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Mycobacterium abscessus is an uncommon cause of iatrogenic infections.
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M. abscess (subgen massiliense) is a nontuberculous mycobacterium that contains a nonfunctional em gene, which confers sensitivity to macrolides.
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The treatment of skin infections caused by M. abscess uses a combination of surgical debridement and several antimicrobial agents.
A 53-year-old previously healthy man presented with painful, red nodules on his anterior scalp 3 weeks after a hair transplant in Panama. The patient had approximately 6000 individual hair follicles manually inserted into the upper and frontal region of his scalp during an 8-hour surgery using the direct hair transplant technique. The procedure was well tolerated and the patient returned to North America. Nineteen days after hair transplantation, the patient noticed nodules on the anterior scalp that gradually increased in size over 4 days, along with erythema, pain and tenderness along the scalp, and spontaneous purulent drainage. He was seen by his family doctor and prescribed 6 days of oral doxycycline (100 mg, twice daily), followed by oral cephalexin (500 mg, 4 times daily). She continued to have spontaneous purulent drainage despite 7 days of antimicrobial therapy and presented to our emergency department 1 day after starting cephalexin.
At presentation, the patient was afebrile and did not show systemic signs of infection. Over the anterior scalp, there was a fluctuation area filled with surgical gauze, with purulent drainage and surrounding erythema. The donor hair region on the posterior scalp appeared normal. He had a normal white blood cell count and normal levels of serum creatinine, electrolytes, and C-reactive protein. In the emergency department, needle aspiration was performed and a deep tissue sample was submitted for microbiological analysis. The emergency physician started 5 days of intravenous cefazolin (2 g/d), oral probeneoxy (1 g/d), and trimethoprim-sulfamethoxazole (1 oral double-strength tablet, twice daily) for 1 week. The infection did not go away with this regimen.
After 5 weeks of incubation, Mycobacterium abscessus (subgen massiliense) was isolated from the deep tissue sample, with antimicrobial susceptibility as reported in Table 1. The patient underwent incision and drainage of 5 anterior scalp abscesses approximately 2 months after hair transplantation (Figure 1). Based on the results of drug susceptibility testing, the infectious disease specialist started the patient on combination antimicrobial therapy with intravenous amikacin (1500 mg [18 mg/kg], 3 times/week) and oral clarithromycin (500 mg, twice daily). We followed the patient with weekly audiometric assessments and blood tests. Therapeutic drug monitoring targeted amikacin peak levels of 65–80 mg/L and trough levels of less than 5 μg/mL.
Sensitivity results of Mycobacterium abscessus (subgen massiliense) was isolated from scalp abscesses of a man after hair transplantation
Skull of a 53-year-old man with Mycobacterium abscessus infection after scalp nodule incision and drainage (with quarter-inch tape sealing strips in situ), 2 months after hair transplantation and before initiation of amikacin and clarithromycin.
One month after initiation of antimicrobial therapy, the patient noted nocturnal tinnitus and audiometric testing revealed mild hearing loss in the right ear. By this time, she had significant improvement in the erythema and swelling of the nodules (Figure 2). The patient also reported relief of pain and tenderness in the corresponding area. We stopped amikacin and continued monotherapy with clarithromycin for another 5 months. The patient’s tinnitus and hearing loss resolved after discontinuation of amikacin, and his nodules and abscesses resolved completely at the end of treatment. Approximately 3 months after completion of clarithromycin therapy, she had no signs of recurrent infection.
Skull of a 53-year-old man with Mycobacterium abscessus infection after completion of 1 month of amikacin and clarithromycin combination therapy.
