Subcutaneous infection caused by Mycobacterium abscessus following cosmetic injections of botulinum toxin: A case report

lNTRODUCTlON

Nontuberculous mycobacteria (NTM) refer to mycobacteria other thanandwith the common involved organs of the lung, bone, soft tissues, skin, and lymph nodes[1].() is one of the common pathogens in NTM, which is a fast-growing mycobacterium causing skin and soft tissue infections. Meanwhile, the atypical mycobacterial infections are increasing at injection-related sites as the informal cosmetic treatments are performed, which deserves the attention of the cosmetic and medical supervision[2-4]. The case presented here is a subcutaneous infection caused byfollowing cosmetic injections of botulinum toxin.

CASE PRESENTATlON

Chief complaints

文中介紹了一種基于Android平臺的高血壓監測預警系統設計方案，為用戶提供血壓、心率監測、智能預警以及健康指導等功能，對于緩解醫療資源緊張、輔助家庭監護系統、降低患者病死病殘率，提高生活質量等方面具有一定的作用。同時，為高血壓移動醫療軟件的設計與開發提供了新的思路。

History of present illness

The lesions initially presented with erythema after 10 d of the injection then developed to nodules and abscesses after half a month. The patient did not have any concomitant symptoms such as fever, cough,fatigue, sweats, or diarrhea. She was prescribed with antibiotics for 2 wk without alleviation of the lesions.

History of past illness

Nothing special.

Personal and family history

The patient did not have any underlying disease or take any drugs in the past.

Physical examination

Physical examination indicated multiple red papules, nodules, and abscesses on the forehead and both temporal sites with a diameter of 1-3 cm.

Laboratory examinations

The routine blood, urine, and stool tests as well as kidney and liver function tests were in normal levels.The levels of C3, C4 and C-reactive protein were normal. The patient was negative for syphilis, HIV,antinuclear antibodies, and rheumatoid factor. CD3 and CD4 counts were done to check for any immunodeficiency and were within normal limits (Supplementary Table 1).

Imaging examinations

Computed tomography (CT) of the whole body did not find any systemic infection or diseases.

FlNAL DlAGNOSlS

The patient underwent skin biopsy on the nodules of left temporal site. The pathology of skin tissue showed a large number of inflammatory cells including neutrophils, lymphocytes, and multinucleated giant cells distributed in the derma (Figure 2A and 2B). However, periodic acid Schiff (PAS) and acidfast staining were negative. Meanwhile, the skin tissue did not yield any microbiome after culture on different media for bacteria, fungus, or mycobacterium. Considering the low biopsy- and culturepositive rate of some microorganisms, a puncture on abscess of right temporal site was further performed. Gray-white colonies were yielded after being cultured on Mycobacterium Roche's Medium(MRM) for 5 days at 35 °C (Figure 3A). Meanwhile, the pus was positive for acid-fast staining andwas identified by DNA sequencing (Figure 3B). The drug sensitivity test indicated that the microbiome was sensitive to clarithromycin, moxifloxacin, azithromycin, cefoxitin, and amikacin, and was resistant to isoniazid, streptomycin, dapsone, and rifampicin (Supplementary Table 2).

TREATMENT

The patient was initially intramuscularly injected with amikacin 0.2 g and given oral clarithromycin 0.25 g twice a day for 2 wk and then adjusted to moxifloxacin 0.4 g per day and clarithromycin 0.25 g twice a day because of dizziness and vomiting caused by amikacin.

The patient did not show any side effects and presented complete remission of the lesions during the subsequent treatment for 7 mo (Figure 1D-F).

OUTCOME AND FOLLOW-UP

對于陶瓷器物來說，瓷器上的紋飾不僅僅是重要裝飾手段，更是時代審美與人文風氣的縮影。陶瓷器物的繪畫裝飾的手法起源于新石器時代。新石器時代的圖案源自于人們在長期的勞動時間活動中對事物的認識，在經過當時人們的主觀的感想和藝術處理而形成的圖騰形象。在后來的發展中，器物上的紋飾時代氣息更加明顯，文化內涵也發生了翻天覆地的變化，這些紋飾已經不僅僅帶給人視覺上的享受，其中還有耐人尋味的藝術價值。

DlSCUSSlON

With the development of un-standard invasive performance in cosmetic industry, related iatrogenic complications are increasing in the last two decades. Injection pain, local edema, erythema, and transient nausea are common complications with mild symptoms. Life-threatening complications are rarely seen, while severe idiosyncratic reactions can cause patients to die from shock and pseudoaneurysm of the superficial temporal artery may break and cause bleeding to death[5]. Infections are also common complications, which usually can be easily cured with empiric antibiotic therapy. However,atypical mycobacterial infections are increasing these years and resistant to regular antibiotic treatment.To meet the challenge of NTM diagnosis and management, we should learn more about it. In Table 1,previous cases of mycobacterial infections caused by cosmetic performance are reviewed[2-4,6-14], the results of which are consistent with the previous studies[1]. It is common to be seen in female patients aged 25 to 45 years. This phenomenon can be attributed to the fact that these people are more often seeking invasive cosmetic performance.

