Research & Reviews: Journal of Medical and Health Sciences
MenuISSN: 2319-9865
ISSN: 2319-9865
Meghna M Patel*, Shrikant Hiremath, KR.Patel and JA Sisodia
Department of Pulmonary Medicine, Govt. Medical College, Vadodara - 390001, Gujarat, India.
Received: 28/02/2014 Accepted: 14/03/2014 Revised: 09/03/2014
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Mycobacterium abscessus is rapid grower non tuberculouar mycobacteria. As this organism grows rapidly on culture media it is known as rapid grower. It can cause skin and soft tissue infection following surgery, trauma or injection.Here we are presenting a case of Myco. abscessus infection in 43 year old immunocompetent patient who underwent hernioplasty surgery. Myco. Abscessus was isolated from pus by genotype mycobacterium CM test method. For treatment, pus was drained and antituberculous medication started according to drug sensitivity report.
Myco.abscessus, Hernioplasty, Rapid grower NTM, Wound infection
According to RUNYON classification of Mycobacteria, Mycobacterium abscessus (Myco.abscessus) is non tubercular mycobacteria(NTM). There are four groups named photochromogens, scotochromogens, nonphotochromogens and rapid grower [1]. Myco. abscesseus is rapid growing NTM. It is also known as M.chelonae subspecies abscessus in the past. It is ubiquitous in the environment and can be found in water soil and dust, as well as in the animals [2]. It has been known to contaminate medications and products including medical devices. Infection with Myco. abscesseus is usually caused by injection of substances contaminated with the bacterium or through invasive medical procedures employing contaminated equipmental material. There is very little risk of transmission from person to person [3]. Extrapulmonary disease in immunocompetent host is usually due to inoculation(ex. via surgery, injections, trauma) or due to line infection and is often treated successfully with macrolide and other drug (with choice based on in vitro susceptibility) , along with removal of offending focus [4].
Case Report
A 43 years old male patient presented with chief complaints of pain at the operated site. Patient was operated for right inguinal hernia by laparoscopic hernioplasty 3 months back. His post operative recovery was uneventful. After 3 months patient has developed discharge from the operated site. Ultrasonography of lower abdomen was done which showed lax and coiled hernia mesh implant with surrounding loculated collection, with a cutaneous fistula. Overall volume of the extraperitoneal space containing the mesh and the collection around 200 cc ( Image 1). A small track is seen extending across the muscular plane to point at skin in midline in infraumbilical region and a small extension is noted through the right deep ring in to the sub cutaneous plane in right inguinal region ( Image 2 ). Following that repeat surgical intervention was done for the removal of infected mesh and collected pus around it. Pus was removed from the operated site and pus was sent for culture and sensitivity for pyogenic and mycobacterial infection.
Image 1: Lax and coiled hernia mesh implant with surrounding loculated collection
Image 2: Track extending across the muscular plane to skin
Pus culture sensitivity showed scanty growth of non tuberculous mycobacterium (rapid grower) in culture after 1 week of aerobic incubation. Line probe ID molecular NTM (genotype mycobacterium CM test method) showed Myco.abscessus. MIC for rapidly growing mycobacteria showed susceptibility to Clarithomycin, Amikacin, Linezolide and Tobramycin, and resistance to Trimethoprim/sulfamethoxazole, Ciprofloxacin, Moxifloxacin, Cefoxitin Doxycyclin, Imipenem, Amoxicillin/clavulanic acid and Minocyclin.
Post operative ultrasonography showed residual collapsed mesh cavity is with 3-4mm thick hypoechoic walls and anechoic clear contents amounting to approx 20 cc ( Image 3). No significant subcutaneous extension is seen. His Hb 10.8 gm%, total count 8100/cumm, differential count (N/L/E/M - 64/34/2/0), RBS 89 mg/dl, urine sugar is nil and liver function test and renal function test were normal. His HIV and HBsAg are non reactive. His Chest X- ray do not showed any abnormality. We have started medications according to drug sensitivity report. On follow up lesion started to improve and patient feel better symptomatically.
Image 3: Residual mesh cavity with thick hypoechoic wall
Mycobacterium abscesseus is rapid growing NTM. From the rapidly growing mycobacterium M.fortuitum, M.chelonei and Myco.abscessus is the only organism associated with human diseases. Together these organisms constitute approximately 6% of the pathogenic mycobacterium isolate. These organisms grow rapidly and appear within 2 to 5 days on standard mycobacterial media. In addition to being acid fast, they appear as beaded gram positive rods in gram stain preparations. Because of the variations in the drug susceptibility, sensitivity testing should be performed routinely when a pathogenic rapid grower is isolated. These organisms cause variety of skin ,soft tissue, and occasionally bone infections, as well as post surgical infections, and have been reported to cause disseminated tuberculosis [5]. Abscess formation at the site of puncture wounds, or open traumatic injuries or fractures are most often due to rapidly growing mycobacterium species like M.fortuitum, M.chelonei and M.abscessus, etc [6].Out breaks of skin infections are often caused by rapidly growing NTM acquired by skin contamination from surgical instruments injections and other procedures. These infections are typically accompanied by painful, erythematous draining subcutaneous nodules, usually without associated fever and systemic symptoms [7]. Galil et al reported on a multistate outbreak of post injection abscess that were associated with use of unlicensed injectable products that was contaminated by mycobacterium [8].
In our patient Myco.abscessuss infection occurs after mesh hernioplasty surgery. Similar case reports of infecton with rapid grower NTM have been reported [9]. Case reports of Myco. abscessus infection following different surgical procedures like mesotherapy injection, acupuncture and injection administration have been reported [10-13].In our patient Myco.abscessus is isolated from pus by Geno Type Mycobacterium CM test method which is based on DNA strip technology.
The drug regimen is based on in vitro drug susceptibilities. Surgical debridement is an essential component of treatment. A macrolide based drug regimen is frequently used for Myco. abscessus [14]. Myco. abscessus is highly resistant to standard first line antituberculous regimen but usually are susceptible to clarithromycin,ciprofloxacin,ofloxacin,amikacin,sulfonamide, cefoxitin, imipenem and doxycyclin. In addition some strains are sensitive to clofazimine and to tobramycin. Isolates of Myco. abscessus are 100% susceptible to clarithromycin,and have a lower frequency of being susceptible to clofazimine, amikacin, and cefoxitin. Serious infection caused by Myco. abscessus should be treated with amikacin given intravenously in a dose of 10 to 15 mg/kg daily (to achieve serum level of approximately 20 mcg/dl) , plus cefoxitin, approximately 200 mg/kg also given IV. Intravenous therapy should be continued until clinical improvement is seen, or for atleast 2 weeks. Oral therapy based on susceptibility testing results may be used after initial phase of intravenous therapy. Long term suppressive therapy with clarithromycin is often necessary. Treatment should be continued for 4 to 6 months [5].
In our patient Myco. abscessus infection occur following mesh hernioplasty surgery. This case emphasis on adequate sterile measure during any surgical intervention and procedures, and also emphasis on suspectiong non tuberculous mycobacterium infection in patient who developed post surgical infection particularly if it does not respond to conventional antimicrobial therapy. Surgical debridement and removal of pus along with proper medications per drug sensitivity report is very crucial for management of post operative and post procedure Myco. abscessus infections.