Aesth Plast Surg DOI 10.1007/s00266-014-0281-y
LETTER TO THE EDITOR
GENERAL RECONSTRUCTION
Mycobacterium tuberculosis Silicone Gluteus Abscesses with Bone Involvement T. Pe´rez de la Fuente • E. Sandoval • C. Ca´rcamo Hermoso • L. Garcı´a Pardo
Received: 25 November 2013 / Accepted: 19 January 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Sir, With great interest we read the article by Carella et al. [1] entitled ‘‘Skin ulcer: a long-term complication after massive liquid silicone oil infiltration.’’ The authors concluded that surgery is the most effective treatment for complications due to liquid silicone oil infiltration. We agree that surgical treatment is an option; nevertheless, we believe that it is challenging and has severe complications. For this reason, conservative therapies initially should be considered. On the other hand, we strongly recommend surgery in cases of infected silicone granulomas, especially when virulent microbiota is isolated in cultures. Here, we report our experience with a 48-year-old HIV-positive transgender who presented with severe silicone gluteus abscesses infected with Mycobacterium tuberculosis, which was associated with septic left-knee arthritis involving bone destruction in the femoral aspect. Six years before coming to us she had been injected with 6 L of illicit oil silicone for soft-tissue augmentation in the buttocks. Eight years before she had suffered from mediastinal tuberculosis, which had been treated chronically with rifater and myambutol, and the regimen was followed T. P. de la Fuente (&) C. C. Hermoso L. G. Pardo Department of Plastic and Reconstructive Surgery, Fundacio´n Jime´nez Dı´az, Avd/Reyes Cato´licos 2, 28040 Madrid, Spain e-mail: [email protected] E. Sandoval Department of Orthopedic Surgery, Fundacio´n Jime´nez Dı´az, Avd/Reyes Cato´licos 2, 28040 Madrid, Spain
erratically by the patient. She affirmed that she regularly followed her antiretroviral treatment for HIV and blood tests showed [300 CD4? T cells/lL and undetectable HIV RNA. When she first visited our institution, chest X-ray and sputum cultures for M. tuberculosis were negative. However, she presented with huge bilateral gluteal silicone granulomas infected with M. tuberculosis and septic arthritis in her left knee with severe bone destruction that produced disabling pain making her unable to walk. The gluteal abscesses had fistulized along the leg to the knee. An arthroscopic knee synovectomy was performed and the tissue obtained was also positive for M. tuberculosis. To treat the disabling knee pain and the progression of bone destruction, an open knee joint debridement along with implantation of a custom-made streptomycinimpregnated spacer implant, which would allow a future joint arthroplasty when the infection had relieved, was planned. Prior to that surgery, it was necessary to remove from her buttock as much infected tissue as possible to diminish mycobacterial charge (Figs. 1, 2). All infected tissue from around both hips was removed and directly suturing was done in a dermolipectomy manner. Wound healing was slow due to a seroma that required negative pressure therapy for 2 months. A skin graft was performed safely after a satisfactory response. The incidence of tuberculosis has increased worldwide in the last few decades due to HIV infection [2]. In these cases, the natural history of the tuberculosis may differ from its classical presentation, leading to more frequent extrapulmonary involvement than in the general population [3]. Abscesses represent a rare form of extrapulmonary tuberculosis and they may appear anywhere in the body. The initial hypothesis is that tuberculosis may be transmitted to muscles via syringes used by people with
123
Aesth Plast Surg
Fig. 1 Gluteal abscesses
Fig. 2 Surgical excision
pulmonary tuberculosis, by contaminated needles, or by contaminated injected material. Nevertheless, recent studies have proposed that muscle tuberculosis develops as the result of hematogenous or lymphatic spread of M. tuberculosis from a pulmonary focus [4]. There is much documentation on pathogenic nontuberculous mycobacteria infections in cosmetic surgery procedures, caused mainly by Mycobacterium abscessus. In contrast to M. tuberculosis, M. abscessus is considered a ‘‘rapid grower’’ because of its ability to grow in normal culture media within 7 days, and, therefore, it is easier to diagnose than M. tuberculosis. Once the diagnosis of mycobacteria infection is made, we believe that treatment should begin with antimicrobial therapy and surgical debridement of nonviable tissue. If prosthetic or foreign material is involved, its removal should be strongly considered. The medical therapy should be maintained at least for 6 months [5–8]. Of note, medical antitubercular therapy is not able to
123
