Nontuberculous Mycobacterial Infection after Aesthetic Procedures: Diagnosis and Treatment Insights from a Retrospective Study

PURPOSE: Nontuberculous mycobacteria (NTM) are an important source of skin and soft tissue infections. It is well known that immunocompromised patients are often infected, but recently there have been increasing reports of infection following invasive procedures (i.e. lipolysis injection, fat grafting, etc.) in healthy adults [1]. The source of infection is not clearly known, but direct inoculation from contaminated objects is most likely [2]. Other routes of transmission have been reported, including skin-to-skin transmission due to inadequate preoperative sterilization, transmission from poorly disinfected surgical instruments, and transmission from ink used for skin marking (gentian violet ink, G-V ink) [3]. Because NTM skin and soft tissue infections are often difficult to diagnose and treat, we would like to share our treatment experience. METHODS: We retrospectively reviewed the data of 19 consecutive cases of NTM skin and soft tissue infection from January 2017 to December 2022. When patients presented to the clinic, a physical examination was performed, and the areas of pustule and abscess where diagnostic incision & drainage could be performed were checked. NTM-related tests were performed during the incision & drainage procedure. NTM identification and drug susceptibility testing took 2 months, so patients were given intravenous amikacin 10mg/kg once a day, oral azithromycin 500mg and linezolid 300mg once a day for 1 month. After discharge from hospital, only oral medication was continued according to the clinical course. RESULTS: The mean age was 40.5 ± 12.1 years and all patients were female. None of the patients had diabetes or immunocompromised conditions, and one patient had a history of pulmonary tuberculosis. Previous procedures included 1 breast augmentation, 1 facelift, 2 blepharoplasty, 6 fat grafting and 9 lipolysis injection. AFB staining was positive in 1 case and NTM was isolated from AFB culture in 13 cases. The most common strain cultured was M. abscessus in 13 cases, followed by the M. chelonae and M. fortuitum complex in one case each. All were susceptible to amikacin in the NTM susceptibility test, so the initial antibiotic selection was appropriate, and most of the clinical signs improved after treatment. However, in some cases, nodules and pustules recurred when the drug was discontinued due to tinnitus or allergic reaction. The median duration of treatment was 7.2 ± 6.2 months, with some patients requiring antibiotic for up to 26 months. Due to the long-term nature of the treatment, close monitoring and proper evaluation of potential side effects (e.g. ototoxicity, leukopenia, and allergic reaction, etc.) are necessary. In most cases, only incision & drainage was performed, but abdominoplasty was performed in one patient with multiple abdominal abscesses. CONCLUSION: NTM infection in skin and soft tissue after aesthetic procedures is challenging to diagnose and treat and requires prolonged and individualized management [4]. In our experience, NTM infections often recur and take a long time to resolve, so it is important to explain the course of the disease to patients at the time of diagnosis and to support and monitor them closely during treatment. References: 1. Dodiuk-Gad R, Dyachenko P, Ziv M, et al. Nontuberculous mycobacterial infections of the skin: A retrospective study of 25 cases. J Am Acad Dermatol 2007;57:413-20. 2. Fida AK, Rashida K. Nontuberculous mycobacterial cutaneous infections: an updated review. Cutis 2011;88:194- 200. 3. Safranek TJ, Jarvis WR, Carson LA, et al. Mycobacterium chelonae wound infections after plastic surgery employing contaminated gentian violet skin-marking solution. N Engl J Med 1987;317:197-201. 4. Wagner D, Young LS. Nontuberculous mycobacterial infections: a clinical review. Infection 2004;32:257-70.