i n d i a n j o u r n a l o f t u b e r c u l o s i s 6 2 ( 2 0 1 5 ) 1 1 4 e1 1 6
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.journals.elsevier.com/indian-journal-oftuberculosis/
Case Report
Iatrogenic Mycobacterium abscessus infection in a trigger finger Edward Calif a,*, Ami Neuberger b, Shalom Stahl a a b
Hand Surgery Specialist, Hand Surgery Unit, Rambam Health Care Campus, Haifa, Israel Specialist in Infectious Diseases, Unit of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
article info
abstract
Article history:
An immunocompetent 63-year-old lady developed Mycobacterium abscessus soft tissue
Received 2 July 2014
infection of the hand following local corticosteroid injection for trigger finger. The patient
Accepted 7 April 2015
was successfully treated with repeated radical debridement and prolonged antimicrobial
Available online 12 June 2015
therapy. Atypical mycobacterial infections, including those caused by M. abscessus, albeit rare, should be considered in cases of late-onset indolent infection following local injury
Keywords:
surgical procedures, and injections. Clinical vigilance, timely diagnosis, combined directed
Mycobacterium abscessus
antimicrobial treatment, coupled with adequate surgical debridement are key for suc-
Incision
cessful management. © 2015 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.
Hand Corticosteroid injection Trigger finger
1.
Introduction
Injection of corticosteroid into the flexor tendon sheath is widely accepted as the first-line therapeutic modality for trigger fingers. The exact incidence of postinjection infection is unknown, but it is quite rare. Mycobacterium abscessus is an acid-fast, rapidly growing nontuberculous mycobacterium. It is considered as the most pathogenic and chemotherapy-resistant mycobacterium of the pathogenic rapidly growing mycobacteria.1 Though an uncommon cause of human disease, M. abscessus may cause pulmonary disease and disseminated infections.2 Cutaneous and soft tissue infection usually occurs after skin injury following inoculation, minor trauma, or surgery.3
M. abscessus hand infections are rare and usually occur in immunocompromised patients and in patients injected with contaminated substances, or through the use of infected needles.4
2.
Clinical record
A 63-year-old nondiabetic woman, treated with dronedarone and warfarin for paroxysmal atrial fibrillation, and losartan potassium/hydrochlorothiazide for hypertension, was initially hospitalized in another institution nearly five weeks prior to presenting to our department because of a two months' growing swelling and increasing pain in her left palm, which started ten days following local injection of
* Corresponding author. The Unit of Hand Surgery, Rambam Health Care Campus, P.O. Box 9602, Haifa 31096, Israel. Tel.: þ972 4 8542619; fax: þ972 4 8542750. E-mail address: [email protected] (E. Calif). http://dx.doi.org/10.1016/j.ijtb.2015.04.001 0019-5707/© 2015 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.
i n d i a n j o u r n a l o f t u b e r c u l o s i s 6 2 ( 2 0 1 5 ) 1 1 4 e1 1 6
115
Fig. 1 e (a,b): Erythematous swelling of both palmar and dorsal aspects of the hand. Notice the dehisced wound at the second interdigital web.