reach soft-tissue abscesses such as silicon collections in the gluteus. These cases may actively spread pathogen microbiota and should be considered a public health issue. Illicit use of injectable liquid silicone for soft-tissue augmentation is not uncommon, especially in the transgender population [9], as this substance acts as an inexpensive injectable filler. The scientific literature reports that industrial silicone used to augment soft tissue may cause terrible complications, which can be unpredictable and uncorrectable. Silicone granulomas manifest clinically as recurrent cellulitis-like reactions with pain, induration, nodules, and local lymphadenopathy. Systemic complications manifest clinically as respiratory embolism, infection, scleroderma, toxic shock syndrome, granulomas, lymphadenopathy, neuropathy, rheumatic symptoms, severe autoimmune and connective tissue disorders, and death [10–14]. Silicone is a permanent filler and treatment of its side effects can be challenging. Long-term antibiotics, oral and intralesional steroids, immunomodulating agents, and surgical excision have been used to treat its complications [11, 15]. When conservative treatments have failed or an associated infection with virulent microbiota is present, surgical excision of the silicone can be an option, taking into account that it is virtually impossible to remove all injected silicone. Therefore, we recommend surgical excision to be limited to symptomatic infected silicone nodules. In the case of bone tuberculosis, surgical excision remains a challenge. Skeletal involvement constitutes less than 3 % of tuberculosis cases, and if bone abscess drainage is not possible, bone excision must be the option [16]. Conflict of interest The authors declare that they have no conflicts of interest to disclose.
References 1. Carella S, Romanzi A, Ciotti M et al (2013) Skin ulcer: a longterm complication after massive liquid silicone oil infiltration. Aesthet Plast Surg 37(6):1220–1224 2. World Health Organization. Global tuberculosis control 2010. Available at http://www.who.int/tb/publications/global_report/ 2010. Accessed 2013 3. Jones BE, Young SM, Antoniskis D et al (1993) Relationship of the manifestations of tuberculosis to CD4 cell counts in patients with human immunodeficiency virus infection. Am Rev Respir Dis 148:1292–1297 4. Gervasoni C, Zanini F, Gabrielli E et al (2011) Tubercular gluteus abscesses: a return to the early 20th century or a consequence of new, unprecedented behaviors. Clin Infect Dis 52(8):1082–1083 5. Safranek TJ, Jarvis WR, Carsib LA et al (1987) Mycobacterium wound infection after plastic surgery employing contaminated gentian violet skin-marking solution. N Engl J Med 317:197–201 6. Newman MI, Camberos AE, Ascherman JA (2005) Mycobacteria abscessus outbreak in US patients linked to offshore surgicenter. Ann Plast Surg 55:107–110
Aesth Plast Surg 7. Furuya EY, Paez A, Srinivasan A et al (2008) Outbreak of Mycobacterium abscessus wound infections among ‘‘lipotourists’’ from the United States who underwent abdominoplasty in the Dominican Republic. Clin Infect Dis 46(8):1181–1188 8. Feldman EM, Ellsworth W, Yuksel E et al (2009) Mycobacterium abscessus infection after breast augmentation: a case of contaminated implants? J Plast Reconstr Aesthet Surg 62(9):e330– e332 9. National Coalition for LGBT health. An overview of U.S. transhealth priorities: a report by the eliminating health disparities working group. Available at http://www.lgbthealth.net. Accessed 16 Dec 2004 10. Restrepo CS, Artunduaga M, Carrillo JA et al (2009) Silicone pulmonary embolism: report of 10 cases and review of the literature. J Comput Assist Tomogr 33(2):233–237
11. Loustau HD, Mayer HF, Catterino L (2009) Dermolipectomy of the thighs and buttock to solve a massive silicone oil injection. Aesthet Plast Surg 33:657–660 12. Betten D, Cantrell F, Chen W et al (2008) Subcutaneous silicone injection leafing to multi-system organ failure. Clin Top 46:834–837 13. Komenaka IK, Ditkoff BA, Schnabel F et al (2004) Free silicone injection causing polyarthropathy and septic shock. Breast J 10:160–161 14. Guerrissi J, Bejar A (1998) Massive injections of adulterated liquid silicone: local complications and development of autoimmune diseases. Ann Plast Surg 41:572–573 15. Paternack FR, Fox LP, Engler DE (2005) Silicone granulomas treated with ertacenept. Arch Dermatol 141(1):13–15 16. Babhulkar SS, Pande SK (2002) Unusual manifestations of osteoarticular infections. Clin Orthop 398:114–120
123
LETTER TO THE EDITOR
GENERAL RECONSTRUCTION
Mycobacterium tuberculosis Silicone Gluteus Abscesses with Bone Involvement T. Pe´rez de la Fuente • E. Sandoval • C. Ca´rcamo Hermoso • L. Garcı´a Pardo
Received: 25 November 2013 / Accepted: 19 January 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Sir, With great interest we read the article by Carella et al. [1] entitled ‘‘Skin ulcer: a long-term complication after massive liquid silicone oil infiltration.’’ The authors concluded that surgery is the most effective treatment for complications due to liquid silicone oil infiltration. We agree that surgical treatment is an option; nevertheless, we believe that it is challenging and has severe complications. For this reason, conservative therapies initially should be considered. On the other hand, we strongly recommend surgery in cases of infected silicone granulomas, especially when virulent microbiota is isolated in cultures. Here, we report our experience with a 48-year-old HIV-positive transgender who presented with severe silicone gluteus abscesses infected with Mycobacterium tuberculosis, which was associated with septic left-knee arthritis involving bone destruction in the femoral aspect. Six years before coming to us she had been injected with 6 L of illicit oil silicone for soft-tissue augmentation in the buttocks. Eight years before she had suffered from mediastinal tuberculosis, which had been treated chronically with rifater and myambutol, and the regimen was followed T. P. de la Fuente (&) C. C. Hermoso L. G. Pardo Department of Plastic and Reconstructive Surgery, Fundacio´n Jime´nez Dı´az, Avd/Reyes Cato´licos 2, 28040 Madrid, Spain e-mail: [email protected] E. Sandoval Department of Orthopedic Surgery, Fundacio´n Jime´nez Dı´az, Avd/Reyes Cato´licos 2, 28040 Madrid, Spain
