Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 1  |  Page : 92-94  

Infection of laparoscopic port wound by Mycobacterium fortuitum


1 Department of Microbiology, M.K.C.G. Medical College, Brahmapur, Odisha, India
2 Department of Surgery, M.K.C.G. Medical College, Brahmapur, Odisha, India

Date of Web Publication9-Jan-2017

Correspondence Address:
Dr. Sarvodaya Tripathy
Department of Microbiology, M.K.C.G. Medical College, Brahmapur, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.197915

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  Abstract 

Cutaneous infection with rapidly growing mycobacteria is not very commonly reported. Unless strongly suspected, its diagnosis can be missed. We report a case of persistent sinus discharge that developed after laparoscopic cholecystectomy surgery, in a healthy adult male, caused by Mycobacterium fortuitum. The case is being reported for its uncommon etiological agent. In this patient, both chronicity as well as repeated supra-added infection of the wound had led to significant discomfort and morbidity.

Keywords: Immunocompetent host, laparoscopic port infection, Mycobacterium fortuitum, postsurgical infection


How to cite this article:
Tripathy S, Padhi S, Panda P, Panigrahi PK. Infection of laparoscopic port wound by Mycobacterium fortuitum. Med J DY Patil Univ 2017;10:92-4

How to cite this URL:
Tripathy S, Padhi S, Panda P, Panigrahi PK. Infection of laparoscopic port wound by Mycobacterium fortuitum. Med J DY Patil Univ [serial online] 2017 [cited 2020 Oct 27];10:92-4. Available from: https://www.mjdrdypu.org/text.asp?2017/10/1/92/197915


  Introduction Top


Nontuberculous mycobacteria (NTM) are commonly found in water, soil, and dust. NTM can infect individuals irrespective of their immune status. They can lead to respiratory infections, lymphadenitis, skin and soft tissue infections, and rarely disseminated systemic illnesses. Medical instruments contaminated with mycobacteria from the environment are often the source of infection. Contaminated injectable medicines can also be responsible for infection. The World Health Organization does not track down NTM infections, so the exact epidemiological data are not available.[1] Distribution can however be worldwide.

Mycobacterium smegmatis, Mycobacterium phlei, Mycobacterium abscessus, Mycobacterium thermoresistible, Mycobacterium fortuitum, Mycobacterium chelonae are placed under Runyon Group IV (rapidly growing NTM). M. fortuitum, M. chelonae, M. abscessus are pathogenic, M. fortuitum – M. chelonae complex being most commonly reported. There are limited numbers of studies focusing on NTM from the wound isolates. Indian studies are also scarce in this regard.

M. fortuitum and M. chelonae were isolated from the purulent discharges obtained from wounds of all patients studied for surgical site infection in an Indian study by Kannaiyan et al.[2] In another Indian study, 80% isolates from the pus/discharge were of NTM spp., all belonging to M. fortuitum – M. chelonae complex.[3]

The incidence of M. fortuitum infection has been estimated to be 4–6/1 million people.[4] Infections of surgical wounds, soft tissues, skin, and lungs are the common infective conditions attributed to M. fortuitum.[5]M. fortuitum has been reported from various cases of soft tissue infections in immunocompetent individuals throughout the world.[6]

Here, we present a rare case report on laparoscopic port infection with M. fortuitum, leading to the formation of a persistent discharging sinus.


  Case Report Top


A 54-year-old male with left-sided inguinal hernia with cholelithiasis had undergone laparoscopic surgery in a private clinic, for both ailments in a single setting. The patient was not a known case of diabetes or hypertension and had no history of contracting tuberculosis in the past. He was nonalcoholic.

Immediate postoperative period was uneventful. Stitches were removed on the 10th postoperative day; the wound was healthy. However, next day onward, the patient had reported about serous discharge from the wound, which in a few days turned purulent. The possibility of retained foreign body (residues of suture material) was thought of, and attempts were made to remove the foreign body.

Despite the efforts, the purulent discharge continued. Pus was sent for microscopic examination and culture to a private laboratory. Pus cultures during that period showed Acinetobacter spp. sensitive to prulifloxacin and cefoperazone/sulbactam. The microscopic examination reports were not available with the patient. The patient was treated with these antibiotic medications.