corticosteroid for trigger middle finger. Incision and drainage of local fluctuating induration were performed twice and intravenous amoxicillin/clavulanate was initiated. However, her symptoms worsened and she moved to another institution where she underwent a third wound debridement and delayed primary suture. M. abscessus was detected by polymerase chain reaction (P.C.R.), and prolonged treatment with oral clarythromycin was recommended. The swelling worsened and spread to the dorsum of the hand, accompanied by pain, stiffness of the fingers and discharge from the wound. She was admitted to our hand surgery unit, and was found to be febrile. She had tender erythematous swelling of both palmar and dorsal aspects of the hand, with maximal tenderness located palmar to the third ray, as well as a discharging dehisced wound extending from the dorsum of the distal third metacarpal into the second interdigital web, and additional minor discharging dorsal sinuses (Fig. 1). There was no clinical evidence for purulent tenosynovitis or arthritis, nor were there signs of ascending lymphangitis. Radiographs showed soft tissue swelling without bone changes. Blood investigation revealed elevated erythrocyte sedimentation rate (50 mm/h), and C-reactive protein was 21.7 mg/L. The patient underwent two surgeries for incision of the fluctuating tissue, drainage, surgical debridement, and irrigation. Tissue samples were obtained, and intravenous amikacin and
imipenem, and oral clarithromycin were initiated. Postoperative local wound care and dressings were performed repeatedly. Histological examination revealed granulation tissue with necrotic foci and abundant inflammatory cells. ZiehleNeelsen stain was negative. Tissue cultures grew nontuberculous mycobacteria, identified by routine microbiologic methods and by PCR as M. abscessus. A slow decrease of pain, swelling, and erythema was witnessed within the first two postoperative weeks, accompanied by formation of granulation tissue and, ultimately, successful secondary healing. The patient received vigorous hand therapy; finger mobility has gradually and progressively improved (Fig. 2). The patient was treated for 30 days with intravenous amikacin and imipenem through a peripherally inserted central catheter (P.I.C.C.), followed by oral clarithromycin for two additional months. During two months of follow-up, no relapse of infection was evident clinically, and total active motion of the third finger was 220 , with good grip.
3.
Discussion
M. abscessus which was first described by Moore and Frerichs5 in 1953, is a ubiquitous environmental pathogen that have been isolated also from diverse hospital environments. The
Fig. 2 e (a,b): Complete wound healing by secondary intention, and gradual functional improvement. A flat fist, and subsequently an effective grasp were achieved following hand therapy.
116
i n d i a n j o u r n a l o f t u b e r c u l o s i s 6 2 ( 2 0 1 5 ) 1 1 4 e1 1 6
clinical range of infections is broad and includes tender erythematous, violaceous nodules and plaques, cellulites, abscesses, ulcers, osteomyelitis, and draining sinuses with serosanguinous discharge. Clinical signs usually develop within a few weeks to a few months after exposure.6 M. abscessus can grow on standard bacteriologic media, and on mycobacterial solid or broth (liquid) media. They appear as Gram-positive, acid-fast, rods. Skin and soft tissue infections caused by M. abscessus have been described as complications following various invasive procedures, including acupuncture, Mohs micrographic surgery, liposuction, and mesotherapy.6 None of these reported cases involved the hand. Mycobacterial infection in our case was circumstantially related to initial local injection. The non-purulent, indolent and persistent course of infection was suggestive, though a direct causation couldn't be decisively confirmed. Furthermore, while initial injection has been done in an office visit, subsequent surgical procedures were undertaken in a sterile setting of an operating theater, further reinforcing the assumption that the initial injection is the probable way of contamination rather than subsequent interventions. While hand infection caused by Mycobacterium marinum is well-known in patients with aquatic or fish exposure,4 those caused by M. abscessus are rare. Galea and Nicklin7 reported a case of M. abscessus infection of the hands in a 55-year-old lady following hand rejuvenation with structural fat grafting. Kang et al4 reported two cases of M. abscessus infection of the hand in otherwise healthy fish handlers. Zenone et al8 reported a case of finger tenosynovitis associated with CD4þ lymphocytopenia. M. abscessus is usually resistant to conventional antituberculous drugs, but generally susceptible to parenteral therapy with amikacin, cefoxitin, and imipenem, and to oral medication with clarithromycin.3 Extended course of combined antimicrobial therapy is recommended, coupled with repeated surgical excision of necrotic tissue, draining of abscesses, removal of foreign bodies, done consecutively as needed over an extended period of up to several months. The single, most important factor for determining the course and prognosis of M. abscessus infection is the underlying immune status of the host.9 Our patient was not immunocompromised, however, a local immunosuppressive effect induced by corticosteroid instillation is possible. The paramount importance of using sterile equipment and employing adequate measures in all medical procedures cannot be overemphasized. Timely diagnosis and aggressive,
combined treatment may minimize morbidity and improve prognosis. Laboratory personnel should be informed that a mycobacterial infection is suspected, a longer incubation period of samples is required, and specific media have to be used. Atypical mycobacterial infections, albeit rare, should be considered in cases of late-onset skin and soft tissue infection following local injury, surgical procedures, and injections. Such infections tend to have an indolent course, non-healing or dehiscent wounds, and poor response to conventional antibiotic and surgical treatments.
