Case Report
The Challenging Treatment of Mycobacterium Abscesses after Gluteal Fat Injections in the Dominican Republic a Rare Pathogen, Becoming a Frequent Problem
Brianne Sullivan*, Eimon Lee and Grace Kim
Department of Surgery, Stony Brook University School of Medicine, USA
*Corresponding author: Brianne Sullivan, Department of Surgery, Stony Brook University School of Medicine, 1111 Amsterdam Avenue, New York, NY 10025, USA
Published: 18 Dec, 2017
Cite this article as: Sullivan B, Lee E, Kim G.
The Challenging Treatment of
Mycobacterium Abscesses after
Gluteal Fat Injections in the Dominican
Republic a Rare Pathogen, Becoming a
Frequent Problem. Ann Clin Case Rep.
2017; 2: 1487.
Abstract
A 53-year-old woman presented with sepsis from gluteal cellulitis and abscesses one month after undergoing abdominoplasty and "buttock sculpting" in the Dominican Republic. The patient required numerous debridements and drainage procedures, in addition to IV antibiotics for over two weeks before her sepsis could be controlled. Eventually, the rare pathogen mycobacterium abscesses was identified as the source of her infection. Though uncommon in the United States, non-tuberculous mycobacterial (NTM) infections are increasingly associated with cosmetic surgery procedures performed in foreign countries. Patients infected with this organism often face a delay in diagnosis, an extended hospital stay, multiple surgical debridements, antimicrobial resistance, prolonged antibiotic course and poor cosmetic results. Clinicians should consider NTM infection in any patient who presents with a surgical site infection after a cosmetic procedure who is not appropriately responding to conventional therapy.
Introduction
This case report demonstrates how an unexpected pathogen can have serious health consequences. The presentation of a NTM infection is variable, and histology, AFB culture, and new technologies like PCR can help make the diagnosis. Involvement of infectious disease and surgical teams is critical for proper evaluation and treatment for a disease process that has proven to have a complicated course and arduous recovery.
Case Presentation
The patient is a 53-year old previously healthy woman who presented to the Emergency Room
with sepsis from gluteal cellulitis and abscesses one month after undergoing abdominoplasty,
abdominal contouring, and bilateral “buttock sculpting” in the Dominican Republic (DR). The
patient reportedly had an uneventful surgery where an abdominoplasty was performed and the
harvested fat was autografted into the buttocks through multiple injections. The patient then stayed
in the DR in a recovery house where she received a two-week course of postoperative intravenous
antibiotics as per protocol before returning to the United States.
Approximately one week after her return, the patient presented to the Emergency Department
with fevers, chills, and buttock pain. The patient had no past medical history, took no medications
and was a non-smoker. On exam, the patient was febrile to 102.7°F and tachycardic. The patient
had edematous, tender buttocks with extensive areas of induration and fluctuance without crepitus,
primarily centered over the bilateral ischial tuberosities. Labs were notable for a WBC of 16.4 K.
A CT scan demonstrated extensive soft tissue densities with thickening in the superficial fat of the
buttock region and lateral pelvis. There were no significant collections identified other than a small
perianal fluid collection in the right ischiorectal fossa. The patient was taken to the operating room
for incision and drainage of the buttock abscesses based on clinical picture.
An extensive incision and drainage with debridement was performed over each buttock.
Approximately 100 ml of yellow purulent material was drained from each buttock. Additionally, the
patient was found to have several other smaller abscess pockets remaining which were sequentially
opened through multiple smaller incisions. All wounds were debrided and irrigated extensively. The
drainage was sent for gram stain and culture. The patient was placed on ceftriaxone, vancomycin,
and flagyl as advised by the Infectious Disease (ID) consultants.
The patient initially improved with less tenderness and resolving
septic parameters. However, over the ensuing days she spiked
temperatures and mounted a leukocytosis. On exam, the primary
wounds were healing appropriately. Yet, additional new discrete
abscesses were discovered throughout her buttocks requiring incision
and drainage. The patient remained subjectively asymptomatic. This
course continued for eight days where multiple subsequent incision
and drainage procedures were performed.