On biopsy, the nonhealing sinus tract at the laparoscopy port, measuring approximately 2 cm × 2 cm × 1.5 cm, showed a lining of nonspecific granulation tissue. The granulation tissue was composed of thin-walled blood vessels, lymphocytes, polymorph, histiocytes, and plasma cells. No evidence of granulomatous inflammation or malignancy was seen. No significant abnormality was found on abdominal ultrasonogram.

Laparotomy was performed to evacuate any residual foreign material following a laparoscopic examination. However, the problem persisted.

Four months after laparotomy, the discharge was still persisting from the wound [Figure 1]a. Hence, the patient was then referred to our set up for microbiological evaluation. A pus culture study was done. Pus was collected in three different sterile swabs avoiding contamination with skin flora. One swab was used for Gram-staining, Ziehl–Neelsen-staining (ZN), and KOH mount. On microscopic examination, pus cells along with Gram-positive cocci were seen. On ZN-staining, beaded acid-fast Bacilli were seen [Figure 1]b. The pus was inoculated in MacConkey Agar, Blood Agar, Chocolate Agar, commercial Lowenstein–Jensen (LJ) medium (HiMedia), and Sabouraud Dextrose Agar. The culture was also put in Robertson cooked meat media (RCM) to exclude anaerobes. All media were incubated at 37°C.
Figure 1: (a) Discharge from laparoscopic port; (b) acid-fast Bacilli from pus; (c) growth in Lowenstein–Jensen medium; (d) subculture from Lowenstein–Jensen medium growth on MacConkey

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Staphylococcus aureus was isolated on MacConkey Agar and Blood Agar within 24 h of incubation. It was detected by the standard conventional methods. It was sensitive to trimethoprim-sulfamethoxazole, linezolid, doxycycline, vancomycin, and levofloxacin when tested by Kirby-Bauer disc diffusion method.

LJ medium was checked every day to detect any growth. On the 5th day, buff-colored butyrous colony appeared [Figure 1]c on LJ medium. A part of the colony from LJ medium was again stained and inoculated in MacConkey Agar (without crystal violet). On 4th day of incubation, there appeared fine colonies [Figure 1]d on MacConkey agar. The isolate was rapidly growing and nonpigmented. Further, it showed positive nitrate reduction, sodium chloride tolerance, and 3-day aryl sulfatase test. Thus, the growth was detected to be of M. fortuitum. Fungal culture showed negative results. Anaerobic bacteria were not found in RCM.

The patient was advised a combination therapy with injection amikacin (750 mg, intramuscular daily) for 2 weeks and clarithromycin (500 mg per oral twice daily) for 4 weeks. After reviewing, he was asked to continue clarithromycin. The discharge subsided and the patient was completely symptom-free after 3 months of starting of therapy.


  Discussion Top


It is evident that NTM can affect immunocompetent individuals, M. fortuitum has been reported following peritoneal dialysis, acupuncture, polypropylene mesh inguinal hernia repair.[7],[8] A case of breast piercing followed by contact with contaminated water leading to M. fortuitum infection in an immunocompetent female has also been reported from the USA.[9]M. chelonae from the wound infection following laparoscopy in a female gynecologist has been reported from Bengaluru, India.[10]

In immunocompetent individuals, skin and soft tissue infections by NTM often emerge in outbreaks. These outbreaks are commonly associated with various interventional procedures such as injections, laser-assisted in situ keratomileusis, plastic surgery, breast implant surgery, liposuction, and mesotherapy.[8] Common sources of infection with mycobacteria are contaminated instruments and injectable drugs.

The inadequate use of disinfectants and antiseptics is a source of nosocomial outbreaks of soft tissue infection. Outbreaks of NTM infection have been reported due to the use of benzalkonium chloride contaminated with NTM in the USA.[11] Epidemic of infection caused by a single clone of M. massiliense after video-assisted surgery (1051 possible cases) caused due to tolerance of organisms to 2% glutaraldehyde has been reported from Brazil.[12]

Our patient was an immunocompetent individual with no history of diabetes. The postsurgical wound infection, which was misdiagnosed for a long-time was due to nondetection of specific NTM pathogens in serial cultures. Isolation of various other agents from the culture at different points in time guided the treatment. However, the last culture isolate revealed the mystery behind the persistent wound discharge. Improper sterilization might have been the major culprit in this case too.