erratically by the patient. She affirmed that she regularly followed her antiretroviral treatment for HIV and blood tests showed [300 CD4? T cells/lL and undetectable HIV RNA. When she first visited our institution, chest X-ray and sputum cultures for M. tuberculosis were negative. However, she presented with huge bilateral gluteal silicone granulomas infected with M. tuberculosis and septic arthritis in her left knee with severe bone destruction that produced disabling pain making her unable to walk. The gluteal abscesses had fistulized along the leg to the knee. An arthroscopic knee synovectomy was performed and the tissue obtained was also positive for M. tuberculosis. To treat the disabling knee pain and the progression of bone destruction, an open knee joint debridement along with implantation of a custom-made streptomycinimpregnated spacer implant, which would allow a future joint arthroplasty when the infection had relieved, was planned. Prior to that surgery, it was necessary to remove from her buttock as much infected tissue as possible to diminish mycobacterial charge (Figs. 1, 2). All infected tissue from around both hips was removed and directly suturing was done in a dermolipectomy manner. Wound healing was slow due to a seroma that required negative pressure therapy for 2 months. A skin graft was performed safely after a satisfactory response. The incidence of tuberculosis has increased worldwide in the last few decades due to HIV infection [2]. In these cases, the natural history of the tuberculosis may differ from its classical presentation, leading to more frequent extrapulmonary involvement than in the general population [3]. Abscesses represent a rare form of extrapulmonary tuberculosis and they may appear anywhere in the body. The initial hypothesis is that tuberculosis may be transmitted to muscles via syringes used by people with
123
Aesth Plast Surg
Fig. 1 Gluteal abscesses
Fig. 2 Surgical excision
pulmonary tuberculosis, by contaminated needles, or by contaminated injected material. Nevertheless, recent studies have proposed that muscle tuberculosis develops as the result of hematogenous or lymphatic spread of M. tuberculosis from a pulmonary focus [4]. There is much documentation on pathogenic nontuberculous mycobacteria infections in cosmetic surgery procedures, caused mainly by Mycobacterium abscessus. In contrast to M. tuberculosis, M. abscessus is considered a ‘‘rapid grower’’ because of its ability to grow in normal culture media within 7 days, and, therefore, it is easier to diagnose than M. tuberculosis. Once the diagnosis of mycobacteria infection is made, we believe that treatment should begin with antimicrobial therapy and surgical debridement of nonviable tissue. If prosthetic or foreign material is involved, its removal should be strongly considered. The medical therapy should be maintained at least for 6 months [5–8]. Of note, medical antitubercular therapy is not able to
123
reach soft-tissue abscesses such as silicon collections in the gluteus. These cases may actively spread pathogen microbiota and should be considered a public health issue. Illicit use of injectable liquid silicone for soft-tissue augmentation is not uncommon, especially in the transgender population [9], as this substance acts as an inexpensive injectable filler. The scientific literature reports that industrial silicone used to augment soft tissue may cause terrible complications, which can be unpredictable and uncorrectable. Silicone granulomas manifest clinically as recurrent cellulitis-like reactions with pain, induration, nodules, and local lymphadenopathy. Systemic complications manifest clinically as respiratory embolism, infection, scleroderma, toxic shock syndrome, granulomas, lymphadenopathy, neuropathy, rheumatic symptoms, severe autoimmune and connective tissue disorders, and death [10–14]. Silicone is a permanent filler and treatment of its side effects can be challenging. Long-term antibiotics, oral and intralesional steroids, immunomodulating agents, and surgical excision have been used to treat its complications [11, 15]. When conservative treatments have failed or an associated infection with virulent microbiota is present, surgical excision of the silicone can be an option, taking into account that it is virtually impossible to remove all injected silicone. Therefore, we recommend surgical excision to be limited to symptomatic infected silicone nodules. In the case of bone tuberculosis, surgical excision remains a challenge. Skeletal involvement constitutes less than 3 % of tuberculosis cases, and if bone abscess drainage is not possible, bone excision must be the option [16]. Conflict of interest The authors declare that they have no conflicts of interest to disclose.
References 1. Carella S, Romanzi A, Ciotti M et al (2013) Skin ulcer: a longterm complication after massive liquid silicone oil infiltration. Aesthet Plast Surg 37(6):1220–1224 2. World Health Organization. Global tuberculosis control 2010. Available at http://www.who.int/tb/publications/global_report/ 2010. Accessed 2013 3. Jones BE, Young SM, Antoniskis D et al (1993) Relationship of the manifestations of tuberculosis to CD4 cell counts in patients with human immunodeficiency virus infection. Am Rev Respir Dis 148:1292–1297 4. Gervasoni C, Zanini F, Gabrielli E et al (2011) Tubercular gluteus abscesses: a return to the early 20th century or a consequence of new, unprecedented behaviors. Clin Infect Dis 52(8):1082–1083 5. Safranek TJ, Jarvis WR, Carsib LA et al (1987) Mycobacterium wound infection after plastic surgery employing contaminated gentian violet skin-marking solution. N Engl J Med 317:197–201 6. Newman MI, Camberos AE, Ascherman JA (2005) Mycobacteria abscessus outbreak in US patients linked to offshore surgicenter. Ann Plast Surg 55:107–110
Aesth Plast Surg 7. Furuya EY, Paez A, Srinivasan A et al (2008) Outbreak of Mycobacterium abscessus wound infections among ‘‘lipotourists’’ from the United States who underwent abdominoplasty in the Dominican Republic. Clin Infect Dis 46(8):1181–1188 8. Feldman EM, Ellsworth W, Yuksel E et al (2009) Mycobacterium abscessus infection after breast augmentation: a case of contaminated implants? J Plast Reconstr Aesthet Surg 62(9):e330– e332 9. National Coalition for LGBT health. An overview of U.S. transhealth priorities: a report by the eliminating health disparities working group. Available at http://www.lgbthealth.net. Accessed 16 Dec 2004 10. Restrepo CS, Artunduaga M, Carrillo JA et al (2009) Silicone pulmonary embolism: report of 10 cases and review of the literature. J Comput Assist Tomogr 33(2):233–237
11. Loustau HD, Mayer HF, Catterino L (2009) Dermolipectomy of the thighs and buttock to solve a massive silicone oil injection. Aesthet Plast Surg 33:657–660 12. Betten D, Cantrell F, Chen W et al (2008) Subcutaneous silicone injection leafing to multi-system organ failure. Clin Top 46:834–837 13. Komenaka IK, Ditkoff BA, Schnabel F et al (2004) Free silicone injection causing polyarthropathy and septic shock. Breast J 10:160–161 14. Guerrissi J, Bejar A (1998) Massive injections of adulterated liquid silicone: local complications and development of autoimmune diseases. Ann Plast Surg 41:572–573 15. Paternack FR, Fox LP, Engler DE (2005) Silicone granulomas treated with ertacenept. Arch Dermatol 141(1):13–15 16. Babhulkar SS, Pande SK (2002) Unusual manifestations of osteoarticular infections. Clin Orthop 398:114–120
123
![[Miliary tuberculosis with pulmonary, meningeal and bone involvement].](/assets/img/hold.png)