Conflicts of interest All authors have none to declare.
references
1. Ricciardo B, Weedon D, Butler G. Mycobacterium abscessus infection complicating a professional tattoo. Australas J Dermatol. 2010;51:287e289. 2. Petrini B. Mycobacterium abscessus: an emerging rapidgrowing potential pathogen. APMIS. 2006;114:319e328. 3. Kwon YH, Lee GY, Kim WS, Kim KJ. A case of skin and soft tissue infection caused by Mycobacterium abscessus. Ann Dermatol. 2009;21:84e87. 4. Kang GC, Gan AW, Yam A, Tan AB, Tay SC. Mycobacterium abscessus hand infections in immunocompetent fish handlers: case report. J Hand Surg Am. 2010;35:1142e1145. 5. Moore M, Frerichs JB. An unusual acid-fast infection of the knee with subcutaneous, abscess-like lesions of the gluteal region; report of a case with a study of the organism, Mycobacterium abscessus, n. sp. J Invest Dermatol. 1953;20:133e169. 6. Wongkitisophon P, Rattanakaemakorn P, Tanrattanakorn S, Vachiramon V. Cutaneous mycobacterium abscessus infection associated with mesotherapy injection. Case Rep Dermatol. 2011;3:37e41. 7. Galea LA, Nicklin S. Mycobacterium abscessus infection complicating hand rejuvenation with structural fat grafting. J Plast Reconstr Aesthet Surg. 2009;62:e15ee16. 8. Zenone T, Boibieux A, Tigaud S, Fredenucci JF, Vincent V, Peyramond D. Nontuberculous mycobacterial tenosynovitis: report of two cases. Clin Infect Dis. 1998;26:1467e1468. 9. Morris-Jones R, Fletcher C, Morris-Jones S, Brown T, Hilton RM, Hay R. Mycobacterium abscessus: a cutaneous infection in a patient on renal replacement therapy. Clin Exp Dermatol. 2001;26:415e418.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.journals.elsevier.com/indian-journal-oftuberculosis/
Case Report
Iatrogenic Mycobacterium abscessus infection in a trigger finger Edward Calif a,*, Ami Neuberger b, Shalom Stahl a a b
Hand Surgery Specialist, Hand Surgery Unit, Rambam Health Care Campus, Haifa, Israel Specialist in Infectious Diseases, Unit of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
article info
abstract
Article history:
An immunocompetent 63-year-old lady developed Mycobacterium abscessus soft tissue
Received 2 July 2014
infection of the hand following local corticosteroid injection for trigger finger. The patient
Accepted 7 April 2015
was successfully treated with repeated radical debridement and prolonged antimicrobial
Available online 12 June 2015
therapy. Atypical mycobacterial infections, including those caused by M. abscessus, albeit rare, should be considered in cases of late-onset indolent infection following local injury
Keywords:
surgical procedures, and injections. Clinical vigilance, timely diagnosis, combined directed
Mycobacterium abscessus
antimicrobial treatment, coupled with adequate surgical debridement are key for suc-
Incision
cessful management. © 2015 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.
Hand Corticosteroid injection Trigger finger
1.
Introduction
Injection of corticosteroid into the flexor tendon sheath is widely accepted as the first-line therapeutic modality for trigger fingers. The exact incidence of postinjection infection is unknown, but it is quite rare. Mycobacterium abscessus is an acid-fast, rapidly growing nontuberculous mycobacterium. It is considered as the most pathogenic and chemotherapy-resistant mycobacterium of the pathogenic rapidly growing mycobacteria.1 Though an uncommon cause of human disease, M. abscessus may cause pulmonary disease and disseminated infections.2 Cutaneous and soft tissue infection usually occurs after skin injury following inoculation, minor trauma, or surgery.3
M. abscessus hand infections are rare and usually occur in immunocompromised patients and in patients injected with contaminated substances, or through the use of infected needles.4
2.