Rapidly growing mycobacteria (RGM) should be subjected to antibacterial susceptibility testing with conventional antitubercular drugs along with other drugs such as amikacin, cefoxitin, clarithromycin, doxycycline, fluoroquinolones, imipenem, and sulphonamide.[6] Susceptibility testing in our case too showed sensitivity to amikacin and clarithromycin.

As NTM infections often go undiagnosed, it is advisable that any specimen collected for culture and aspiration cytology should be evaluated for the presence of AFB. It is important to be aware of these groups of infections from diagnostic and therapeutic viewpoints. High indices of suspicion followed by timely and efficient management of such patients are of critical importance.

The surgeons should be stringent about the following strict sterilization protocols as per the guidelines. Preoperative, proper skin cleansing is also an essential prerequisite to prevent these infections. While evaluating the cases of surgical site infections, RGM must be kept in mind as its nondetection delays the diagnosis and treatment. These infections require to be diagnosed specifically also because they need to be treated with drugs other than the routine antituberculous drugs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Nag V, Rahman W, Maurya A, Kumar M, Kumar A, Dhole T. Non healing post surgical wound due to NTM (Mycobacterium fortuitum) in immunocompetent patient treated by conservatively in tertiary care centre. J Biomed Sci Res 2010;2:227-30.  Back to cited text no. 1
    
2.
Kannaiyan K, Ragunathan L, Sakthivel S, Sasidar AR, Muralidaran, Venkatachalam GK. Surgical site infections due to rapidly growing mycobacteria in puducherry, India. J Clin Diagn Res 2015;9:DC05-8.  Back to cited text no. 2
    
3.
Kalita JB, Rahman H, Baruah KC. Delayed post-operative wound infections due to non-tuberculous Mycobacterium. Indian J Med Res 2005;122:535-9.  Back to cited text no. 3
    
4.
Betal D, Macneill FA. Chronic breast abscess due to Mycobacterium fortuitum: A case report. J Med Case Rep 2011;5:188.  Back to cited text no. 4
    
5.
Ho YS, Adroub SA, Aleisa F, Mahmood H, Othoum G, Rashid F, et al. Complete genome sequence of Mycobacterium fortuitum subsp. Fortuitum type strain DSM46621. J Bacteriol 2012;194:6337-8.  Back to cited text no. 5
    
6.
Sarma S, Thakur R. Cutaneous infection with Mycobacterium fortuitum: An unusual presentation. Indian J Med Microbiol 2008;26:388-90.  Back to cited text no. 6
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7.
Celdrán A, Esteban J, Mañas J, Granizo JJ. Wound infections due to Mycobacterium fortuitum after polypropylene mesh inguinal hernia repair. J Hosp Infect 2007;66:374-7.  Back to cited text no. 7
    
8.
Guevara-Patiño A, Sandoval de Mora M, Farreras A, Rivera-Olivero I, Fermin D, de Waard JH. Soft tissue infection due to Mycobacterium fortuitum following acupuncture: A case report and review of the literature. J Infect Dev Ctries 2010;4:521-5.  Back to cited text no. 8
    
9.
Abbass K, Adnan MK, Markert RJ, Emig M, Khan NA. Mycobacterium fortuitum breast abscess after nipple piercing. Can Fam Physician 2014;60:51-2.  Back to cited text no. 9
    
10.
Devi D, Sridaran D, Indumathi V, Babu P, Belwadi M, Swamy A. Isolation of Mycobacterium chelonae from wound infection following laparoscopy: A case report. Indian J Tuberculosis 2004;51:149-51.  Back to cited text no. 10
    
11.
Tiwari TS, Ray B, Jost KC Jr., Rathod MK, Zhang Y, Brown-Elliott BA, et al. Forty years of disinfectant failure: Outbreak of postinjection Mycobacterium abscessus infection caused by contamination of benzalkonium chloride. Clin Infect Dis 2003;36:954-62.  Back to cited text no. 11
    
12.
Duarte RS, Lourenço MC, Fonseca Lde S, Leão SC, Amorim Ede L, Rocha IL, et al. Epidemic of postsurgical infections caused by Mycobacterium massiliense. J Clin Microbiol 2009;47:2149-55.  Back to cited text no. 12
    


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