Mycobacterium abscessus and Lipotourism
Mycobacterium abscessus and Lipotourism
Abstract & Commentary
By Lin H. Chen, MD, Dr. Chen is Assistant Clinical Professor, Harvard Medical School Director, Travel Medicine Center, Mt. Auburn Hospital, Cambridge, MA.
Dr. Chen reports no financial relationships relevant to this field of study.
This article originally appeared in the August 2008 issue of Travel Medicine Advisor. It was edited by Frank Bia, MD, and peer reviewed by Philip Fischer, MD, DTM&H.
Synopsis: Mycobacterium abscessus has caused postoperative wound infections in patients from the United States who underwent cosmetic surgery in the Dominican Republic. Increasing numbers of US residents are obtaining medical and dental care overseas, practices that can be associated with infectious diseases and complications following their return.
Source: Furuya EY, et al. Outbreak of Mycobacterium abscessus wound infections among "lipotourists" from the United States who underwent abdominoplasty in the Dominican Republic. Clin Infect Dis 2008;46:1181-1188.
In March 2004, an infectious disease specialist in New York queried the Emerging Infections Network (EIN) listserv about treatment of a patient with M. abscessus wound infection following abdominoplasty in the Dominican Republic. A second physician with a similar patient saw this message and communicated with the physician in New York, which led to a review of the hospital's clinical microbiology records. Four more cases of M. abscessus infection were identified following surgery in the Dominican Republic, and the New York City Department of Health and Mental Hygiene and the CDC were notified and undertook an investigation of the cases.
Additional cases were identified through EIN and interviewed. Laboratory tests for Mycobacteria were done, including Auramine O staining of specimens and examination by fluorescent microscopy, mycobacterial cultures, Kinyoun staining of bacteria from colonies, and identification using liquid chromatography. CDC laboratories performed molecular characterization by pulse field gel electrophoresis (PFGE) and polymerase chain reaction (PCR), as well as susceptibility testing.
Twenty patients were identified and 19 were interviewed. They were all female, with median age of 33 years; all had had abdominoplasty. Among the 19 patients, nine had surgery at one clinic in Santo Domingo. Isolates from eight of these patients were related, whereas the other 11 were not. Seven of the patients were Dominican, and one was Puerto Rican. Ten of the patients also had breast surgery, and eight also had liposuction.
Among the eight patients with related isolates from one clinic, all had abdominal wall infection, and two also had breast infection. Their symptom onset ranged from 2-18 weeks after surgery, and patients sought evaluation a median of three weeks following their surgery. All patients had skin manifestations, a single lesion (three patients) or multiple lesions (five patients) that were palpable, 2-5 cm. Some patients presented with draining and painful lesions, whereas some presented with subjective fever, weight loss, fatigue, and nausea. None showed a leukocytosis.
The correct diagnosis was made at times ranging from < 1 to 23 weeks. Four patients had AFB present on stain, and M. abscessus grew from 3-28 days on cultures. The seven isolates tested by CDC were more resistant than the other 12 cases: intermediate or resistant to clarithromycin, imipenem, cefoxitin, amikacin, and were resistant to sulfamethoxazole, doxycycline, tobramycin, and ciprofloxacin. Five patients were hospitalized; all except one were eventually cured. All underwent drainage, and all required prolonged antimicrobial treatment (median six months).
Commentary
Mycobacterium abscessus was formerly classified as M. chelonae, subspecies abscessus.1 It is a rapidly growing mycobacterium (RGM), classified along with seven others (see Table 1), two of which have been speciated based on DNA homology studies. As the name suggests, these organisms grow rapidly on culture (usually within two weeks, as compared to several weeks for M. tuberculosis, M. leprae, and other slowly growing nontuberculous mycobacteria). They are environmental organisms, and ubiquitous in water and soil. It is important to identify RGM since therapy differs from that utilized for M. tuberculosis, and M. abscessus is usually resistant to antituberculous agents. It is recommended that susceptibility testing be carefully performed using a broth microdilution technique.
The RGM can cause skin and soft-tissue infection, pulmonary disease, lymphadenitis, disseminated disease, musculoskeletal infection, prosthetic device infections, surgical site infections, and catheter-related infections. Skin and soft-tissue infections associated with RGM include nodules (frequently with purple discoloration), recurrent abscesses, or chronic discharging sinuses. M. abscessus and M. chelonae tend to present as multiple lesions, whereas M. fortuitum infections more commonly present as a single lesion.3 One recent outbreak of M. abscessus was due to illicit soft-tissue augmentation in New York City, and traced to a contaminated hyaluronic acid derivative smuggled in from Venezuela.4
Among the RGM, M. abscessus has been the species most commonly associated with pulmonary disease. One study of 154 such patients found 82% to be caused by M. abscessus, and M. fortuitum accounted for 15%. The major findings were: female predominance; cough was the most common presenting symptom; diagnosis was established > 2 years after symptom onset; chest radiography included interstitial, mixed interstitial and alveolar, and reticulonodular patterns; cavitation was infrequent; mycobacterial lung disease with respiratory failure caused death in 14%.5
This report raises some important questions. For example, how many US residents seek medical care overseas? Although the volume of patients is not tracked, a quick search on the Internet found 190,000 sites, including medical facilities listing their services to US residents, tips for patients planning to go overseas for care, reports of employers looking overseas for less expensive health care, news reports on medical tourism, and companies specializing in arranging medical care overseas. This report describes affected patients who have had cosmetic surgery, which is typically not covered by US health insurance plans. However, many of the web sites cater to patients who lack health insurance in the United States, or cannot afford the out-of-pocket costs of essential health care.
What is the quality of care overseas? Two organizations assess the quality of foreign hospitals: the International Organization for Standardization (ISO) accredits certification bodies, and Joint Commission International (JCI) is an affiliate of The Joint Commission (TJC). These have certified or accredited a number of hospitals overseas, for example in Thailand and India. Nonetheless, the patient who has a complication following the procedure or medical negligence would have lesser recourse than can be expected at home.
Does the number of US residents seeking surgery overseas affect residents of developing countries? A World Bank economist concluded that the income from treating US residents in a developing country may improve health care in that country through retention of their health care professionals (or their return to their home countries following overseas training).6 Globalization and US health insurance costs are expected to continue the trend in seeking medical care overseas. With the increasing numbers of US residents obtaining medical and dental care overseas, health care providers need to be aware of possible complications following their procedures.
References
- Wallace RJ Jr. Recent changes in taxonomy and disease manifestations of the rapidly growing mycobacteria. Eur J Clin Microbiol Infect Dis. 1994;13:953-960.
- CDC. Nontuberculous mycobacterial infections after cosmetic surgery — Santo Domingo, Dominican Republic, 2003-2004. MMWR Morb Mortal Wkly Rep. 2004;53:509.
- Uslan DZ, et al. Skin and soft tissue infections due to rapidly growing mycobacteria: comparison of clinical features, treatment, and susceptibility. Arch Dermatol. 2006;142:1287-1292.
- Toy BR, Frank PJ. Outbreak of Mycobacterium abscessus infection after soft tissue augmentation. Dermatol Surg. 2003;29:971-973.
- Griffith DE, et al. Clinical features of pulmonary disease caused by rapidly growing mycobacteria: an analysis of 154 patients. Am Rev Respir Dis. 1993;147:1271-1278.
- Milstein A, Smith M. America's new refugees — seeking affordable surgery offshore. N Engl J Med. 2006;355:1637-1640.
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