{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T12:02:17Z","timestamp":1784721737634,"version":"3.55.0"},"reference-count":45,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T00:00:00Z","timestamp":1784678400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Hainan Province Health and Medical Science and Technology Innovation Joint Foundation of China","award":["WSJK2025QN110"],"award-info":[{"award-number":["WSJK2025QN110"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Pathogens"],"abstract":"<jats:p>Cutaneous co-infection with Mycobacterium tuberculosis (MTB) and Mycobacterium avium complex (MAC) is extremely rare and easily missed due to overlapping histopathological features. We report a previously healthy, HIV-negative middle-aged woman who presented with a progressive destructive mass in the left inguinal-perineal region. Imaging revealed sinus tract formation, osteolytic bone lesions, and chronic inflammation in the right middle lobe of the lung. Initial metagenomic next-generation sequencing (mNGS) detected 3756 reads of the Mycobacterium tuberculosis complex (MTBC) and 111 reads of Mycobacterium intracellulare (M. intracellulare); the latter was interpreted as possible colonization or contamination because of its low abundance. Empirical anti-tuberculosis therapy produced only transient partial improvement, followed by paradoxical worsening, local recurrence, and new bone destruction. After a high suspicion of mixed infection, a MAC-directed combination regimen (including azithromycin and a short course of amikacin) was added, leading to complete clinical cure; subsequent repeat cultures confirmed the presence of MAC. This is the first report of cutaneous MTB-MAC co-infection in the inguinal-perineal region of an adult without overt immune abnormalities, accompanied by disseminated bone lesions. This case highlights that in regions where nontuberculous mycobacteria (NTM) are co-endemic, atypical destructive skin lesions with paradoxical worsening despite initial response to anti-tuberculosis therapy should raise suspicion of MAC co-infection. The combination of mNGS and conventional culture facilitates identification of mixed infections and guides precision therapy, but mNGS results must be interpreted cautiously in the clinical context.<\/jats:p>","DOI":"10.3390\/pathogens15070774","type":"journal-article","created":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T10:48:28Z","timestamp":1784717308000},"page":"774","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Mycobacterium tuberculosis and Mycobacterium avium Complex Cutaneous Co-Infection: Diagnostic and Therapeutic Challenges"],"prefix":"10.3390","volume":"15","author":[{"given":"Minhua","family":"Weng","sequence":"first","affiliation":[{"name":"Department of Infectious and Tropical Diseases, The Second Affiliated Hospital of Hainan Medical University, Haikou 570311, China"},{"name":"Department of Internal Medicine, The Hainan Public Health Clinical Center, Haikou 571129, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guizhong","family":"Zhou","sequence":"additional","affiliation":[{"name":"Department of Infectious and Tropical Diseases, The Second Affiliated Hospital of Hainan Medical University, Haikou 570311, China"},{"name":"Department of Internal Medicine, The Hainan Public Health Clinical Center, Haikou 571129, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qiuping","family":"Wu","sequence":"additional","affiliation":[{"name":"Department of Infectious and Tropical Diseases, The Second Affiliated Hospital of Hainan Medical University, Haikou 570311, China"},{"name":"Department of Internal Medicine, The Hainan Public Health Clinical Center, Haikou 571129, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qiong","family":"Chen","sequence":"additional","affiliation":[{"name":"Department of Infectious and Tropical Diseases, The Second Affiliated Hospital of Hainan Medical University, Haikou 570311, China"},{"name":"Department of Internal Medicine, The Hainan Public Health Clinical Center, Haikou 571129, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6539-1802","authenticated-orcid":false,"given":"Jiabin","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zheng","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Respiratory and Critical Care Medicine, Henan Provincial People\u2019s Hospital, Zhengzhou 450003, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7734-4838","authenticated-orcid":false,"given":"Wenting","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e00069-18","DOI":"10.1128\/CMR.00069-18","article-title":"Cutaneous Mycobacterial Infections","volume":"32","author":"Marcos","year":"2018","journal-title":"Clin. Microbiol. Rev."