Soft Tissue Infection Caused by Rapid Growing Mycobacterium following Medical Procedures: Two Case Reports and Literature Review

Complicated Surgical Site Infection with Mycobacterium Abscessus After Liposuction and Affections of Corticosteroids in the Treatment Regimen: Three Cases Report and a Systematic Review

INTRODUCTION

Mycobacterium abscessus infection after liposuction/fat grafting is a rare complication that is hard to diagnose and treat. Misdiagnosis could result in treatment failure and prolonged hospital stays. The paradoxical reaction is another complication that rarely occurs in non-HIV patients infected with nontuberculosis mycobacteria. This study reported 3 cases infected with M. abscessus complicated by the paradoxical reaction after liposuction and fat grafting. It highlighted characteristics giving clues of the paradoxical reaction and a successful strategy. Also, a systematic review was conducted to comprehensively provide varied aspects of M. abscessus infection after liposuction and/or fat grafting.

METHODS

Three cases were retrospectively included reporting data characteristics of patients, cosmetic procedures, and treatment strategy. PubMed, Scopus, Virtual Health Library (VHL), and Global Health Library (GHL) were searched to find and include cases with M. abscessus infection after liposuction and/or fat grafting based on defined selection criteria. Relevant data were extracted and summarized. The risk of bias in included studies was assessed using JBI critical appraisal checklists.

RESULTS

Twenty-four articles were included in the systematic review. Symptoms often developed approximately 1 month after the cosmetic surgery. Culture, AFB, and PCR were common methods of diagnosis of M. abscessus after liposuction and/or fat grafting. It took about 33 days on average from the presentation to isolate and detect the pathogens. Antibiotics based on susceptibility testing results along with surgical interventions were effective methods of treatment. Our three cases which were complicated by the paradox were addressed by adding methylprednisolone for 2 weeks to the macrolide-based therapy.

CONCLUSIONS

Awareness of this disease should be widely raised among physicians for early diagnosis and proper treatments. Cultures of specimens and AFB should be repeated many times before excluding the possibility of Mycobacterium spp. A paradoxical reaction should be suspected if the symptoms were worse after the antibiotic therapy based on susceptibility testing results and proper surgical interventions, especially if patients had taken corticosteroids before being admitted.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Ferritin from Mycobacterium abscessus is involved in resistance to antibiotics and oxidative stress

Mycobacterium abscessus subsp. massiliense (Mycma) is a rapidly growing Mycobacterium belonging to the M. abscessus complex that is often associated with lung and soft tissue infection outbreaks. Mycma is resistant to many antimicrobials, including those used for treating tuberculosis. Therefore, Mycma infections are difficult to treat and may lead to high infectious complication rates. Iron is essential for bacterial growth and establishment of infection. During infection, the host reduces iron concentrations as a defense mechanism. To counteract the host-induced iron deficiency, Mycma produces siderophores to capture iron. Mycma has two ferritins (encoded by mycma_0076 and mycma_0077) modulated by different iron concentrations, which allow the survival of this pathogen during iron scarcity. In this study, we constructed knockout (Mycma 0076KO) and complemented (Mycma 0076KOc) gene strains for mycma_0076 to understand the function of 0076 ferritin. Deletion of mycma_0076 in Mycma led to the transition in colony morphology from smooth to rough, alteration of the glycopeptidolipids spectra, increased permeability of the envelope, reduction in biofilm formation, increased susceptibility to antimicrobials and hydrogen peroxide-induced oxidative stress, and decreased internalization by macrophages. This study shows that Mycma_0076 ferritin in Mycma is involved in resistance to oxidative stress and antimicrobials, and alteration of cell envelope architecture. KEY POINTS: • Deletion of the mycma_0076 gene altered colony morphology to rough; • Mycma 0076KO changed GPL profile; • Absence of Mycma_0076 ferritin results in increased susceptibility to antimicrobials and oxidative stress in Mycma. Legend: a In wild-type M. abscessus subsp. massiliense strain, iron is captured from the environment by carboxymycobactins and mycobactins (1). Iron-dependent regulator (IdeR) proteins bind to ferrous iron (Fe⁺²) in the bacterial cytoplasm leading to the activation of the IdeR-Fe⁺² complex (2). The activated complex binds to the promoter regions of iron-dependent genes, called iron box, which in turn help in the recruitment of RNA polymerase to promote transcription of genes such as mycma_0076 and mycma_0077 ferritin genes (3). Mycma_0076 and Mycma_0077 ferritins bind to excess iron in the medium and promote Fe²⁺ oxidation into ferric iron (Fe³⁺) and store iron molecules to be released under iron scarcity conditions. (4) Genes related to biosynthesis and transport of glycopeptidolipids (GPL) are expressed normally and the cell envelope is composed of different GPL species (colored squares represented on the cell surface (GPLs). Consequently, WT Mycma present smooth colony phenotype (5). b In Mycma 0076KO strain, the lack of ferritin 0076 causes overexpression of mycma_0077 (6), but does not restore wild-type iron homeostasis and thus may result in free intracellular iron, even in the presence of miniferritins (MaDps). The excess iron potentiates oxidative stress (7) by generating hydroxyl radicals through Fenton Reaction. During this process, through an unknown mechanism, that could involve Lsr2 (8), the expression of GPL synthesis locus is regulated positively and/or negatively, resulting in alteration of GPL composition in the membrane (as represented by different colors of squares on the cell surface), resulting in a rough colony phenotype (9). The changes of GPL can increase cell wall permeability, contributing to antimicrobial susceptibility (10).