The original cultures were negative for over a week until they
finally demonstrated acid fast bacilli (AFB). To ascertain precise
speciation, the specimen was sent to the New York State Department
of Health. Based on the smouldering course, it was presumed that
this represented a mycobacterial infection, and the patient was
continued on broad spectrum intravenous antibiotics (imipenem,
cefoxitin, and vancomycin) and oral clarithromycin per revised ID
recommendations.
The patient was ultimately discharged on antibiotics and with
visiting nursing for wound care, seventeen days after her original
operative incision and drainage. Final speciation demonstrated
mycobacterium abscessus two weeks after her inpatient discharge.
Discussion
This clinical scenario is becoming more common as residents of
the United States increasingly seek cosmetic surgery internationally.
Lipotourism, or cosmetic tourism, has become a popular practice for
Americans due to lower costs and patient anonymity [1]. According
to a 2002 survey, 3%-4% of travellers to Central and South America
selected "health treatment" as the purpose for their visit [2]. Though
generally routine, these cosmetic procedures can potentially have
devastating complications. They tend to present in a delayed fashion,
leaving physicians in the United States responsible for diagnosis and
treatment without a clear sense of the nature of the operation or
conditions under which it was performed. Ironically, the monetary
cost to recovery often well exceeds the cost of the original domestic
procedure with exceedingly disappointing cosmetic results [1].
Further confounding the care of these patients, surgical site
infections associated with lipotourism are caused by pathogens
uncommon and unexpected in the United States, such as atypical
mycobacterial or non-tuberculous (NTM) infections. The most
common NTM infections include M. chelonae, M. fortuitum, and
M. abscessus [3]. The first reported case of an atypical mycobacterial
infection after liposuction was published in 1990 with a subsequent
outbreak of 9 cases in Venezuela in 1998 [4]. There are multiple case
reports of both foreign and domestic infections of NTM occurring
after a wide variety of procedures, ranging from injections of vitamin
preparations, DPT vaccine, iron dextran and penicillin, in addition
to cosmetic surgeries involving fat injection, liposuction, breast/
penile implants, cardiothoracic surgery, facelift and blepharoplasty
[5-7]. The exact mechanism of infection is not entirely clear, though a
possible cause is the use of tap water for cleaning surgical instruments
followed by poor sterilization, since NTM are found in biofilms in
aqueous systems and are relatively resistant to standard disinfectant
techniques. NTM also tend to grow on inert materials, hence the
propensity for implants and fat grafts [3].
The clinical presentation of NTM infections can range from
cellulitis, abscess formation, draining sinuses, and/or delayed
postoperative wound infection ranging from two to eight weeks after
initial operation [8]. Systemic signs of infection are variable [9]. In one study, patients presented with unimpressive cutaneous draining
nodular lesions seven weeks post-procedure without systemic signs.
The drainage can be malodorous or odor-free. The drainage is usually
non-purulent, appearing light yellow and serous. CRP may be
elevated [4]. The presentation of NTM infections often may appear
deceptively mild at initial evaluation.
In a review of 88 case reports of NTM, Rok and colleagues
composed clinical criteria in which NTM should be highly suspected
and empirically treated. Major criteria included previous history of
aesthetic procedure operation in the last 3 months and minor criteria
included negative bacterial culture, no response to routine oral
antibiotics in two weeks, localized infection at previous procedure
site, and predisposing factor of immunosuppression. The authors
note the physical exam skin findings for NTM is slightly different
from pyogenic bacterial infections with darker, purplish erythema,
likely due to the chronicity of the disease process [10].
The diagnosis of NTM is usually delayed for numerous reasons.
The infection runs a smouldering course and is generally only
considered after the patient fails conventional antibiotic therapy
and initial cultures have been finalized as “negative.” Because the
microbiologic confirmation of this infection may be a lengthy
process, some advocate other means of diagnosis including the
characteristic histiologic findings such as central caseous necrosis
with amorphous granular debris and presence of Langhan’s giant
cells [3,10]. The traditional AFB stain is rapid but has low sensitivity
and is not adequate to make the diagnosis. The AFB culture is highly
sensitive but can take 6-8 weeks for non-rapidly growing strains.
