At a glance
- The patient was admitted through the emergency department with recurrent left buttock pain and swelling and a fever.
- She admitted receiving a cosmetic injection for buttock augmentation a few weeks ago.
- Physical exam was notable for ecchymosis and a large area of induration on the left buttock.
Ms. P, a 34-year-old of Hispanic descent, was admitted through the emergency department with complaints of recurrent left buttock pain and swelling and a subjective report of fever. She had been discharged from the hospital five days earlier following a weeklong hospitalization for the same complaints.
During the woman’s initial hospital stay, a pelvic CT with contrast showed myositis of the left gluteus maximus muscle with cellulitis of the overlying fat and skin; no evidence of abscess was noted. The patient reported no history of smoking, alcohol abuse, or IV drug abuse. On further questioning, she admitted to receiving a cosmetic injection for buttock augmentation within the past few weeks. IV cefazolin administered to treat a left gluteal cellulitis/IM abscess resulted in improvement. Blood cultures showed no growth. Consultation with surgeons determined that there was no need for surgical intervention. The patient was HIV-negative. Her medical history was significant only for asthma; she had no past surgical history. The woman was discharged home on oral cephalexin (Keflex) for one week.
1. RE-ADMISSION FINDINGS
On re-admission, Ms. P’s temperature was 99.1ºF, pulse 76 beats per minute, respiration rate 12 breaths per minute, and BP 90/52 mm Hg. She was well-nourished and in no apparent distress. Her physical examination was notable for ecchymosis and a large area of induration on the left buttock (Figure 1). No discharge was noted. Cardiac examination revealed a normal S1 and S2, without murmur. Lungs were clear.
Laboratory results included a WBC count of 11,600/µL, hemoglobin 11.8 g/dL, and hematocrit 35.6%. A repeat pelvic CT with contrast showed persistent asymmetric enlargement of the left gluteus maximus.
Her only medication was the previously prescribed Keflex.
The patient was treated with IV ampicillin/sulbactam (Unasyn) for presumed recurrent cellulitis of the left buttock. Once again, blood cultures showed no growth. Following an infectious disease consult, antibiotics were discontinued for 48 hours so surgeons could perform a biopsy of the left buttock. Culture of the biopsy specimen grew out Klebsiella oxytoca. Although Mycobacterium abscessus was not isolated, we suspected that it was
also causative. The patient was started on imipenem-cilastatin 500 mg IV every six hours, amikacin 5 mg/kg IV every eight hours, and clarithromycin 500 mg p.o. every 12 hours to cover for K. oxytoca and for presumed M. abscessus infection of the buttock. After two weeks on this regimen, the patient showed rapid improvement. She was discharged home on levofloxacin (Levaquin) 500 mg p.o. daily for two weeks and clarithromycin (Biaxin) 500 mg p.o. twice daily for at least six months.
Although it was not isolated from tissue culture, M. abscessus was thought to be the cause of this patient’s gluteal infection. Both her history of recent cosmetic buttock augmentation and her failure to respond to conventional therapy with cephalosporin made the treating team consider the possibility of infection with this atypical organism.
Mycobacterium abscessus is an acid-fast, rapidly growing nontuberculosis mycobacterium that is ubiquitous. It has been isolated in well water, soil, dust, domestic and wild animals, milk, and food.1 Although infection in immunocompetent hosts is rare, numerous cases of skin and soft-tissue infection have been reported following inoculation of contaminated fluids, injectable medications, and soft-tissue augmentation. On June 30, 2002, the New York City Department of Health issued an alert about a cluster of four cases of M. abscessus infection following injections for cosmetic procedures. All of the cases involved Hispanic females who ranged in age from 31-65 years, lived in the New York metropolitan area, and presented with soft-tissue infections (two in the buttocks and two in the face) at three different New York hospitals.2 Subsequently, on July 17, 2002, the New York City police arrested a Venezuelan woman and her husband on charges of assault, scheming to defraud, and practicing medicine without a license. A soft-tissue filling agent called Hyacell, a hyaluronic acid derivative, was found in the couple’s possession. They eventually pleaded guilty to the charges and were sentenced to two to seven years in prison and eventual deportation.3
Typically, symptoms of M. abscessus infection do not manifest for weeks to months after inoculation and patients present with “indolent, localized, chronic, nonhealing lesions that are refractory to conventional therapy.”4 The organism invades and replicates inside macrophages as the host initiates a granulomatous reaction, ultimately forming an abscess.5 As has happened in other cases, M. abscessus was not suspected at our patient’s initial clinical presentation, and only after failure to respond to traditional treatment and a deteriorating clinical picture was this organism considered.
Once mycobacterial infection is suspected, acid-fast stains and mycobacterium cultures need to be obtained from both wound drainage and tissue biopsy samples. Mycobacterium abscessus is rapid-growing and should grow adequately on agar plates within seven days.6 When the diagnosis is made, involvement of an infectious disease team is advisable. Treatment begins with removal of infected tissue or prosthetic material, followed by antimicrobial therapy. The organism is generally resistant to most antimycobacterial antibiotics, including tetracyclines, fluoroquinolones, and sulfonamide.7 Current guidelines suggest that most isolates of M. abscessus are susceptible to clarithromycin, amikacin, imipenem, and cefoxitin. As in our case, an immunocompetent patient with a localized infection should be treated with a regimen that includes some of these drugs for at least six months, whereas a patient with disseminated disease may require more than six months of treatment.1,6 Our patient received levofloxacin and clarithromycin for at least six months.
Dr. Kass is a resident in psychiatry at University of California at Los Angeles, Semel Institute for Neuroscience, and Dr. Wong is an attending physician in internal medicine at Columbia-Presbyterian Medical Center in New York City.
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3. Toy BR, Frank PJ. Outbreak of Mycobacterium abscessus infection after soft tissue augmentation. Dermatol Surg. 2003;29:971-973.
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7. Petrini B. Mycobacterium abscessus: an emerging rapid-growing potential pathogen. APMIS. 2006;114:319-328.