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1091","DOI":"10.1016\/j.jaad.2021.12.063","article-title":"Cutaneous tuberculosis. Part I: Pathogenesis, classification, and clinical features","volume":"89","author":"Kaul","year":"2023","journal-title":"J. Am. Acad. Dermatol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1016\/j.jdin.2023.05.001","article-title":"Cutaneous tuberculosis in the pediatric population: A review","volume":"12","author":"Maloney","year":"2023","journal-title":"JAAD Int."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"ofaf239","DOI":"10.1093\/ofid\/ofaf239","article-title":"Distinct Clinical Features of Extrapulmonary and Disseminated Tuberculosis in HIV- and Non-HIV-Associated Immunosuppression: A Retrospective Cohort Study","volume":"12","year":"2025","journal-title":"Open Forum Infect. Dis."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"465","DOI":"10.1016\/j.ijtb.2024.01.002","article-title":"Unmasking the enigma: Investigating the clinicoepidemiological and histopathological dimensions of cutaneous tuberculosis in a Western Indian tertiary care hospital","volume":"71","author":"Kothari","year":"2024","journal-title":"Indian J. Tuberc."},{"key":"ref_6","first-page":"793","article-title":"Recognising cutaneous tuberculosis","volume":"23","author":"Gramminger","year":"2025","journal-title":"J. Dtsch. Dermatol. Ges."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"102655","DOI":"10.1016\/j.jiph.2025.102655","article-title":"Epidemiology and clinical outcomes in skin and soft tissue nontuberculous mycobacteria infections: A retrospective study","volume":"18","author":"Zhou","year":"2025","journal-title":"J. Infect. Public Health"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"bcr-2017-222762","DOI":"10.1136\/bcr-2017-222762","article-title":"Cutaneous Mycobacterium massiliense infection from tattooing: A common yet under-reported and persistent epidemic hazard for dermatologists","volume":"2018","author":"Velez","year":"2018","journal-title":"BMJ Case Rep."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"497","DOI":"10.1111\/pde.15491","article-title":"Cutaneous Mycobacterium avium-intracellulare infection masquerading as sarcoidosis","volume":"41","author":"Hirt","year":"2024","journal-title":"Pediatr. Dermatol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"290","DOI":"10.1016\/j.annder.2016.10.002","article-title":"Cutaneous lesions during hot-tub hypersensitivity pneumonitis: Pseudomonas folliculitis?","volume":"144","author":"Sokolowsky","year":"2017","journal-title":"Ann. Dermatol. Venereol."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Tebruegge, M., Pantazidou, A., MacGregor, D., Gonis, G., Leslie, D., Sedda, L., Ritz, N., Connell, T., and Curtis, N. (2016). Nontuberculous Mycobacterial Disease in Children-Epidemiology, Diagnosis & Management at a Tertiary Center. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0147513"},{"key":"ref_12","first-page":"1491","article-title":"A surprising case of Mycobacterium avium complex skin infection in an immunocompetent patient","volume":"13","author":"Landriscina","year":"2014","journal-title":"J. Drugs Dermatol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"916","DOI":"10.1056\/NEJM199009273231313","article-title":"Isolation of Mycobacterium tuberculosis and M. avium complex from the same skin lesions in AIDS","volume":"323","author":"Lombardo","year":"1990","journal-title":"N. Engl. J. Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1111\/j.1346-8138.1997.tb02811.x","article-title":"Concurrent cytomegalovirus, M. tuberculosis and M. avium-intracellulare cutaneous infection in an HIV patient","volume":"24","author":"Nunez","year":"1997","journal-title":"J. Dermatol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e00081-24","DOI":"10.1128\/asmcr.00081-24","article-title":"Colonization or coinfection? A case report of Mycobacterium avium complex detected in a patient with pulmonary tuberculosis","volume":"1","author":"Bui","year":"2025","journal-title":"ASM Case Rep."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1093\/clinchem\/hvab173","article-title":"The Role of Metagenomics and Next-Generation Sequencing in Infectious Disease Diagnosis","volume":"68","author":"Miller","year":"2021","journal-title":"Clin. Chem."