Toxic shock syndrome after explantation of breast implants: a case report and review of the literature

Review of Early Signs of Breast Implant Infection

BACKGROUND

Breast implant infection remains a problem despite various prevention methods. Common pathogens such as staphylococcus aureus typically present acutely with fever, erythema, swelling, and pain. However, with the increasing occurrence of mycobacterial infections, associated early signs and symptoms are typically absent, making early detection difficult.

METHOD

A retrospective chart review of patients who underwent esthetic breast augmentation by senior surgeon FDP in an outpatient surgical facility from 1992 to 2021 was conducted. Cases of infections and related information including infection onset, presenting signs and symptoms, and culture results were recorded. Presentation differences between infections caused by common pathogens and mycobacteria were compared.

RESULTS

A total of nine infections were reported in 365 patients. Seven cases were due to common pathogens: staphylococcus aureus, pseudomonas aeruginosa, methicillin-resistant staphylococcus aureus (MRSA), and staphylococcus epidermidis. Fever, erythema was presented within an average of 10 days after surgery. Two cases were due to mycobacterium chelonae (non-tuberculous mycobacterium) infection. In the latter, the earliest signs and symptoms consisted of mild pain and swelling in the absence of fever and erythema, which began on average of 54 days after the operation.

CONCLUSION

Common breast implant infection pathogens usually present early with fever and erythema. However, our study found that non-tuberculous mycobacteria infections occur much later and fever and erythema are typically absent. The purpose of this study is to increase the awareness of clinicians with this rare but rapidly increasing variety of infections and to advise the operating surgeon to include mycobacteria infections in the differential diagnosis.

LEVEL OF EVIDENCE IV

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Breast Implant Infections: An Update

Prosthetic breast implantation is a common surgical procedure for augmentation and reconstruction after mastectomy. The incidence of implant infection is 1% to 2.5% and is higher for reconstruction following mastectomy compared with augmentation. Most infections are caused by gram-positive pathogens, such as coagulase-negative staphylococci, Cutibacterium species, Staphylococcus aureus, and streptococci. Acute infections are usually associated with fever and breast pain, erythema, and drainage. Subacute infections may present with chronic pain, persistent drainage, failed healing of the incision site, or migration of the implant. Depending on severity of infection, patients are started on empiric intravenous or oral antibiotics and closely monitored.

A case of toxic shock syndrome following a DIEP breast reconstruction

Mastectomy with immediate breast reconstruction has become the standard treatment for Carcinoma breast in UK and many parts of the world. Autologus reconstruction with muscle sparing TRAM/ DIEP is the 'Gold Standard' for assessing the newer options for breast reconstruction. Toxic Shock Syndrome (TSS) is a rare but fatal condition particularly seen in the female population. Few cases of TSS have been reported in the Plastic Surgery literature following Silicone implant based reconstruction. We report a case of TSS following Deep Inferior Epigastric Perforator flap (DIEP)reconstruction. Due to the aggressive nature of TSS, the European Society of Intensive Care Medicine (ESICM) has initiated the 'Surviving Sepsis' campaign to propagate, information and management guidelines for the general public and health professionals. We present a case report with the pathophysiology of TSS.

Streptococcal Toxic Shock Syndrome After Breast Reconstruction

Streptococcal toxic shock syndrome (STSS) is an increasingly common disease entity but has rarely been described in the plastic surgery literature. We present the first known case of STSS associated with a reconstructive procedure. Two weeks postoperatively from a transverse rectus abdominis musculocutaneous flap for breast reconstruction, our patient presented with flulike symptoms and progressed rapidly to multiorgan failure. Though initially no nidus for infection was evident, the abdominal donor site was surgically debrided and found to contain group A Streptococcus. Following aggressive rehydration and antibiotic therapy, the patient gradually made a full recovery. In this case report, we review the presentation and epidemiology of STSS and compare it to the more common staphylococcal toxic shock syndrome. In addition, we discuss the management and outcomes of STSS, with an emphasis on raising clinical suspicion for this rare but dangerous entity.

Toxic shock syndrome associated with the use of the vacuum-assisted closure device

The vacuum-assisted wound closure technique and device (the V.A.C.) has become a widely accepted technique in the management of chronic and difficult wounds. The authors present the first reported case of toxic shock syndrome associated with its use. This article does not question the efficacy of the V.A.C. technique in the treatment of difficult wounds, but focuses on raising the index of suspicion of toxic shock syndrome in patients with wounds managed with the V.A.C. who develop early signs or symptoms that may be consistent with the diagnosis.

Infectious disease update

Many newly described or "re-emerging" infectious diseases may present to the dermatologist, often with potentially life-threatening implications. Prompt recognition and early intervention can greatly diminish the morbidity and mortality associated with these diseases.