Clinical record
A 63-year-old nondiabetic woman, treated with dronedarone and warfarin for paroxysmal atrial fibrillation, and losartan potassium/hydrochlorothiazide for hypertension, was initially hospitalized in another institution nearly five weeks prior to presenting to our department because of a two months' growing swelling and increasing pain in her left palm, which started ten days following local injection of
* Corresponding author. The Unit of Hand Surgery, Rambam Health Care Campus, P.O. Box 9602, Haifa 31096, Israel. Tel.: þ972 4 8542619; fax: þ972 4 8542750. E-mail address: [email protected] (E. Calif). http://dx.doi.org/10.1016/j.ijtb.2015.04.001 0019-5707/© 2015 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.
i n d i a n j o u r n a l o f t u b e r c u l o s i s 6 2 ( 2 0 1 5 ) 1 1 4 e1 1 6
115
Fig. 1 e (a,b): Erythematous swelling of both palmar and dorsal aspects of the hand. Notice the dehisced wound at the second interdigital web.
corticosteroid for trigger middle finger. Incision and drainage of local fluctuating induration were performed twice and intravenous amoxicillin/clavulanate was initiated. However, her symptoms worsened and she moved to another institution where she underwent a third wound debridement and delayed primary suture. M. abscessus was detected by polymerase chain reaction (P.C.R.), and prolonged treatment with oral clarythromycin was recommended. The swelling worsened and spread to the dorsum of the hand, accompanied by pain, stiffness of the fingers and discharge from the wound. She was admitted to our hand surgery unit, and was found to be febrile. She had tender erythematous swelling of both palmar and dorsal aspects of the hand, with maximal tenderness located palmar to the third ray, as well as a discharging dehisced wound extending from the dorsum of the distal third metacarpal into the second interdigital web, and additional minor discharging dorsal sinuses (Fig. 1). There was no clinical evidence for purulent tenosynovitis or arthritis, nor were there signs of ascending lymphangitis. Radiographs showed soft tissue swelling without bone changes. Blood investigation revealed elevated erythrocyte sedimentation rate (50 mm/h), and C-reactive protein was 21.7 mg/L. The patient underwent two surgeries for incision of the fluctuating tissue, drainage, surgical debridement, and irrigation. Tissue samples were obtained, and intravenous amikacin and
imipenem, and oral clarithromycin were initiated. Postoperative local wound care and dressings were performed repeatedly. Histological examination revealed granulation tissue with necrotic foci and abundant inflammatory cells. ZiehleNeelsen stain was negative. Tissue cultures grew nontuberculous mycobacteria, identified by routine microbiologic methods and by PCR as M. abscessus. A slow decrease of pain, swelling, and erythema was witnessed within the first two postoperative weeks, accompanied by formation of granulation tissue and, ultimately, successful secondary healing. The patient received vigorous hand therapy; finger mobility has gradually and progressively improved (Fig. 2). The patient was treated for 30 days with intravenous amikacin and imipenem through a peripherally inserted central catheter (P.I.C.C.), followed by oral clarithromycin for two additional months. During two months of follow-up, no relapse of infection was evident clinically, and total active motion of the third finger was 220 , with good grip.
3.
Discussion
M. abscessus which was first described by Moore and Frerichs5 in 1953, is a ubiquitous environmental pathogen that have been isolated also from diverse hospital environments. The
Fig. 2 e (a,b): Complete wound healing by secondary intention, and gradual functional improvement. A flat fist, and subsequently an effective grasp were achieved following hand therapy.