There are newer tests including real-time PCR, restriction fragment
length polymorphism (RFLP), and PCR-reverse blot hybridization
assay (REBA) which are costly and not yet readily available.
Treatment usually requires aggressive surgical debridement,
repeated as more abscesses develop, and long-term macrolidebased
antibiotic therapy [3]. Local wound care is often found to be
insufficient [9]. The use of negative wound pressure has also been
suggested by some surgeons [1]. In a 2008 review of 20 cases of NTM
after cosmetic surgery in the DR it took an average of 9 months of
antibiotic treatment until patients were cured [2]. This is consistent
with other case reports in the literature [3,4]. A literature review by Lin
and colleagues recommends a minimum of 4 to 6 months of systemic
antibiotic treatment, usually with clarithromycin or fluroquinolones
[11]. One case report of facial injection with autologous fat took a full
year of treatment until symptoms resolved completely [12].
Most literature on NTM is found in plastic surgery or infectious
disease journals. Yet, because of the increase in lipotourism, this is
a clinical problem with which general surgeons and internists must
become more familiar. Additionally, patient education and a push for
greater public awareness of the risks associated with cosmetic tourism
are important steps to reverse the current trend that appears to be
gaining popularity.
References
- Cai SS, Chopra K, Lifchez SD. Management of Mycobacterium abscessus infection after medical tourism in cosmetic surgery and a review of the literature. Ann Plast Surg. 2016;77:678-682.
- Furuya EY, Paez A, Srinivasan A, Cooksey R, Augenbraun M, Baron M, et al. Outbreak of Mycobacterium abscessus wound infections among "lipotourists" from the United States who underwent abdominoplasty in the Dominican Republic. Clin Infect Dis. 2008;46:1181-1188.
- Rüegg E, Cheretakis A, Modarressi A, Harbarth S, Pittet-Cuénod B. Multisite infection with Mycobacterium abscessus after replacement of breast implants and gluteal lipofilling. Case Rep Infect Dis. 2015;2015:361340.
- Zosso C, Lienhard R, Siegrist HH, Malinverni R, Clerc O. Post liposuction infections by rapidly growing mycobacteria. Infect Dis. 2015;47:69-72.
- Devi DR, Indumathi VA, Indira S, Babu PR, Sridharan D, Belwadi MR. Injection site abscess due to Mycobacterium fortuitum: a case report. Indian J Med Microbiol. 2003;21:133-134.
- Schlarb D, Idelevich EA, Krause-Bergmann A, Stollwerck P. Successful interdisciplinary radical treatment of Mycobacterium fortuitum infection in a lipotourist from Germany after abdominoplasty in Turkey. New Microbes New Infect. 2015;10:21-23.
- Galea LA, Nicklin S. Mycobacterium abscessus infection complicating hand rejuvenation with structural fat grafting. J Plast Reconstr Aesthet Surg. 2009;62:15-16.
- Lim JM, Kim JH, Yang HJ. Management of infections with rapidly growing mycobacteria after unexpected complications of skin and subcutaneous surgical procedures. Arch Plast Surg. 2012;39:18-24.
- Engdahl R, Cohen L, Pouch S, Rohde C. Management of Mycobacterium abscessus post abdominoplasty. Aesthetic Plast Surg. 2014;38:1138-1142.
- Kim HR, Yoon ES, Kim DW, Hwang NH, Shon YS, Lee BI, et al. Empirical treatment of highly suspected nontuberculous mycobacteria infections following aesthetic procedures. Arch Plast Surg. 2014;41:759-767.
- Lin SS, Lee CC, Jang TN. Soft Tissue infection caused by rapid growing Mycobacterium following medical procedures: Two Case Reports and Literature Review. Ann Dermatol. 2014; 26: 236-240.
- Yang P, Lu Y, Liu T, Zhou Y, Guo Y, Zhu J, et al. Mycobacterium abscessus infection after facial injection with autologous fat: A case report. Ann Plast Surg. 2016;78:138-140.