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An Unusual Case of Mycobacterial Wound Infection
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A2192 - An Unusual Case of Mycobacterial Wound Infection
Author Block: P. Sharma, B. Smith, M. Yassin; UPMC Mercy, Pittsburgh, PA, United States.
Introduction:
Mediastinitis is a major complication of cardiac surgery. Non-tuberculous mycobacteria (NTM) are emerging pathogens with bypass machine post-cardiac surgery.
Case Report:
75-year-old female with past medical history of coronary artery disease and rheumatoid arthritis, presented to the hospital for evaluation of wound dehiscence from sternotomy site. Patient had a history of CABG around 10-years ago, and no additional surgical interventions were performed in the interim. Patient was on low-dose prednisone for rheumatoid arthritis on presentation, however she had been treated with methotrexate and leflunomide in the past. Examination showed erythema and serous drainage from sternotomy site. Laboratory investigations revealed low normal white count. CT chest showed a fluid collection at the sternotomy site, and multiple non-calcified bilateral lung nodules. MRI of chest showed absent sternum and fluid collection at sternotomy defect measuring 7 x 11 x 10 cm. Irrigation and debridement of mediastinal wound was performed and patient was started on broad-spectrum antibiotics. Abscess culture turned positive for Mycobacterium avium complex (MAC). Antibiotics were switched to azithromycin, rifampin, and ethambutol. Patient underwent sternal debridement with bilateral pectoralis muscle flap advancement and closure.
Discussion:
MAC organisms are the most commonly isolated NTM in the United States.1 Health care-associated NTM infections have been reported and these outbreaks are presumed to be due to exposure to liquid contaminated with NTM. 1 Localized skin and soft tissue infections are commonly associated with M. fortuitum, M. abscessus, M. chelonae, M. marinum, and M. ulcerans. Nosocomial skin infections like post-injection abscesses and wound infections after plastic surgery have been reported.2-4 A literature review of 70-cases of post-operative NTM sternal wound infection following cardiac surgery showed average time of infection post-surgery was 49±58 days and rapidly growing mycobacteria were most commonly isolated.2 It is imperative to maintain a high index of suspicion for NTM as pathogens for wound infection in post-surgical patients.
References:
1. Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. 2007;175(4):367-416.
2. Unai S, Miessau J, Karbowski P, Bajwa G, Hirose H. Sternal wound infection caused by Mycobacterium chelonae. Journal of cardiac surgery. 2013;28(6):687-692.
3. Wallace RJ, Jr., Brown BA, Griffith DE. Nosocomial outbreaks/pseudo-outbreaks caused by nontuberculous mycobacteria. Annual review of microbiology. 1998;52:453-490.
4. Macadam SA, Mehling BM, Fanning A, et al. Nontuberculous mycobacterial breast implant infections. Plastic and reconstructive surgery. 2007;119(1):337-344.
Author Block: P. Sharma, B. Smith, M. Yassin; UPMC Mercy, Pittsburgh, PA, United States.
Introduction:
Mediastinitis is a major complication of cardiac surgery. Non-tuberculous mycobacteria (NTM) are emerging pathogens with bypass machine post-cardiac surgery.
Case Report:
75-year-old female with past medical history of coronary artery disease and rheumatoid arthritis, presented to the hospital for evaluation of wound dehiscence from sternotomy site. Patient had a history of CABG around 10-years ago, and no additional surgical interventions were performed in the interim. Patient was on low-dose prednisone for rheumatoid arthritis on presentation, however she had been treated with methotrexate and leflunomide in the past. Examination showed erythema and serous drainage from sternotomy site. Laboratory investigations revealed low normal white count. CT chest showed a fluid collection at the sternotomy site, and multiple non-calcified bilateral lung nodules. MRI of chest showed absent sternum and fluid collection at sternotomy defect measuring 7 x 11 x 10 cm. Irrigation and debridement of mediastinal wound was performed and patient was started on broad-spectrum antibiotics. Abscess culture turned positive for Mycobacterium avium complex (MAC). Antibiotics were switched to azithromycin, rifampin, and ethambutol. Patient underwent sternal debridement with bilateral pectoralis muscle flap advancement and closure.
Discussion:
MAC organisms are the most commonly isolated NTM in the United States.1 Health care-associated NTM infections have been reported and these outbreaks are presumed to be due to exposure to liquid contaminated with NTM. 1 Localized skin and soft tissue infections are commonly associated with M. fortuitum, M. abscessus, M. chelonae, M. marinum, and M. ulcerans. Nosocomial skin infections like post-injection abscesses and wound infections after plastic surgery have been reported.2-4 A literature review of 70-cases of post-operative NTM sternal wound infection following cardiac surgery showed average time of infection post-surgery was 49±58 days and rapidly growing mycobacteria were most commonly isolated.2 It is imperative to maintain a high index of suspicion for NTM as pathogens for wound infection in post-surgical patients.
References:
1. Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. 2007;175(4):367-416.
2. Unai S, Miessau J, Karbowski P, Bajwa G, Hirose H. Sternal wound infection caused by Mycobacterium chelonae. Journal of cardiac surgery. 2013;28(6):687-692.
3. Wallace RJ, Jr., Brown BA, Griffith DE. Nosocomial outbreaks/pseudo-outbreaks caused by nontuberculous mycobacteria. Annual review of microbiology. 1998;52:453-490.
4. Macadam SA, Mehling BM, Fanning A, et al. Nontuberculous mycobacterial breast implant infections. Plastic and reconstructive surgery. 2007;119(1):337-344.
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