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 ~  Abstract
 ~  Case Report
 ~  Discussion
 ~  Acknowledgement
 ~  References

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CASE REPORT
Year : 2003  |  Volume : 21  |  Issue : 2  |  Page : 133-134
 

Injection site abscess due to mycobacterium fortuitum: A case report


Departments of Microbiology, MS Ramaiah Medical Teaching Hospital, Bangalore - 560 054, Karnataka, India

Correspondence Address:
Departments of Microbiology, MS Ramaiah Medical Teaching Hospital, Bangalore - 560 054, Karnataka, India

 ~ Abstract 

Injection abscess is an iatrogenic infection occurring as an isolated case or as cluster outbreak. These infections occur due to contaminated injectables or lapse in sterilisation protocol. While pathogens such as Pseudomonas, Klebsiella, E. coli, and S. aureus are the usual causative agents, unusual organisms such as mycobacteria, particularly the rapidly growing non-tuberculous mycobacteria (NTM) may cause the abscess. The chances of overlooking these organisms is high unless an acid fast bacilli (AFB) smear and culture is done on all aspirated pus specimens. We report a case of a three year old child who presented with a gluteal abscess following an intramuscular infection with an unknown preparation.

How to cite this article:
Devi DG, Indumathi V A, Indira S, Babu PS, Sridharan D, Belwadi MS. Injection site abscess due to mycobacterium fortuitum: A case report. Indian J Med Microbiol 2003;21:133-4


How to cite this URL:
Devi DG, Indumathi V A, Indira S, Babu PS, Sridharan D, Belwadi MS. Injection site abscess due to mycobacterium fortuitum: A case report. Indian J Med Microbiol [serial online] 2003 [cited 2014 Oct 24];21:133-4. Available from: http://www.ijmm.org/text.asp?2003/21/2/133/7993


Injection site abscess is an iatrogenic infection and is a simple out patient procedure to treat. Most of these cases go undocumented and uninvestigated. Commonly involved microorganisms include Pseudomonas, Klebsiella, E. coli, S. aureus, etc. Unusual organisms such as Mycobacteria, particularly the rapidly growing non-tuberculous mycobacteria (NTM) may be involved. M. chelonae, M. fortuitum and M. abscessus are the most important rapidly growing mycobacteria associated with such infections.[1],[2],[3] DaCosta Cruz characterised the first strain of M. fortuitum following its recovery from the site of vitamin injection.[4] Literature reports of injection abscess due to NTM such as M. fortuitum, M. chelonae, and M. abscessus following the injection of vitamin preparation, DPT vaccine, iron dextran and penicillin have been documented.[5],[6] However, the reports from India are found to be limited.[7] NTM are rare human pathogens which are found in the environment, particularly water. Infection by these organisms leads to delayed wound healing with chronic serous discharge and require prolonged course of expensive antibiotics.[8] The chances of overlooking these organisms is high unless an acid fast bacilli (AFB) smear and culture is done on all aspirated pus specimens. The case reported here emphasises these aspects.

 ~ Case Report Top

A three year male child belonging to upper middle class presented with a complaint of gluteal swelling for the past 15 days. Previous history revealed that he was given some unknown injection for fever one month ago by a local general practitioner. There after the fever subsided and the child was apparently healthy. Subsequently, he developed a swelling at the injection site which gradually increased in size. Patient also had mild pain associated with on and off low grade fever. The case was referred to paediatric surgery.
Clinical examination revealed a 6 x 5 cm, tense, tender and indurated swelling on left supero-lateral quandrant of the gluteal region. Systemic examination was normal with normal blood picture. X-ray chest and spine were within normal limits. Mantoux test was negative. The abscess was drained aseptically under local anaesthesia. About 15-20 mL of thick yellowish non foul smelling pus was aspirated and sent for culture and sensitivity.
Gram stain showed numerous pus cells and no organisms. Routine culture for aerobic and anaerobic organisms yeilded no growth. Ziehl-Neelsen's (ZN) stain for AFB was found to be positive. Culture on Lowenstein Jensen (LJ) medium showed non-pigmented colonies by fifth day which was presumptively identified as a rapidly growing NTM. The same organism was isolated from the second sample collected after five days. Identification procedure such as growth on MacConkey agar also revealed pale pink colored colonies after three days. In addition, nitrate reduction, iron uptake , urease test, PNB test, 5 percent Nacl tolerance, and aryl phosphatase test were found to be positive. These results confirmed the identification of the organism to be M. fortuitum. Culture confirmation and antitubercular sensitivity was also done at National Tuberculosis Institute (NTI), Bangalore.
The patient was started on six weeks course of ethambutol, pyraxzinamide and clarithromycin.[9] Dressing was done on alternate days. Exudative drainage turned serosanguinuous a week later but, discharge persisted for nearly six weeks. The patients recovered completely with the course of therapy that lasted for six weeks.