Discussion
Increasingly, patients are seeking medical treatment abroad and reports of difficult postoperative surgical site infections are increasing. Our patient’s multiresistant M. abscess Scalp infection after hair transplantation in Central America is an example of the precautionary concern warranted for people seeking cosmetic procedures outside of Canada. Although M. abscess is widespread throughout the world, the frequency of infection can vary.1 Areas such as East Asia and islands in the south and central Pacific Ocean have been shown to have higher rates M. abscess infections.1,2 In British Columbia, the incidence of non-tuberculous mycobacterial (NTM) pulmonary disease is lower than in other regions, at about 1.6 per 100,000, with skin infections being less common.2,3
Nontuberculous mycobacteria are ubiquitous in the environment and cause 7 major clinical syndromes: pulmonary disease, lymphadenitis, skin and soft tissue infection, skeletal infection, disseminated infection, catheter-related infection, and hypersensitivity pneumonitis.4 The most common NTMs causing skin and soft tissue infections are Mycobacterium chelonae, Mycobacterium fortuitum and M. abscess.5
M. abscess it grows quickly, is resistant to drugs and can withstand high temperatures and nutrient-poor environments.4 It has been associated with contamination of water sources, hospital equipment and drugs.6–10 It has also been described in complications after hair transplantation.11 The M. abscess The complex includes 3 subspecies, viz M. abscess subspecies abscess, M. abscess subspecies bolletii and M. abscess subspecies massiliense. Infections caused by M. abscess they are often difficult to treat because they are inherently resistant to classic antituberculosis drugs and most classes of antibiotics. The presence of an operative erm(41) gene inactivates macrolides through inducible macrolide resistance. M. abscess subspecies massiliense isolations do not contain the operating system erm(41) gene and thus are intrinsically sensitive to macrolides.12 These isolates respond well to clarithromycin-based regimens.
His clinical presentation M. abscess Infection includes abscesses, nodules, cellulitis, panniculitis, ulcers, and sinus drainage, often occurring weeks to months after surgery.13 Diagnosis is made by isolating the organism from clinical samples. Nontuberculous mycobacteria are difficult to detect on Gram stain and routine cultures. Combined with the slow turnaround time of antimicrobial susceptibility testing of NTMs, this difficulty often results in a delay in diagnosis and initiation of appropriate antimicrobial therapy. The choice of antibiotics is usually guided by drug susceptibility results, given the complexity of antimicrobial resistance.13
A case series of 6 surgical site infections caused by NTMs in India reported response to treatment with clarithromycin monotherapy in 5 of 6 cases after 2 months, with 1 case in the shoulder joint requiring a combination of clarithromycin and amikacin. All 6 NTM strains were sensitive to clarithromycin and surgical debridement was not performed.14 Another case series was reported 5 M. abscess subspecies abscess infections after cosmetic surgery in Ecuador successfully treated with surgical debridement and combination antimicrobial therapy for 7 months.15 A third case series reported 10 surgical site infections caused by NTM in Venezuela that were successfully treated with a combination of surgical debridement and prolonged combination antimicrobial therapy (> 3 months), including clarithromycin.13
Clarithromycin monotherapy has been shown to be less effective than a combination of surgery and antibiotic therapy.16 In addition, another study found that the concomitant use of clarithromycin and amikacin may be associated with increased resolution of lesions compared with monotherapy with either antibiotic in patients who developed M. abscess skin infection after acupuncture.17 In a study comparing a combination of amikacin and clarithromycin or azithromycin with triple therapy with amikacin, either clarithromycin or azithromycin and either cefoxitin or imipenem in patients with M. abscess lung disease, treatment success and recurrence rates were comparable. However, the triple agent regimen was associated with an increased incidence of adverse events.18
Given the lack of data on its treatment M. abscess skin infections, we expanded the use of combination therapy based on sensitivity for our patient with M. abscess scalp infection. We treated it with a combination of surgical debridement and targeted antimicrobial therapy. We used both clarithromycin and amikacin, as well as close monitoring of audiometry and therapeutic drug levels. We chose weekly audiometry monitoring because we expected a prolonged course of amikacin exposure. The amikacin course was limited by tinnitus in 1 month, so we prescribed clarithromycin monotherapy for another 5 months.
With an increasing number of patients seeking medical treatment abroad, infectious complications are a challenge for patients and healthcare systems. M. abscess Infections are an uncommon complication of cosmetic surgery, but should be considered in patients with postoperative infections unresponsive to standard antimicrobial therapy. Microbiological samples should be taken to determine the organism and antibiotic sensitivity. Surgical drainage and debridement should be used in conjunction with antibiotics.
Footnotes
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Competing interests: None declared.
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This article has been peer reviewed.
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The authors have obtained patient consent.
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Coefficients: All authors contributed to the conception and design of the project, drafted the manuscript, revised it critically for important intellectual content, gave final approval of the version to be published and agreed to be responsible for all aspects of the project.
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https://www.cmaj.ca/content/195/42/E1440