Cutaneous Mycobacterium chelonae in a Patient with Sjogren's Syndrome

A case of cutaneous Mycobacterium chelonae infection in a patient with Sjogren's syndrome (SS) was misdiagnosed as sporotrichosis. A 56-year-old female patient was admitted to another hospital. Based on results of the histopathological examination and secretion culture obtained at the other hospital, the patient was diagnosed with sporotrichosis and received antifungal therapy. After treatment failure, the patient was admitted to our hospital, and a histopathological examination and secretion culture were performed again. The secretion culture revealed the presence of Mycobacterium chelonae. The antinuclear antibody test suggested SS, and the patient was treated with antibiotics and corticosteroids.

Acute disseminated mycobacteriosis in captive Atlantic guitarfish (Rhinobatos lentiginosus)

An adult female captive-born Atlantic guitarfish ( Rhinobatos lentiginosus) was found acutely moribund on exhibit and died soon after presentation. Abnormalities on autopsy were focal cutaneous erythema on the tail, a small liver, many variably sized friable ovarian follicles, and coelomic effusion. Histologic examination revealed systemic bacterial embolization, and yolk coelomitis with minimal associated inflammation and some mineralization. Bacterial culture of blood and coelomic effusion grew a rapidly growing Mycobacterium species that was further identified as Mycobacterium chelonae by PCR amplification and sequencing of the RNA polymerase subunit beta ( rpoB) gene of isolated genomic DNA. Concurrent reproductive disease may have caused immunosuppression, thus predisposing to the mycobacterial infection. At another institution, an adult male wild-caught Atlantic guitarfish was found dead on exhibit with no premonitory signs. Abnormalities on autopsy were a thin body condition, small liver, and coelomic effusion. Histologic examination revealed acute mycobacterial septicemia. M. chelonae was also identified in this fish by PCR amplification and sequencing. Mycobacteriosis has rarely been reported in captive elasmobranchs. Guitarfish may have greater susceptibility to mycobacteriosis than other elasmobranchs, and acute and chronic manifestations of the disease may exist in this species.

Mycobacteriological characteristics and treatment outcomes in extrapulmonary Mycobacterium abscessus complex infections

OBJECTIVES

The differentiation between Mycobacterium abscessus subspecies abscessus (M. abscessus) and Mycobacterium abscessus subspecies massiliense (M. massiliense) and determination of the presence of inducible resistance to macrolide antibiotics are important factors in the management of patients with Mycobacterium abscessus complex (MABC) infections. Unlike pulmonary MABC infections, little information on extrapulmonary MABC infections is available.