 ~ Discussion Top

Diseases due to NTM are relatively rare. NTM are ubiquitous organisms found both in soil and water and are increasingly recognised as pathogens causing nosocomial infections.[1],[2] Among the rapidly growing NTM, M. fortuitum and M. chelonae cause skin and wound infections and abscesses. These NTM organisms are probably transmitted by aerosol route or via soil, dust, water or by ingestion or by skin inoculation, whereas its spread between persons is rare. Development of local pain, swelling, and drainage upto 4-8 weeks following accidental trauma with potential wound contamination associated with little or no systemic symptoms is a classic presentation of infection due to M. fortuitum. Most of these cases are otherwise healthy. Diagnosis is confirmed by culture of aspirate and biopsy specimen. Infection by these organisms leads to delayed wound healing with chronic serous discharge and requires prolonged course of expensive antibiotics. The first line of anti-tubercular treatment have no role in the therapy of rapidly growing mycobacterial diseases. Hence, susceptibility testing of clinically significant rapidly growing mycobaceria should not be performed only with antitubercular agents. They should be tested against antibacterial drugs such as amikacin, doxycycline, imipenem, fluorenated quinolones, sulfonamide cefoxitin and clarithromycin.[10]
From the foregoing, it is concluded that every sterile aspirated specimen of infection abscess has to be investigated and documented and also subjected for AFB examination. An awareness of the probable contamination of injectable preparations with NTM and also strict attention to sterilisation technique while administering any parenteral preparation is imperative.
In the present case, it was found that M. fortuitum is a clinically important NTM causing an injection abscess which was diagnosed on time and led to complete recovery following proper treatment.

 ~ Acknowledgement Top

We acknowledge the kind assistance of NTI, Bangalore for confirmation of the isolate. 

 ~ References Top

1.Wenger JD, Spika JS, Smithwick RW, Pryor V, Dodson DW, Carden GA, Klontz KC. Outbreak of Mycobacterium chelonae infection associated with use of jet injectors. JAMA 1990;264:373-376.  Back to cited text no. 1    
2.Laussucq S, Baltch AL, Smith RP, Smithwick RW, Davis BJ, Desjardin EK, Silcox VA, Speilacy AB, Zeimis RT, Gruft HM, Good RC, Cohen ML. Nosocomial Mycobacterium fortuitum colonisation from a contaminated ice machine. Am Rev Respir Dis 1988;138:891-894.  Back to cited text no. 2    
3.Inman PM, Beck A, Brown AE, Stanford. Outbreak of injection abscess due to Mycobacterium abscessus. Arch Dermat 1969;100:141-142.  Back to cited text no. 3    
4.DaCosta Cruz JC. Mycobacterium fortuitum umnovo bacilo acidoresistance patogenica para o homen. Acta Med 1938;1:298-301.  Back to cited text no. 4    
5.Beck A. Mycobacterium fortuitum abscess in man. J Clin Path 1965;18:307-308.  Back to cited text no. 5    
6.Borghans JGA, Stanford JL. Mycobacterium chelonae in abscess after infection of DPT polio vaccine. Am Rev Respir Dis 1973;107:1-5.  Back to cited text no. 6    
7.Sethi S, Sharma M, Ray P, Singh M, Gupta A. Mycobacterium fortuitum wound infection following laparoscopy. Indian J Med Res 2001;113:83-84.  Back to cited text no. 7    
8.Ward JM. Mycobacterium fortuitum and Mycobacterium chelonae: Fast growing mycobacteria: A review with a case report. Br J Dermatol 1975;92:453-455.  Back to cited text no. 8    
9.Powderly WG. Treatment of infection due to Mycobacterium avium complex. Pediatr Infect Dis J 1999;18:468-469.  Back to cited text no. 9    
10.Wallace RJ, Glassroth J, Griffith EF, Olivier KN, Cook JL, Gordin F. Diagnosis and treatment of disease caused by NTM. Am J Respir Crit Care Med 1997;156:S1-S25.  Back to cited text no. 10    
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2004 - Indian Journal of Medical Microbiology
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