The rare pathogen ofis the main mycobacteria isolated from lesions cultured, which can involve the skin, soft tissue, and lymph nodes in immunocompetent or immunosuppressed patients[1,15]. The cutaneous infection caused bygenerally occurs following surgery, subcutaneous injection, or acupuncture[16]. Becausehas a hydrophobic biofilm, by whichcan be resistant to disinfectants and heavy metals, and lead to nosocomial infections[17]. The lesions of the patient presented here develop at the injected point of botulinum toxin. We suspected that the infection may be caused by the non-standard aseptic operation and injection, surgery, equipment contamination,or intraoperative infection. Iatrogenic infections have become one of the common causes of fast-growing mycobacterial infection because of the unstandardized aseptic operation during injection and surgery causing an increase in opportunistic infections and great pain to patients. Therefore, when managing such cases, attention should be paid to these agents.

The skin lesions can be the initial symptoms or secondary to disseminated infections, which often present with multiple papules, herpes, nodules, erythema, or abscesses[1]. The initial symptoms of our patient presented as multiple erythema then developed to nodules and abscess. She was prescribed with multiple antibiotics but without remission of the lesions. The unspecific infection caused by fungus,, or NTM was suspected. Finally, the patient was diagnosed as having subcutaneous infection caused by. The golden standard for diagnosing NTM infections is histopathology and mycobacteria culture. Acid-fast staining is the most convenient and common laboratory test, while PCR sequencing and DNA chip technology have emerged as fast and accurate methods in identifying NTM[15]. However, the acid-fast staining of nodule of this patient was negative and did not yield any culture on MRM. Fortunately, the puncture fluid of abscess was positive for acid-fast staining andwas yielded and identified by PCR sequencing. Therefore, once NTM infection is clinically suspected, multiple specimens should be tested by histopathology, culture, and molecular biology identification. The successful diagnosis of this patient depended on the awareness of mycobacterial infections and attitude of insistence.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

CONCLUSlON

NTM infection should be aware in patients with refractory lesions, particularly followed by cosmetic procedure. Moreover, the drug sensitivity test needs to be performed to obtain early diagnosis and appropriate treatment to avoid dissemination and deformity.

Informed consent was obtained from the patient for publication of this case report.

FOOTNOTES

Yu XH and Deng L were the patient’ dermatologists; Deng L collected the data; Luo YZ and Liu F contributed to manuscript drafting and literature review.

“以癌癥為例，中國人非常恐癌?！敝茚泛舱f，國際抗癌聯盟曾公布的一項調查數據顯示，面對癌癥，中國人持消極態度的高達43%。其實，良好的心理、精神狀態對治療調養有很大作用。

The authors declare that they have no conflicts of interest to disclose.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

NTM are intracellular colonies whose high hydrophobicity on the cell surface and cell wall permeability barrier make them resistant to traditional anti-tuberculosis drugs and difficult to treat[17].is the most resistant strain of mycobacterium, and is highly resistant to traditional antituberculosis drugs; hence, it needs to be tested for drug susceptibility when yielding positive cultures.is often sensitive to clarithromycin, amikacin, and cefoxitin. However, a single drug is easy to induce drug resistance according to the guidelines of the American Thoracic Society and the American Society of Infectious Diseases, therefore the combination of two kinds of sensitive drugs is recommended for treatment until the lesions are completely healed[18]. Meanwhile, drug susceptibility testing needs to be performed once culture of NTM is yielded to ensure the effective treatment.

目前，市場上周氏嚙小蜂蛹售價一般為5.5元/個，考慮到釋放45～120枚/hm2的寄生率及防治效果差異不大，如果為節省成本，一般可采用60枚孕蜂蛹/hm2的釋放量。

近年來,人們對于健康的認識也越來越深,在此背景下,護理工作的重要性已經被人們所廣泛認知和接受。經過多年的發展,傳統的單一護理工作已經逐漸演變成為如今以人為本的新型人性化護理,其給醫院的護理工作增添了新的含義,同時也給處在病癥中的患者帶來了強烈的人文關懷。本文的研究結果顯示,對婦產科患者采用人性化護理可以改善心理狀況。此外,由于人性化護理能夠及時解答患者家屬的疑問,講解相關的健康知識,安撫他們的情緒,并及時通過交流了解患者的心理活動,因而也得到了家屬的強烈支持與贊同能夠有效提升患者抗擊病痛的信心和毅力,同時也可以提高患者對醫護人員的信任,從而更好地提升護理效果。

China

Lin Deng 0000-0001-9574-4632; Ying-Zhi Luo 0000-0002-9662-2562; Fang Liu 0000-0001-6961-0219; Xiao-Hong Yu 0000-0001-8932-499X.

Xing YX

(2)語言神態描寫：①他對人說話，總是滿口之乎者也，教人半懂不懂的。說明他以讀書人自居，賣弄學問。迂腐可笑的性格。②孔乙己睜大眼睛說，“你怎么這樣憑空污人清白……”說明他死要面子，怕人嘲笑。③孔乙己便漲紅了臉，額上的青筋條條綻出，爭辯道，“竊書不能算偷……竊書!……讀書人的事，能算偷么？”說明他自命清高、迂腐不堪、自欺欺人，死要面子的性格。④孔乙己看著問他的人，顯出不屑置辯的神氣。說明孔乙己自命清高。⑤“孔乙己立刻顯出頹唐不安模樣。臉亡籠上了一層灰色，嘴里說些話；這回可是全是之乎者也之類，一些不懂了。說明孔乙己深受封建科舉制度毒害，至死不悟。

Wang TQ

Xing YX