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.
Synopsis: Mycobacterium abscessus has caused postoperative wound infections in patients from the U.S. who underwent cosmetic surgery in the Dominican Republic. Increasing numbers of U.S. residents are obtaining medical and dental care overseas, practices that can be associated with infectious diseases and complications following their return.
Source: Furuya EY, Paez A, Srinivasan A, 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, and all had abdominoplasty. Among the 19 patients, 9 had surgery at one clinic in Santo Domingo. Isolates from 8 of these patients were related, whereas the other 11 were not. Seven of the patients were Dominican, and 1 was Puerto Rican. Ten of the patients also had breast surgery, and 8 also had liposuction.
Among the 8 patients with related isolates from one clinic, all had abdominal wall infection, and 2 also had breast infection. Their symptom onset ranged from 2-18 weeks after surgery, and patients sought evaluation a median of 3 weeks following their surgery. All patients had skin manifestations, a single lesion (3 patients) or multiple lesions (5 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 7 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 1 eventually were cured. All underwent drainage, and all required prolonged antimicrobial treatment (median 6 months).
Commentary
Mycobacterium abscessus was formerly classified as M. chelonae, subspecies abscessus.1 It is a rapidly growing mycobacterium (RGM), classified along with 7 others (see Table 1, below.), two of which have been speciated based on DNA homology studies. As the name suggests, these organisms grow rapidly on culture (usually within 2 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, 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 U.S. 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 U.S. 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 U.S. 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 U.S. residents seeking surgery overseas affect residents of developing countries? A World Bank economist concluded that the income from treating U.S. 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 U.S. health insurance costs are expected to continue the trend in seeking medical care overseas. With the increasing numbers of U.S. 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(11):953-960.
- Centers for Disease Control and Prevention. Nontuberculous Mycobacterial infections after cosmetic surgery—Santo Domingo, Dominican Republic, 2003-2004. MMWR 2004;53(23):509.
- Uslan DZ, Kowalski TJ, Wengenack NL, et al. Skin and soft tissue infections due to rapidly growing mycobacteria: Comparison of clinical features, treatment, and susceptibility. Arch Dermatol 2006;142:1287.
- Toy BR, Frank PJ. Outbreak of Mycobacterium abscessus infection after soft tissue augmentation. Dermatol Surg 2003;29(9):971-973.
- Griffith DE, Girard WM, Wallace RJ. Clincal 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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