METHODS

The molecular identification of clinical isolates was performed, and the clinical characteristics and treatment outcomes of 20 consecutive patients with extrapulmonary MABC infections were assessed.

RESULTS

M. abscessus and M. massiliense each caused 10 (50%) of the cases. Eight (80%) M. abscessus isolates that had inducible resistance to clarithromycin harbored an intact erm(41) gene of the T28 variant, whereas two (20%) M. abscessus isolates had the C28 erm(41) variant and were susceptible to clarithromycin. All M. massiliense isolates had a truncated erm(41) gene and were susceptible to clarithromycin. The drug susceptibility profiles other than clarithromycin were similar for the M. abscessus and M. massiliense isolates. Of the 20 patients, 17 (85%) showed a favorable outcome, including all patients with M. massiliense infection and 70% (7/10) of patients with M. abscessus infection. Favorable outcomes were associated with M. massiliense and M. abscessus isolates with a non-functional erm(41) gene (p=0.049).

CONCLUSIONS

Precise species and subspecies identification and the determination of macrolide susceptibility are recommended for the optimal treatment of extrapulmonary MABC infections.

Mycobacterium chelonae hand infection after steroid injection in a patient with rheumatoid arthritis receiving long-term linezolid therapy

A 66-year-old multimorbid man with rheumatoid arthritis developed an infection after a steroid injection in the hand. Mycobacterium chelonae was cultured 1-month after presentation. In the mean time, his third finger had been amputated. Further treatment was based on preliminary susceptibility testing and the American Thoracic Society guidelines. No regression of the infection was observed before the addition of linezolid (600 mg×1/day) to a combination antimicrobial therapy also consisting of clarithromycin (500 mg×2/day) and moxifloxacin (400 mg×1/day), even though two methods of susceptibility testing, the E-test and broth microdilution, had shown susceptibility to other antimicrobial drugs. The healing was complete 12 months after presentation. There were no serious side effects observed with the use of linezolid in reduced dosage of 600 mg×1/day for a duration of 9 months.

Treatment of Mycobacterium abscessus Infection

Mycobacterium abscessus is often resistant to multiple antimicrobial drugs, and data supporting effective drugs or dosing regimens are limited. To better identify treatment approaches and associated toxicities, we collected a series of case reports from the Emerging Infections Network. Side effects were common and often led to changing or discontinuing therapy.

Prolonged postprocedural outbreak of Mycobacterium massiliense infections associated with ultrasound transmission gel

Postprocedural infections by Mycobacterium abscessus complex are increasing worldwide, and the source and route of transmission are infrequently identified. Here the extension of a previous clustering of paediatric patients with surgical site infections due to a single strain of the subspecies M. massiliense is reported. The investigation was conducted at a 2200-bed teaching hospital in Taiwan and included microbial surveillance of the environment (water, air, equipment and supplies) and a case-control study. We performed molecular identification and typing of the isolates by a trilocus sequencing scheme, confirmed by multilocus sequencing typing and pulsed-field gel electrophoresis. We investigated 40 patients who developed postprocedure soft tissue or bloodstream infections by M. massiliense (TPE101) during a 3-year period. Thirty-eight patients were identified at hospital A, and one newborn and her mother were identified at hospital B (185 km from hospital A). A case-control study identified the association of invasive procedures (adjusted odds ratio, 9.13) and ultrasonography (adjusted odds ratio, 2.97) (both p <0.05) with acquiring the outbreak strain. Isolates from the cases and unopened bottles of ultrasound transmission gel were all of strain ST48 and indistinguishable or closely related by pulsed-field gel electrophoresis. After replacement of contaminated gel, no new cases were detected during 18 months' follow-up. This investigation identified the use of contaminated gel as the common source causing an outbreak on a larger scale than had been recognized. Our findings halted production by the manufacturer and prompted revision of hospital guidelines.