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"905","DOI":"10.1093\/cid\/ciaa1125","article-title":"Treatment of Nontuberculous Mycobacterial Pulmonary Disease: An Official ATS\/ERS\/ESCMID\/IDSA Clinical Practice Guideline","volume":"71","author":"Daley","year":"2020","journal-title":"Clin. Infect. Dis."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"615","DOI":"10.3349\/ymj.2008.49.4.615","article-title":"Endobronchial tuberculosis presenting as right middle lobe syndrome: Clinical characteristics and bronchoscopic findings in 22 cases","volume":"49","author":"Kim","year":"2008","journal-title":"Yonsei Med. J."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"387","DOI":"10.5603\/PiAP.2015.0062","article-title":"Middle lobe syndrome: An extraordinary presentation of endobronchial tuberculosis","volume":"83","author":"Garg","year":"2015","journal-title":"Adv. Respir. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"224A","DOI":"10.1378\/chest.1679027","article-title":"Right Middle Lobe Syndrome Due to Endobronchial Tuberculosis in Immunocompromised Young Female-An Interesting Case Report from Western India","volume":"144","author":"Chopra","year":"2013","journal-title":"Chest"},{"key":"ref_21","first-page":"353202","article-title":"Lung and Nodal Involvement in Nontuberculous Mycobacterial Disease: PET\/CT Role","volume":"2015","author":"Bianco","year":"2015","journal-title":"BioMed Res. Int."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"ofae708","DOI":"10.1093\/ofid\/ofae708","article-title":"Utility of 18F-Fluorodeoxyglucose Positron Emission Tomography in Evaluating Disseminated Nontuberculous Mycobacterial Infection in Patients with Anti-interferon-\u03b3 Autoantibodies","volume":"11","author":"Chuang","year":"2024","journal-title":"Open Forum Infect. Dis."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"aqaf121-501","DOI":"10.1093\/ajcp\/aqaf121.501","article-title":"74 Beyond the Binary: Understanding the Factors Behind Indeterminate Results on the QuantiFERON-TB Gold Plus Assay","volume":"164","author":"Ali","year":"2025","journal-title":"Am. J. Clin. Pathol."},{"key":"ref_24","first-page":"e85872","article-title":"Overview of Mendelian Susceptibility to Mycobacterial Diseases (MSMD)","volume":"17","author":"Raghuraman","year":"2025","journal-title":"Cureus"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"100540","DOI":"10.1016\/j.jacig.2025.100540","article-title":"Clinical recommendations for diagnosis and management of Mendelian susceptibility to mycobacterial disease in resource-limited settings","volume":"4","author":"Cornelissen","year":"2025","journal-title":"J. Allergy Clin. Immunol. Glob."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"102952","DOI":"10.1016\/j.jiph.2025.102952","article-title":"Clinical characteristics analysis of anti-interferon-gamma autoantibodies-associated adult-onset immunodeficiency with Mycobacterium tuberculosis infection","volume":"18","author":"Huang","year":"2025","journal-title":"J. Infect. Public Health"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"407","DOI":"10.4103\/ijmy.ijmy_191_25","article-title":"Anti-interferon-\u03b3 Autoantibody-mediated Adult-onset Immunodeficiency with Disseminated Mycobacterium abscessus Complex Infection: A Report of Three Cases","volume":"14","author":"Deng","year":"2025","journal-title":"Int. J. Mycobacteriol."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Cheng, B., Bajwa, B., Choi, S., Martin, H., Miao, T., Werry, D., Perlman, M., and Mirzanejad, Y. (2025). Anti-IFN-\u03b3 Autoantibody Syndrome Presenting with Disseminated Nontuberculous Mycobacteria Infections: A Case Series of Therapeutic Implications and Review of Literature. Trop. Med. Infect. Dis., 10.","DOI":"10.3390\/tropicalmed10070202"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Varzari, A., Deyneko, I.V., Bruun, G.H., Dembic, M., Hofmann, W., Cebotari, V.M., Ginda, S.S., Andresen, B.S., and Illig, T. (2022). Candidate genes and sequence variants for susceptibility to mycobacterial infection identified by whole-exome sequencing. Front. Genet., 13.","DOI":"10.3389\/fgene.2022.969895"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"101923","DOI":"10.1016\/j.xcrm.2024.101923","article-title":"A genome-wide association study identified PRKCB as a causal gene and therapeutic target for Mycobacterium avium complex disease","volume":"6","author":"Zheng","year":"2025","journal-title":"Cell Rep. Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1011","DOI":"10.1056\/NEJMra041809","article-title":"Anemia of Chronic Disease","volume":"352","author":"Guenter","year":"2005","journal-title":"N. Engl. J. Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"2636","DOI":"10.1038\/s41467-025-57819-1","article-title":"CD4 T cell dysfunction is associated with bacterial recrudescence during chronic tuberculosis","volume":"16","author":"Chang","year":"2025","journal-title":"Nat. Commun."},{"key":"ref_33","first-page":"e63108","article-title":"Mycobacterium tuberculosis and Mycobacterium avium Coinfection in an Immunocompetent Patient","volume":"16","author":"Karki","year":"2024","journal-title":"Cureus"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1043","DOI":"10.1093\/qjmed\/hcu090","article-title":"Primary cutaneous tuberculosis in an elderly man","volume":"107","author":"Tseng","year":"2014","journal-title":"QJM Int. J. Med."},{"key":"ref_35","unstructured":"I\u00e7meli, \u00d6.S., T\u00fcrker, H., \u00c7ft\u00e7i, M., G\u00fcndogus, B., and Kavala, M. (2012). Cutaneous tuberculosis: Two cases report. Eur. Respir. J., 40."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"e0041224","DOI":"10.1128\/spectrum.00412-24","article-title":"Immunoinhibitory effects of anti-tuberculosis therapy induce the host vulnerability to tuberculosis recurrence","volume":"12","author":"Pahuja","year":"2024","journal-title":"Microbiol. Spectr."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1258\/0022215001906426","article-title":"Dual infection with atypical mycobacteria and Mycobacterium tuberculosis causing cervical lymphadenopathy in a child","volume":"114","author":"Ganesan","year":"2000","journal-title":"J. Laryngol. Otol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"759","DOI":"10.1097\/INF.0b013e31816ffc27","article-title":"Intrathoracic lymphadenitis caused by Mycobacterium avium and Mycobacterium tuberculosis in an immunocompetent child","volume":"27","author":"Tuerlinckx","year":"2008","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"985S","DOI":"10.1378\/chest.126.4_MeetingAbstracts.985S-b","article-title":"A case of Mycobacterium tuberculosis (MTB) and Mycobacterium avium-complex (MAC) co-infection in an immunocompetent host: A pathogen and a colonizer or two pathogens in the same host?","volume":"126","author":"Damian","year":"2004","journal-title":"Chest"},{"key":"ref_40","first-page":"e100932","article-title":"Dual Mycobacterial Infection: Rare Coinfection of Mycobacterium tuberculosis and Nontuberculous Mycobacteria","volume":"18","author":"Aryal","year":"2026","journal-title":"Cureus"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"bcr2016218372","DOI":"10.1136\/bcr-2016-218372","article-title":"Multiplex PCR-based detection of Mycobacterium tuberculosis and Mycobacterium avium in a single host: One coloniser or dual infection?","volume":"2017","author":"Sharma","year":"2017","journal-title":"BMJ Case Rep."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"S151","DOI":"10.4103\/0255-0857.150940","article-title":"Multiplex PCR in diagnosis of M. tuberculosis and M. avium co-infection from lymph node in an AIDS patient","volume":"33","author":"Sharma","year":"2015","journal-title":"Indian J. Med. Microbiol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1319","DOI":"10.4102\/sajhivmed.v23i1.1319","article-title":"Multiple opportunistic infections (pulmonary tuberculosis, Mycobacterium avium complex and parvovirus B19) in a single patient","volume":"23","author":"John","year":"2022","journal-title":"South. Afr. J. HIV Med."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1789","DOI":"10.1099\/jmm.0.045898-0","article-title":"PCR detection of co-infection with Mycobacterium tuberculosis and Mycobacterium avium in AIDS patients with meningitis","volume":"61","author":"Sharma","year":"2012","journal-title":"J. Med. Microbiol."},{"key":"ref_45","first-page":"e91532","article-title":"Disseminated Extrapulmonary Tuberculosis and Pulmonary Mycobacterium avium Complex Co-infection in a Newly Diagnosed HIV Patient: A Case Report","volume":"17","author":"Lopez","year":"2025","journal-title":"Cureus"}],"container-title":["Pathogens"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-0817\/15\/7\/774\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T11:15:58Z","timestamp":1784718958000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-0817\/15\/7\/774"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,22]]},"references-count":45,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["pathogens15070774"],"URL":"https:\/\/doi.org\/10.3390\/pathogens15070774","relation":{},"ISSN":["2076-0817"],"issn-type":[{"value":"2076-0817","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,22]]}}}