116
i n d i a n j o u r n a l o f t u b e r c u l o s i s 6 2 ( 2 0 1 5 ) 1 1 4 e1 1 6
clinical range of infections is broad and includes tender erythematous, violaceous nodules and plaques, cellulites, abscesses, ulcers, osteomyelitis, and draining sinuses with serosanguinous discharge. Clinical signs usually develop within a few weeks to a few months after exposure.6 M. abscessus can grow on standard bacteriologic media, and on mycobacterial solid or broth (liquid) media. They appear as Gram-positive, acid-fast, rods. Skin and soft tissue infections caused by M. abscessus have been described as complications following various invasive procedures, including acupuncture, Mohs micrographic surgery, liposuction, and mesotherapy.6 None of these reported cases involved the hand. Mycobacterial infection in our case was circumstantially related to initial local injection. The non-purulent, indolent and persistent course of infection was suggestive, though a direct causation couldn't be decisively confirmed. Furthermore, while initial injection has been done in an office visit, subsequent surgical procedures were undertaken in a sterile setting of an operating theater, further reinforcing the assumption that the initial injection is the probable way of contamination rather than subsequent interventions. While hand infection caused by Mycobacterium marinum is well-known in patients with aquatic or fish exposure,4 those caused by M. abscessus are rare. Galea and Nicklin7 reported a case of M. abscessus infection of the hands in a 55-year-old lady following hand rejuvenation with structural fat grafting. Kang et al4 reported two cases of M. abscessus infection of the hand in otherwise healthy fish handlers. Zenone et al8 reported a case of finger tenosynovitis associated with CD4þ lymphocytopenia. M. abscessus is usually resistant to conventional antituberculous drugs, but generally susceptible to parenteral therapy with amikacin, cefoxitin, and imipenem, and to oral medication with clarithromycin.3 Extended course of combined antimicrobial therapy is recommended, coupled with repeated surgical excision of necrotic tissue, draining of abscesses, removal of foreign bodies, done consecutively as needed over an extended period of up to several months. The single, most important factor for determining the course and prognosis of M. abscessus infection is the underlying immune status of the host.9 Our patient was not immunocompromised, however, a local immunosuppressive effect induced by corticosteroid instillation is possible. The paramount importance of using sterile equipment and employing adequate measures in all medical procedures cannot be overemphasized. Timely diagnosis and aggressive,
combined treatment may minimize morbidity and improve prognosis. Laboratory personnel should be informed that a mycobacterial infection is suspected, a longer incubation period of samples is required, and specific media have to be used. Atypical mycobacterial infections, albeit rare, should be considered in cases of late-onset skin and soft tissue infection following local injury, surgical procedures, and injections. Such infections tend to have an indolent course, non-healing or dehiscent wounds, and poor response to conventional antibiotic and surgical treatments.
Conflicts of interest All authors have none to declare.
references
1. Ricciardo B, Weedon D, Butler G. Mycobacterium abscessus infection complicating a professional tattoo. Australas J Dermatol. 2010;51:287e289. 2. Petrini B. Mycobacterium abscessus: an emerging rapidgrowing potential pathogen. APMIS. 2006;114:319e328. 3. Kwon YH, Lee GY, Kim WS, Kim KJ. A case of skin and soft tissue infection caused by Mycobacterium abscessus. Ann Dermatol. 2009;21:84e87. 4. Kang GC, Gan AW, Yam A, Tan AB, Tay SC. Mycobacterium abscessus hand infections in immunocompetent fish handlers: case report. J Hand Surg Am. 2010;35:1142e1145. 5. Moore M, Frerichs JB. An unusual acid-fast infection of the knee with subcutaneous, abscess-like lesions of the gluteal region; report of a case with a study of the organism, Mycobacterium abscessus, n. sp. J Invest Dermatol. 1953;20:133e169. 6. Wongkitisophon P, Rattanakaemakorn P, Tanrattanakorn S, Vachiramon V. Cutaneous mycobacterium abscessus infection associated with mesotherapy injection. Case Rep Dermatol. 2011;3:37e41. 7. Galea LA, Nicklin S. Mycobacterium abscessus infection complicating hand rejuvenation with structural fat grafting. J Plast Reconstr Aesthet Surg. 2009;62:e15ee16. 8. Zenone T, Boibieux A, Tigaud S, Fredenucci JF, Vincent V, Peyramond D. Nontuberculous mycobacterial tenosynovitis: report of two cases. Clin Infect Dis. 1998;26:1467e1468. 9. Morris-Jones R, Fletcher C, Morris-Jones S, Brown T, Hilton RM, Hay R. Mycobacterium abscessus: a cutaneous infection in a patient on renal replacement therapy. Clin Exp Dermatol. 2001;26:415e418.
