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Mycobacterium abscessus peritonitis associated with laparoscopic gastric banding
© Hakami et al.; licensee BioMed Central Ltd. 2013
Received: 13 April 2013
Accepted: 10 July 2013
Published: 15 July 2013
Mycobacterium abscessus is a rapidly growing Mycobacterium that is a common water contaminant in the environment. We report a case of M. abscessus infection with band erosion following laparoscopic gastric banding.
A 34-year-old woman developed insidiously progressing abdominal distension over a period of 1 year associated with abdominal pain, fatigue, night sweating and anorexia 4 years after laparoscopic gastric banding for obesity. Investigation revealed significant ascites with caseating granuloma in peritoneal biopsies from which M. abscessus was isolated. Band erosion with infection and multiple abdominal adhesions were confirmed during laparoscopic removal of the gastric band. To the best of our knowledge, this is the first reported case of M. abscessus infection after laparoscopic gastric banding surgery. We discuss the possible sources of infection, its indolent presentation, and therapeutic challenges.
It is important to consider environmentally acquired infection in patients with signs and symptoms of infection in the presence of surgical prosthesis.
Mycobacterium abscessus is a rapidly growing Mycobacterium that is a common water contaminant. Clinical disease due to M. abscessus most often presents as chronic lung disease, or as skin, bone or soft-tissue infection following trauma [1–3]. Disseminated disease has been reported in immunocompromised patients . Although nosocomial infections associated with infected prostheses have been reported, such as otitis media following tympanostomy tube placement, peritoneal catheter-related peritonitis, infection after breast augmentation and septic arthritis with joint prosthesis [5–8], there are no reported cases associated with laparoscopic gastric banding devices. Infections with other mycobacteria other than tuberculosis (MOTT) have been reported after gastric banding [9–11]. This report describes a case of M. abscessus peritonitis in a patient with a history of laparoscopic gastric banding surgery. We discuss the possible sources and therapeutic challenges of infection, and highlight environmentally acquired infection in patients with signs and symptoms of infection in the presence of surgical prosthesis.
Broth microdilution interpretive criteria for rapidly growing mycobacteria
MIC (μg / mL) for category
M. abscessus is a rapidly growing Mycobacterium that is a common water contaminant. Human disease is suspected to result from environmental exposure. Literature review on Mycobacterium infections after laparoscopic gastric banding identified three reported cases of M. fortuitum infections. The first case was a young patient who developed peritonitis within a few days after gastric banding surgery. The other two patients had laparoscopic gastric banding procedures on the same day and in the same operating room [10, 11]. M. bolletii infection was isolated in another reported case after revision of gastric banding . To our knowledge this is the first case of M. abscessus infection following laparoscopic gastric banding.
We believe that the most likely sources of Mycobacterium were the gastric band itself, the surgical environment or contaminated injected saline. Although M. abscessus was isolated from the inflamed tissue around the gastric band, unfortunately no microbiological culture was sent from either the gastric band itself or the saline. The patient developed abdominal distension 4 years after gastric banding and had three saline band injections. Our patient had a delayed presentation 4 years after surgery, while in the other reported cases of Mycobacterium-infected gastric bands, infection occurred within 2 months of surgery.
Our patient developed infection 4 years post-surgery, suggesting an indolent course of this organism. This course is similar to a case of M. abscessus peritonitis that occurred in the 3rd year after peritoneal catheter placement and after 2 years of persistent isolation of M. abscessus from the catheter exit site without initial evidence of peritonitis .
M. abscessus isolates are uniformly resistant to standard antituberculosis agents. M. abscessus is susceptible to clarithromycin (100%), amikacin (90%), cefoxitin (70%), imipenem, linezolid, clofazimine and tigecycline. The role of drug susceptibility testing in the choice of agents for antimicrobial treatment of M. abscessus remains a subject of debate. There are important discrepancies between drug susceptibility measured in vitro and the activity of the drug observed in vivo, partly deriving from laboratory technical issues, and no clear standardized treatment method exists. Until the relationship between in vitro susceptibility and clinical response of M. abscessus to antimicrobial drugs is better understood and clarified, antibiotic susceptibility testing of all clinically significant isolates is recommended.
Treatment regimens include clarithromycin for 6 months in cases of skin and soft tissue infections and at least 12 months for pulmonary infections. For serious disseminated infections combination therapy with amikacin plus imipenem or cefoxitin for the first 2–6 weeks usually produces clinical and microbiologic improvement . Regarding M. abscessus infection and prosthesis, a small number of previously reported cases exist. These include chronic otitis media after tympanostomy tube placement, peritonitis with peritoneal catheter, mastitis after breast augmentation, and septic arthritis with prosthetic joints. Almost all cases required removal of prostheses and antibiotic therapy based on in vtro sensitivity for an average duration of 5–6 months, with at least 4–6 weeks of parenteral antibiotics [5–8].
This case highlights an environmentally acquired infection after laparoscopic gastric banding. Physicians need to consider MOTT as a cause of infection in the presence of surgical prosthesis. Treatment should include removal of any infected prosthesis and the use of appropriate antibiotics based on susceptibility testing.
Our case highlights the potential therapeutic complication of Mycobacterium infection in association with laparoscopic gastric banding procedures. When treating patients with signs and symptoms of infection and a history of surgical prosthesis, clinicians should consider MOTT as potential pathogens. Once diagnosed, initial treatment should include appropriate antibiotics selected based on susceptibility results as well as the removal of any infected materials.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Hanan Hakami: Fellow in Infectious Diseases, Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. Alaa Alhazmi: Consultant of General and Minimal Invasive Surgery, Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. Abdulrahman Alrajhi: Consultant in Infectious Diseases and Deputy Executive Director, Academic and Training Affairs, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. He authored a chapter on tuberculosis and infectious disease epidemiology. He also obtained a Master’s degree of Public Health from Harvard School of Public Health, Boston, Massachusetts, in International Health/Epidemiology of Infectious Disease.
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