Case report
A 32-year-old woman presented to the dermatology clinic with a tender lump over the right maxilla of 6 weeks’ duration. The lesion developed acutely 1 to 2 months after the patient began using a microdermabrasion device at home, which she regularly cleaned with tap water. Physical examination was notable for a 1.5-cm soft, superficially indurated plaque on the right cheek without associated lymphadenopathy (Figure).
A 1.5-cm soft, superficially indurated plaque on the right cheek without associated lymphadenopathy, which was caused by Mycobacterium abscessus infection after dermabrasion at home.
A punch biopsy revealed underlying necrotic fat. Computed tomography of the neck showed a 20-mm thickening of the skin over the right zygomatic arch, with minimal subcutaneous soft tissue apposition and active lymph nodes. Further histological examination of the biopsy specimen revealed inflammatory granulomatous tissue with granulomatous inflammation.
Mycobacterium marinum remains an unknown cause of skin infections
Bacterial culture with acidity was positive. Subsequent speciation revealed that the causative agent is multidrug resistant Mycobacterium abscessus. The patient was initially treated with trimethoprim-sulfamethoxazole, which was changed to a combination of doxycycline and levofloxacin a few days later after the initial culture returned. The following week, after the specific susceptibility organism was confirmed, therapy was changed to intravenous (IV) tigecycline and amikacin. This regimen was continued for 2 more months via a peripherally inserted central catheter and then discontinued after complete resolution of the skin lesion.
Comment
Mycobacterial Infection
Nontuberculous mycobacteria were not recognized as human pathogens until the 1950s. They are known to cause skin disease, lymphadenitis, skeletal infection, pulmonary disease, and disseminated infection, with pulmonary disease being the most common clinical form overall.1Mycobacterium abscessus is a member of a more specific group known as fast-growing nontuberculous mycobacteria, which also includes Mycobacterium fortuitum and Mycobacterium chelonae.2 Commonly found in water, soil and dust, Abscess causes skin and soft tissue infection after skin injury by inoculation, minor trauma, or surgery.2-4 An increased rate of infections recently has been attributed to the increase in cosmetic procedures such as tattooing, liposuction, mesotherapy, pedicures and body piercing. Mycobacterial infections transmitted through acupuncture have also been documented.5,6
Causes of skin and soft tissue infections
Skin and soft tissue infections due to rapidly growing mycobacteria are often associated with systemic immunosuppressive comorbidities and immunosuppressive drugs.7 Our patient had no preexisting comorbidities and was not taking long-term medication. When multiple lesions were reported, patients were more likely to either have systemic comorbidity or receive immunosuppressive drugs compared to patients with a single lesion. A history of penetrating trauma or invasive surgery has been reported more often in patients with a single lesion.7
Our patient had a solitary facial lesion. Improper sterile technique when using a microdermabrasion device at home was thought to be the cause of the infection. Although generally considered a minimally abrasive treatment method, microdermabrasion caused enough trauma to create an infection in our patient.
Presentation
Cutaneous infection by rapidly growing mycobacteria may present as a nonhealing ulcer, subcutaneous abscess, sinus drainage, or subcutaneous fluctuating or fixed nodules. Erythema may be found in association with ulcers or chronic drainage from a surgical wound.2.7
Sporocapillary Pattern of Mycobacterium chelonae-abscessus Infection
The histopathological appearance varies, depending on the progression of the disease and the immune status of the host. Tuberculous, palisade and sarcoid granulomas. a diffuse infiltrate of histiocytic foam cells. acute and chronic panniculitis. nonspecific chronic inflammation. skin abscess; granuloma suppurativa? and necrotizing folliculitis can all be seen.8 Immunosuppressed patients are less likely to form granulomas.6 Diagnosis is often delayed because acid-fast bacterial culture is not routinely performed on skin biopsy specimens or surgical wound infections.7 Fortunately, a high index of suspicion in our patient’s case allowed early diagnosis and rapid treatment.
Management
Mycobacterium abscessus tends to be resistant to conventional antituberculosis drugs. in general, it is considered a highly drug-resistant pathogen that is difficult to treat.9,10 Treatment usually requires 3 to 6 months of therapy, with oral clarithromycin considered the first-line agent for localized infection.5 Because cases of resistance to clarithromycin have been reported in patients with M chelonae infection, caution is required when deciding between monotherapy and combination therapy.7 Multidrug resistance often requires prolonged intravenous therapy. Amikacin is the most commonly used intravenous agent for Abscess contamination. Adverse effects of treatment are common, often leading to a change or discontinuation of treatment.11
Our patient was initially treated with trimethoprim-sulfamethoxazole before switching to doxycycline and levofloxacin prior to final susceptibility test results. Ultimately, due to its multi-resistant nature Abscess, clarithromycin was not a viable option. Therefore, the patient was administered tigecycline and amikacin via a peripherally inserted central catheter until complete resolution of symptoms.
Surgery may be an important adjunctive measure for some patients, especially those with a single lesion.7 Our patient did well with medical treatment alone.
Primary cutaneous Mycobacterium avium infection after resection of squamous cell carcinoma
conclusion
Given the difficulty of treating skin and soft tissue infections caused by Abscess and related mycobacteria, it is worth noting that these infections are increasingly caused by procedures that are generally considered minimally invasive. Microdermabrasion—performed at home in a non-sterile environment rather than by a trained physician—was the causative procedure in this case. An important issue is whether clinicians can feel comfortable using these treatments at home or whether they should advise patients against home treatment who have potentially serious complications.
