+
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, e1ee2
CORRESPONDENCE AND COMMUNICATION Pasteurella multocida infection of a tissue expander following breast reconstruction
Dear Sir, A 50-year-old woman with history of left-sided lobular breast cancer presented seeking reconstructive options following planned mastectomies. She was scheduled to undergo bilateral mastectomy and reconstruction with the deep inferior epigastric perforator (DIEP) flap assuming a negative sentinel node or unilateral mastectomy and expander placement if there was nodal disease. During the initial procedure, a large sentinel lymph node was found. Pathology analysis showed metastatic carcinoma. The decision was made to place a tissue expander with an acellular dermal matrix sling. Jackson-Pratt (JP) drains were placed. Her hospital stay remained uneventful. Eighteen days following surgery, the patient was seen for postoperative evaluation. No complaints were reported. There was approximately 25 cc in each breast drain. No sign of infection was present. The following day she complained of an odor and a worsening erythema on the lateral surface of her breast; prophylactic ciprofloxacin was started. Over the next 24 h she noted episodes of fever, with a sensation of “pressure and engorgement”. At that time, the patient sent us several pictures of the affected area that were taken with her handheld device (Figures 1 and 2). On subsequent evaluation, she indicated that while sleeping two days prior onset of symptoms, one of her cats had chewed through the drainage tubing on the affected side. She cut and removed the bitten segment, plugging back the remainder of the tube to the suction bulb of the JP drain. On physical examination, the patient had frank erythema to the anterolateral portion of the breast, which was warmth and tender to light palpation, with prominent edema of the affected area; the drainage contained a serosanguineous fluid, without purulent discharge. She was admitted to the hospital for intravenous antibiotics. In an attempt to salvage the expander-based reconstruction, she underwent uncomplicated debridement of granulation tissue and thorough lavage with a triple antibiotic solution of
gentamicin, bacitracin and tobramycin. A pediatric feeding tube was placed for continuous antibiotic (Bacitracin) irrigation of the superior pocket with a drainage tube in the inferior aspect. She was discharged home after 5 days on oral doxycycline. Final results from fluid cultures taken during surgery yielded Pasteurella multocida. The patient completed oral antibiotic therapy and was seen at our office one week following discharge. P. multocida is a Gram-negative, aerobic coccobacillus that colonizes the oral cavity and upper respiratory tract of a wide variety of animals, including dogs and cats. Zoonosis with these bacteria remains a sporadic event, with the majority of the cases associated with animal bites. An acute onset of erythema, inflammation and pain is characteristic of pasteurellosis, with symptoms manifesting within 3e6 h of the initial infection. Purulent or serosanguineous discharge can develop within 24e48 h. Soft tissue and integument infections are common manifestations; tenosynovitis and abscess formation are frequent complication of soft tissue infection, with a complication rate of 39%.1 Despite its low virulence, reported cases of bacteremia with Pasteurella spp. can reach a mortality rate as high as 37%, especially in patients with comorbidities such as liver dysfunction or respiratory compromise.2
Figure 1 The drainage tubes can be seen in the bottom of the image.
1748-6815/$ - see front matter ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.023
Please cite this article in press as: Martinez CA, et al., Pasteurella multocida infection of a tissue expander following breast reconstruction, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.01.023
+
MODEL
e2
Correspondence and communication
Conflict of interest/funding None.
References
Figure 2
Erythema to the inferolateral region of the breast.
Tissue expander infections caused by Pasteurella spp. are extremely rare. Johnson et al.3 and Mathieu et al.4 reported the only two other cases of expander infection caused by P. multocida. In both cases, patients stated living with dogs or cats, although neither recalled been scratched or bitten. Moreover, both cases accounted for loss of the prosthesis despite aggressive therapy with IV antibiotics. Our case is the third event in the literature, and was likely caused by transmission due to an infected fomite. It is also important to remark the surgical approach as an option complimentary to antibiotic therapy; salvage of the prosthesis can be achieved with prompt diagnosis and meticulous intraoperative lavage of the expander. Postoperative wound infections by Pasteurella spp. must be considered as a potential complication if the patient is in close contact with pets. Appropriate counseling in relation with the safety around animals, potentially modifies the outcome of the surgery, especially if we recommend basic rules of hygiene and avoid wound or devices (in our case the JP drain) contact by animals.
1. Weber DJ, Wolfson JS, Swartz MN, et al. Pasteurella multocida infections. Medicine 1984;249:514e5. 2. Pestana AO. Mycotic aneurysm and osteomyelitis secondary to infection with Pasteurella multocida. Am J Clin Pathol 1974;62: 355e60. 3. Johnson LB, Busuito MJ, Khatib R. Breast implant infection in a cat owner due to Pasteurella multocida. J Infect 2000;41: 110e1. 4. Mathieu D, Rodriguez H, Jacobs F. Breast prosthesis infected by Pasteurella multocida. Acta Clin Belg 2008;63:351.
Carlos A. Martinez Houston Plastic & Craniofacial Surgery, 6400 Fannin, