Mycobacterium abscessus infection among transplant recipients in California,  associated with a contaminated environmental water source.

 2014     15 cases of Mycobacterium abscessus infection at a South Carolina hospital, associated with contact between equipment and contaminated tap water

 2015      2 cases of Mycobacterium chelonae  keratitis in Ohio, associated with use of contaminated humidifier in a laser in situ keratomileusis (LASIK) clinic.

 2015      9 cases of Mycobacterium abscessus odontogenic infections at a Georgia practice,  among children undergoing dental pulpotomy.

 2015     Outbreaks of Mycobacterium chimaera infections in Switzerland, the Netherlands, Germany, the United Kingdom and the United States (Pennsylvania) associated with a contaminated heater-cooler water unit manufactured in Germany, and subsequently in the United Kingdom.

 2016     58 cases of Mycobacterium abscessus wound infection in California, associated with use of contaminated water during root-canal surgery at a dental practice.


 * year of publication



  1. Berger SA, 2017. Gideon Guide to Outbreaks. 1,181 pages, 5,170 tables, 47,454 references. Gideon e-books,

Note featured in ProMED

Seal Finger in Canada

A recent case of “seal finger” in Canada complements an increasing number of zoonotic bacterial diseases associated with animal bites.

The following list is extracted from Gideon (primary references available on request) :


Bacteroides pyogenes  – case of bacteremia following a cat bite.

Bacteroides tectus –  cat bites

Bergeyella zoohelcum –  dog-bite infection

Bisgaard’s taxon 16 –  animal bite wounds

Canibacter oris –  dog-bite infection

Capnocytophaga canimorsus –  dog-bite infection

Capnocytophaga cynodegmi –  dog-bite infection

Corynebacterium canis –  dog-bite infection

Corynebacterium freiburgense  – recovered from a dog-bite

Corynebacterium kutscheri  – implicated in cases of animal-bite infection

CDC NO-1 –  dog- and cat-bite wounds

Dietzia cinnamea –  dog-bite infection

Erysipelothrix rhusiopathiae –  related to contact wih animals / fish or their products

Frederiksenia canicola –  dog-bite infection

Fusobacterium canifelinum –  animal-bite wounds

Halomonas venusta –  fish-bite infection

Kingella potus –  wound from a kinkajou

Mannheimia glucosida –  infected lamb-bite

Moraxella canis –  dog-bite infection

Mycobacterium vulneris –  dog-bite infection

Mycoplasma phocicerebrale –  seal-bite infection (“seal-finger”)

Neisseria animaloris –  animal-bites

Neisseria canis –  animal-bite infection

Neisseria weaveri –  animal-bite infection

Neisseria zoodegmatis –  aminal bite infection

Pasteurella aerogenes –  wound infections

Pasteurella caballi –  horse-bite infection

Pasteurella canis –  dog-bite infection

Pasteurella dagmatis –  cat- and dog-bite infection

Pasteurella multocida –  animal-bite infection

Pasteurella stomatis –  animal-bite infection

Porphyromonas macacae –  cat-bite infection

Psychrobacter immobilis –  animal-bite infection

Staphylococcus intermedius –  animal-bite infection

Vibrio harveyi –  shark-bite infection


Note featured on ProMED


One Health – By the Numbers

Those of us who work in Human and Animal Health encounter zoonotic infectious diseases on an almost daily basis.  But precisely how common are these conditions?  A preliminary overview was undertaken to quantify and collate the impact of relevant diseases.  Data were generated using an interactive tool in Gideon. *

As depicted in the following tables, 59% (209) of all generic infectious diseases affecting mankind are derived from animal reservoirs.  Surprisingly, this percentage varies little when data are analyzed for specific countries selected at random from widely diverse regions.  Similarly, the distribution of diseases from country-to-country varies little, when collated by pathogen class, vector, vehicle and reservoir.

* See video tutorial at  – scroll down to Diseases – Fingerprint

Zoonotic Infectious Diseases – Distribution by Reservoir

Region Diseases Zoonoses   Bird   Dog   Cattle   Rodent   Pig  
Worldwide 354 209 59% 49 14% 64 18% 50 14% 86 24% 39 11%
United States 247 129 52% 30 12% 43 17% 36 15% 52 21% 27 11%
China 253 132 52% 32 13% 47 19% 37 15% 53 21% 30 12%
France 222 106 48% 26 12% 36 16% 32 14% 38 17% 24 11%
Ghana 225 98 44% 22 10% 32 14% 30 13% 33 15% 23 10%
Brazil 257 130 51% 30 12% 42 16% 34 13% 50 19% 29 11%
Australia 220 102 46% 28 13% 31 14% 27 12% 33 15% 23 10%


Zoonotic Infectious Diseases – by Pathogen, Vector or Vehicle

Region Diseases Zoonoses   Virus   Parasite   Bacterium   Arthropod   Food  
Worldwide 354 209 59% 68 19% 72 20% 56 16% 79 22% 71 20%
UnitedStates 247 129 52% 28 11% 46 19% 45 18% 36 15% 51 21%
China 253 132 52% 24 9% 54 21% 47 19% 45 18% 58 23%
France 222 106 48% 19 9% 40 18% 42 19% 26 12% 44 20%
Ghana 225 98 44% 17 8% 36 16% 38 17% 20 9% 41 18%
Brazil 257 130 51% 30 12% 48 19% 42 16% 36 14% 51 20%
Australia 220 102 46% 28 13% 34 15% 41 19% 25 11% 44 20%

Pythiosis in Humans

The following background data are abstracted from Gideon Primary references are available on request.

Human pythiosis was first described in Thailand, in 1987; and thirty-two cases had been published worldwide as of 2002.  Most cases are reported from tropical and subtropical regions; however, human infection has also been encountered in United States, Israel and Australia.  The principal pathogen is identified as Pythium insidiosum, and at least one case of Pythium aphanidermatum infection has been reported.

Most case reports of pythiosis are published from Thailand, which accounted for 78% of published reports to 2002 – over 90% of these in farmers. Pythium insidiosum is identified in irrigation water in endemic agricultural areas; and 64% of soil samples in endemic areas contain the organism. 102 cases of human infection were identified in Thailand through active case finding during 1985 to 2003 – 59% vascular, 33% ocular, 5% cutaneous / subcutaneous and 3% disseminated.

Natural infection of dogs, cats, cattle, horses, and other mammals is described in South America (Argentina, Brazil, Colombia and Venezuela), Central America and the Caribbean (Costa Rica, Guatemala, Haiti, Jamaica, Panama, and Nicaragua), North America (the United States, notably in Florida, Louisiana, Mississippi, and Texas), Australia and Asia (India, Indonesia, Japan, New Guinea, New Zealand, North Korea, and Thailand).  A single case (dog in Mali) had been reported in Africa as of 2005.

Infection is acquired through direct contact or trauma, and presents as granulomatous cutaneous and subcutaneous lesions. Patients often have underlying thalassemia. Vascular pythiosis is characterized by ascending purulent infection and thrombosis of major arteries, usually of the lower extremities. If a major vessel is involved, the patient usually dies within weeks. Symptoms include intermittent claudication, resting calf pain and other signs of arterial insufficiency. Fever and weight loss are not described.

Ocular disease is characterizewd by ulcerative keratitis which may progress to endophthalmitis and require enucleation. Eleven cases of Pythium endophthalmitis were reported from a single Thai hospital in 2004.  Legenidium, a related genus of oomycetes, has been associated with infections of the skin and eyes in Thailand.

Pythium insidiosum is not susceptible to antifungal agents, and excision is the only proven form of therapy. Saturated solutions of potassium iodide have been recommended for localized skin infections. Immune therapy consisting of injection of Pythium antigen into infected patients has been successful in animal models, and has been used for human disease in Thailand.

A single outbreak (4 cases of keratitis) of pythiosis has been reported, in Thailand in 2009; and at least three instances of cross-border pythiosis have been published:

2005 (publication year) – Pythiosis was documented in a German Shepherd dog exported from Mali to France.
2011 (publication year) – An American soldier acquired traumatic wound infection by Pythium aphanidermatum in Afghanistan.
2015 (publication year) – A French traveler acquired Pythium insidiosum keratitis in Thailand.

Campylobacteriosis in Iceland

A recent posting in ProMED belies the fact that Iceland reports the lowest rates of campylobacteriosis in that region of Europe. [1-2] See graph [3] Note that an earlier outbreak (436 cases) was reported in 1999.


1. Berger SA. Infectious Diseases of Iceland, 2014 371 pages, 75 graphs, 1,455 references. Gideon e-books,
2. Berger SA. Campylobacteriosis: Global Status, 2014 104 pages, 96 graphs, 1,073 references. Gideon e-books,
3. Gideon graph tool at

GIDEON and Global Disease

We have developed an on-line system which follows the status of all Infectious Diseases – in every country – in real time. One of the GIDEON modules contains an ongoing chronology of every outbreak / survey on a global / country-specific level. As of 2014, the site contains 32,000 incidence graphs + details regarding 33,000 individual outbreaks and 36,000 prevalence surveys. Sample graphs and maps follow (red dots are links to country-specific text notes in the program).

The computer server has also been engineered to publish a series of 213 eBooks (115,000 pages, 410,000 references) – with all titles updated yearly. These include the only published books on diseases of YOUR country and YOUR particular disease-of-interest – including all Neglected Tropical Disease. Full list of titles at Users can also create custom graphs which contast multiple diseases of interest – a few maps / graphs follow:






Fatal Plague in Madagascar

Madagascar accounts for most plague deaths in the world – see graph

plague deaths

Barmah Forest Disease in Australia

The following background on Barmah Forest Disease in Australia is abstracted from Gideon and the Gideon e-book series. [1,2]

Barmah Forest disease virus was first isolated from mosquitoes (Culex annulirostris) in the Barmah Forest, Northern Victoria in 1974. Human infection was subsequently reported along the south coast of New South Wales during the mid-1980’s; in Queensland during 1988 to 1989; in the Northern Territory in 1992 ; and in southwestern Western Australia in 1993. A new focus was described in Gippsland (Victoria) during 1993 to 1994. The number of localities reporting Barmah Forest Disease increased during 1996 to 1998, and again during 1999 to 2001.

Disease incidence has increased somewhat since 2000, with most cases reported from Queensland and New South Wales. In the following chart, I have contrasted incidence data for Barmah Forest disease with those of a similar illness, Ross River disease [3]


Seroprevalence surveys:
6.5% of healthy adults in Queensland.
11.3% of horses in Brisbane, 1.2% of dogs, 10.7% of bushtail possum (Trichosaurus volpecula) , 1.5% of cats, 0% of flying foxes (1977 to 1999) 8

– The known vectors are Ochlerotatus vigilax, Culex annulirostris, Ae. (Oc.) camptorhynchus, Ae. normanensis and Coquillettidia species.
– Aedes notoscriptus is considered an additional potential vector.
– BFD virus has also been recovered from Aedes vigilax in eastern Australia (2005 to 2008)

Wallabies and kangaroos serve as reservoirs for the virus; however, antibody is also present in cattle and horses.

Related viruses:
– Similar local illnesses have been ascribed to Trubanaman and Gan Gan viruses (Bunyaviridae); and Kokobera, Stratford and Edge Hill viruses (Flaviviridae).
– A single human case of Edge Hill virus infection has been described.
– A case of Kokobera fever was reported from Darwin in 1998.
– Kokobera virus has been isolated from Culex annulirostris in the Northern Territory and northern Queensland.
– Kokobera virus was isolated from 18 of 25,351 Cx. annulirostris tested in Cape York in 1998.

Notable outbreaks:
1992 to 1994 – An outbreak (22 cases) of Barmah Forest disease was reported in the south-west of Western Australia.
1995 – An outbreak (135 cases) was reported along the south coast of New South Wales.
2002 – An outbreak (47 cases) was reported in Victoria.
2002 to 2003 – An outbreak (297 cases) was reported in Queensland.
2005 to 2006 – An outbreak (1,895 cases) was reported.

1. Berger SA. Infectious Diseases of Australia, 2013. 540 pages, 162 graphs, 3364 references.
2. Berger SA. Australo-Pacific Arboviruses: Global Status, 2013. 32 pages, 20 graphs, 307 references.
3. Gideon Graph Tool, see tutorial at

Note featured on ProMed

Vaccination Uptake in Afghanistan

Although childhood vaccination has registered considerable success during the past three decades, Afghanistan continues to lag behind other nations in the region. In the following charts I have contrasted WHO estimates of vaccine uptake in Afghanstan with those of bordering countries. [1-3]


1. Berger SA. Infectious Diseases of Afghanistan, 2012. 326 pages, 37 graphs, 1239 references. Gideon e-books,
3. Gideon Graph Tool, see tutorial at

Note featured on ProMED

Pathogens Associated with Animal Bites

Gideon lists 31 species of bacteria which have been associated with human infection following the bites of animals:
– Bacteroides tectus
– Bergeyella zoohelcum
– Bisgaard’s taxon
– Capnocytophaga canimorsus
– Corynebacterium canis
– Capnocytophaga cynodegmi
– Corynebacterium freiburgense
– Corynebacterium kutscheri
– CDC NO-1
– Erysipelothrix rhusiopathiae
– Fusobacterium canifelinum
– Halomonas venusta
– Kingella potus
– Moraxella canis
– Mycobacterium vulneris
– Neisseria animaloris
– Neisseria canis
– Neisseria weaveri
– Neisseria zoodegmatis
– Pasteurella caballi
– Pasteurella canis
– Pasteurella dagmatis
– Pasteurella multocida
– Pasteurella stomatis
– Psychrobacter immobilis
– Spirillum minus
– Staphylococcus intermedius
– Streptobacillus moniliformis
– Vibrio charchariae
– Vibrio harveyi

Although virtually all literature on the subject advocates administration of tetanus prophylaxis following animal bites, few if any cases of bite-associated tetanus have been documented.