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Infectious Complications in the Returning Medical Tourist: A Case of Mycobacterium abscessuss

Authors: Carrie A. Flynn, MS1; Emilie O’Neill, MD2; Sumit R. Kumar, MD, MPA2; Anna Dill, MD2; Abhay J. Dhond, MD, MPH, FACP2

Author Affiliations: 1Medical Scientist Training Program, Yale School of Medicine; 2Yale Primary Care Internal Medicine Residency Program, Department of Internal Medicine, Yale School of Medicine

Introduction: The most pathogenic rapidly growing mycobacteria (RGM), Mycobacterium abscessus is a rare cause of human infection despite its ubiquity in the environment. Consisting of the subspecies abscessus, massiliense, and bolletii, 1 M. abscessus is characterized by biofilm formation and intrinsic resistance to many disinfectants, qualities which have led to postsurgical infections through contamination of surgical equipment and injection solutions2-4. The rise of medical tourism among US patients, especially for cosmetic procedures, has led to a rise in M. abscessus infections, presenting an important public health problem in the US5-8. This problem is complicated by challenges physicians face in diagnosing and adequately treating these infections1,9-11.

Case Presentation

This case regards a 36-year-old woman who presented to the emergency department (ED) with lower abdominal pain and swelling over her surgical site, where 2 weeks prior she had undergone abdominoplasty and liposuction in the Dominican Republic. She also noted increased output from a drain placed during the surgery. On initial evaluation, the patient was afebrile and tachycardic to the low 100s with otherwise stable vitals. Physical exam and laboratory findings were grossly within normal limits. A CT of the abdomen revealed skin induration and thickening thought to be consistent with wound healing, and she was discharged home. Over the next month, the patient visited the ED three more times as well as her primary care physician (PCP) and an outpatient plastic surgeon with worsening pain and swelling, but infection was not suspected. At her final ED visit she was mildly febrile prompting a repeat abdominal CT scan which revealed development of multiple abscesses in the ventral abdominal wall. She was admitted, underwent Interventional Radiology-guided drainage of the abscesses, and was initially started on empiric broad spectrum antibiotics. When culture Results: returned with M. abscessus, the patient was started on clarithromycin, amikacin, and cefoxitin with improvement in her symptoms and discharged to outpatient care with her PCP and an Infectious Disease specialist.

Discussion

This case highlights many of the issues physicians and public health agencies face when caring for medical tourists, from drains or hardware that may be placed without clear instructions for follow up to infections with otherwise uncommon etiologies. As in this patient's case, the presentation of nontuberculous mycobacteria can be subtle and insidious, and medical tourism can result in outbreaks outside of traditional geographic distributions. Additionally, gram staining and standard cultures are not sensitive for this pathogen, and most clinical microbiology laboratories are unable to distinguish between subspecies of M. abscessus or conduct sensitivity testing. Together, this can make diagnosis difficult and delay treatment. As medical tourism and its health consequences become increasingly common in the US, more comprehensive reporting of cases like this is an important objective.

References

1Ford, Emily S., et al. “Species-Specific Risk Factors, Treatment Decisions and Clinical Outcomes for Laboratory Isolates of Less Common Nontuberculous Mycobacteria in Washington State.” Annals of the American Thoracic Society ja (2017).

2Phillips, Michael S., and C. Fordham Von Reyn. “Nosocomial infections due to nontuberculous mycobacteria.” Clinical infectious diseases 33.8 (2001): 1363-1374.

3Zosso, Caroline, et al. “Post liposuction infections by rapidly growing mycobacteria.” Infectious Diseases 47.2 (2015): 69-72.

4Burgess, Winona, et al. “Disinfectant Susceptibility Profiling of Glutaraldehyde-Resistant Nontuberculous Mycobacteria.” Infection Control & Hospital Epidemiology (2017): 1-8.

5Cai, Stephen S., Karan Chopra, and Scott D. Lifchez. “Management of mycobacterium abscessus infection after medical tourism in cosmetic surgery and a review of literature.” Annals of plastic surgery 77.6 (2016): 678-682.

6Furuya, E. Yoko, et al. “Outbreak of Mycobacterium abscessus wound infections among “lipotourists” from the United States who underwent abdominoplasty in the Dominican Republic.” Clinical Infectious Diseases 46.8 (2008): 1181-1188

7Newman, Martin I., Alfonso E. Camberos, and Jeffrey Ascherman. “Mycobacteria abscessus outbreak in US patients linked to offshore surgicenter.” Annals of plastic surgery 55.1 (2005): 107-110.

8Sasikumar, Chinnu, Unnati Desai, and Jyotsna Joshi. “Post-lower segment cesarean section wound infection with Mycobacterium abscessus.” Indian Journal of Dermatology, Venereology and Leprology 83.3 (2017).

9Jeong, Suk Hyeon, et al. “Mycobacteriological characteristics and treatment outcomes in extrapulmonary Mycobacterium abscessus complex infections.” International Journal of Infectious Diseases 60 (2017): 49-56.

10Duarte, Rafael Silva, et al. “Epidemic of postsurgical infections caused by Mycobacterium massiliense.” Journal of clinical microbiology 47.7 (2009): 2149-2155.

11Mougari, Faiza, et al. “Standardized interpretation of antibiotic susceptibility testing and resistance genotyping for Mycobacterium abscessus with regard to subspecies and erm41 sequevar.” Journal of Antimicrobial Chemotherapy71.8 (2016): 2208-2212.

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