Mycobacterium abscessus scalp infection after hair transplantation in Central America

Discussion

Increasingly, patients seek medical treatment abroad, and reports of challenging postoperative surgical site infections are increasing. Our patient’s multidrug-resistant M. abscessus scalp infection after hair transplantation in Central America exemplifies the precautionary concern that is warranted for people who seek cosmetic procedures outside Canada. Although M. abscessus is prevalent throughout the world, the incidence of infection can vary.1 Regions such as East Asia and the islands in the south and central Pacific Ocean have been shown to have higher rates of M. abscessus infections.1^,2 In British Columbia, the incidence of nontuberculous mycobacteria (NTM) pulmonary disease is lower than in other regions and is about 1.6 out of 100 000, with cutaneous infections being less common.2^,3

Nontuberculous mycobacteria are found ubiquitously 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. abscessus.5

M. abscessus grows rapidly, is drug-resistant and can resist high temperatures and nutritionally deficient environments.4 It has been associated with contamination of water sources, hospital equipment and medications.6^–10 It has also been described in complications following hair transplantation.11 The M. abscessus complex comprises 3 subspecies, namely M. abscessus subspecies abscessus, M. abscessus subspecies bolletii and M. abscessus subspecies massiliense. Infections caused by M. abscessus are often difficult to treat because they are intrinsically resistant to classic antituberculous medications and most classes of antibiotics. The presence of a functional erm(41) gene inactivates macrolides through inducible macrolide resistance. M. abscessus subspecies massiliense isolates do not contain the functional erm(41) gene and so are intrinsically susceptible to macrolide.12 These isolates respond well to clarithromycin-based regimens.

The clinical presentation of M. abscessus infection includes abscesses, nodules, cellulitis, panniculitis, ulcers and sinus drainage, often presenting weeks to months after the surgical procedure.13 Diagnosis is made by isolation of the organism from clinical specimens. Nontuberculous mycobacteria are difficult to identify on Gram stains and routine cultures. Combined with the slow turnaround time for antimicrobial susceptibility testing of NTMs, this difficulty often leads to a delay in diagnosis and starting appropriate antimicrobial therapy. The selection of antibiotics is typically 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 combination clarithromycin and amikacin. All 6 NTM isolates were susceptible to clarithromycin, and surgical débridement was not performed.14 Another case series reported 5 M. abscessus subspecies abscessus infections after cosmetic surgical procedures in Ecuador that were successfully treated with surgical débridement and combination antimicrobial therapy for 7 months.15 A third case series reported 10 surgical site infections caused by NTMs in Venezuela that were successfully treated with a combination of surgical débridement and prolonged combination antimicrobial therapy (> 3 mo), including clarithromycin.13

Clarithromycin monotherapy has been shown to be less efficacious than a combination of surgical intervention and antibiotic therapy.16 Furthermore, another study found that concomitant use of clarithromycin and amikacin may be associated with increased resolution of lesions when compared with monotherapy with either antibiotic in patients who developed a M. abscessus cutaneous infection after acupuncture.17 In a study comparing combination amikacin and clarithromycin or azithromycin to triple therapy with amikacin, either clarithromycin or azithromycin, and either cefoxitin or imipenem in patients with M. abscessus pulmonary disease, rates of treatment success and relapse were comparable. However, the triple-agent regimen was associated with an increased frequency of adverse reactions.18

Given the paucity of data on treatment of M. abscessus cutaneous infections, we extrapolated the use of susceptibility-based combination treatment for our patient with M. abscessus scalp infection. We treated him with a combination of surgical débridement and targeted antimicrobial therapy. We used both clarithromycin and amikacin, as well as close monitoring of audiometry and therapeutic drug levels. We opted for weekly audiometry monitoring because we anticipated a prolonged course of exposure to amikacin. The amikacin course was limited by tinnitus at 1 month, so we prescribed clarithromycin monotherapy for another 5 months.

With an increasing number of patients seeking medical treatment abroad, infectious complications pose a challenge for patients and health care systems. M. abscessus infections are an uncommon complication of cosmetic surgical procedures, but should be considered in patients with postoperative infections that do not respond to standard antimicrobial therapy. Microbiological specimens should be obtained to determine the organism and susceptibilities to antibiotics. Surgical drainage and débridement should be used in combination with antibiotics.