A rare but serious disseminated cutaneous mycobacterium abscessus infection in a healthy young lady following traditional Chinese medicine threading therapy

Kwok-ho Li 李國豪，Yuk-wah Hung 洪煜華，Carson KB Kwok 郭嘉邦，Jason CH Fan 范智豪，Alexander PH Chan 陳伯顯， Ellis LF Wong 王洛輝

HK Pract 2018;40:85-89

Summary

Traditional Chinese Medicine (TCM) procedures are gaining popularity in Hong Kong. Yet the possible sequalae are often underestimated by both the medical field and the public. Here we describe the case of a young healthy subject who became the victim of severe disseminated cutaneous Mycobacterium abscessus infection after Threading Therapy. The current inadequencies in the public awareness and the monitoring of TCM procedures are discussed with recommendations suggested.

摘要

中醫藥的醫療程序在香港日益普及。然而，醫療領域 和公眾往往低估了可能發生的後果。在這裡，我們描述一 個年輕健康的人成為受害者，因為中醫埋綫療法受到嚴重 膿腫分枝桿菌瀰漫性皮膚感染。對於目前公眾意識和對中 醫醫療程序監測的不足，本文作出討論並提供建議。

The case

A 27-year-old lady with a good past medical history was admitted to the Alice Ho Miu Ling Nethersole Hospital (AHNH) orthopaedic ward in August 2016 for swellings in her right thigh and buttock. Earlier she had had Threading Therapy performed by a registered Traditional Chinese Medicine (TCM) practitioner four months before for weight reduction. This involved the embedding of a thread in the subcutaneous layer of her abdomen.

She had noted two swellings, one was over her right buttock and the other was over the posterior aspect of her thigh three months after the TCM procedure. The swellings were increasing in size and causing intolerable pain affecting her sleep and daily activities.

Presentation

On her first presentation, the patient was afebrile with stable vitals. There was an abscess over her right posterior thigh, measuring 4 x 4 cm which had ruptured with active pus discharge and another 3 x 3 cm over her right buttock swelling (Figure 1). Bedside needle aspiration of the right buttock swelling yielded no pus. A raised white blood cell count (WCC) (12.2 x 10^9/L), C-reactive protein (CRP) (19.6 mg/l) and Erythrocyte sedimentation rate (ESR) (49 mm/hr) were noted. A bigger incision and drainage of the thigh abscess was performed with wound swabs sent for culture. Intravenous Augmentin was commenced on this lady.

Ultrasound of the right lower limb two days later revealed a subcutaneous hypoechoic area with fluid content measuring 2.8 x 0.9 x 7.5 cm suggestive of a further residual abscess in her thigh. An irregular hypoechoicity in the lower abdominal subcutaneous layer was also identified when the patient newly noted another mass over the area of previous Threading Therapy treatment. Ultrasound (USG) guided aspiration was performed with specimen sent for culture.

Incision and drainage of the right buttock abscess was also performed after the discovery of turbid discharge the next day. Further excisional debridement was performed in the same week (Figure 1). All the wounds were dressed daily with hibitane and oral Ciprofloxacin was added to her treatment regim.

Routine culture and sensitivity test

The routine cultures yielded no growth while the mycobacterium culture result was still pending. The patient was discharged a week later when the wounds became dry. Augmentin and Cloxacillin were prescribed for a total of 14 and 7 days respectively.

The patient was called back two weeks later as the abscess aspirate grew Mycobacterium abscessus sensitive only to Amikacin. Clinical microbiologists were consulted and a combination of intravenous Tienam, Amikacin and oral Clarithromycin was started to target the multidrug-resistant Mycobacterium abscessus, as well as both the aerobic and anaerobic, Gram-positive and Gram-negative organisms.

Computerised tomography

Computed tomography (CT) scan of her right lower limb (Figure 2) revealed a residual collection in her right posterior thigh, measuring 0.9 x 5.2 x 4.0 cm just superficial to the hamstring muscle in the deep subcutaneous region. It also showed a multiloculated rim-enhancing lesion, measuring 3.1 x 1.9 x 1.7 cm in her right anterior abdominal wall in the subcutaneous layer just below the umbilicus. Excisional debridement and drainage was performed under general anaesthesia for the abdominal abscess after ultrasound mapping. Repeated wound debridement was performed for all the three wounds. The abdominal and right buttock wounds were sutured and closed 2 weeks afterwards. The right thigh wound still appeared slimy and vacuum-assisted closure dressing was implemented for another ten days and was then sutured. The patient was discharged after a total of one month of hospitalisation. Both the blood tests done for WCC (7.4 x 10^9/L) and CRP (1.8 mg/l) had normalised on discharge. A total of 4 weeks of intravenous Tienam and Amikacin, and oral Clarithromycin were prescribed during her hospitalisation. Oral Clarithromycin and Septrin were planned for another 3-6 months upon discharge.

On discharge

The patient was worked up for possible underlying immunocompromising conditions which would render her susceptible to Mycobacterium abscessus infections. All investigations yielded negative results. Her fasting glucose was normal, blood counts apart from a raised white cell count were normal, liver and renal function tests were normal, and she was not on any long term medications nor had any family history of immunocompromising conditions.

Discussion

Threading therapy, also known as embedding therapy or implant acupuncture, is a procedure employed by TCM and developed from the concept of acupuncture and meridians. It is gaining popularity among Hong Kong citizens as TCM is a common practice in this district. Threading therapy involves the insertion of an absorbable thread by an acupuncture needle through the skin and embedding the thread at acupuncture points. The thread is absorbed by the body in one to four months’ time, depending on the type of threads used. It is thought that by stimulating various acupuncture points, metabolism would be enhanced leading to weight reduction, enhance immunity and balance endocrine function, promoting general wellbeing.

Mycobacterium abscessus is a rapidly growing bacterium which is found in contaminated water, soil and dust. Healthcare-associated infections due to this bacterium usually occur in immunocompromised subjects and include skin and soft tissue infections, lung infections in those with chronic lung diseases, and rarely central nervous system infections and ocular infections. It is one of the most virulent and difficult to treat bacteria due to its resistance to most of the currently available antibiotics.¹ This is the first documented Mycobacterium infection after TCM threading therapy in Asia. Though rare, Mycobacterium in other invasive TCM therapies and cosmetic therapies are not unheard of, e.g. Mycobacterium abscessus and Mycobacterium tuberculosis infection after acupuncture^2,3, Mycobacterium massiliense infection after Tread Lifting (a technique which has its origins in South Korea).⁴

In many occasions, the risks of these procedures are deprecated to gather attention. As in the above case, clients were informed that weight reduction would be achieved by a “minimally invasive” procedure which would only last around ten to twenty minutes with the only possible side effects of pain and bruising. Disseminated deep seated severe infection in a healthy and young subject which leads to months of hospitalisation or even death is not one of the complications which was anticipated by the client. Informed consent becomes an issue here as the client / patient was not fully aware of the risks she was taking before she underwent these procedures. More stringent supervision of the media, propaganda materials, or even cosmetic or medical practice on the issue of informed consent is necessary. Awareness of both the public and the medical field should be raised concerning the risks of such “minimally-invasive” procedures which appear non-threatening but may indeed result in catastrophic consequences.

Another issue raised is the sterilisation quality of the instruments and the hygienic condition of the procedure. The patient retrieved an intact sample of the thread used for the procedure from the TCM practitioner. It was sealed up in an airtight aluminium packaging (Figure 2). However, there was no printed expiry date, nor any text stating whether it was sterilised or how it was sterilised, nor any instructions. Whether the procedure was performed under aseptic technique is also another concern. In the USA, a study found that steam sterilisation can effectively disinfect nebulizers inoculated with nontuberculous mycobacteria.⁵ Perhaps sterilisation techniques on TCM implants should be further evaluated as well.

Conclusion

Though Mycobacterium infection after TCM procedures is rare, it can cause serious disseminated cutaneous infection even in a healthy person. In view of the increasing popularity of TCM procedures in Hong Kong, raising awareness of the possible associated complications by the public and medical field, and implementing standardised and closely supervised sterilisation protocols are necessary.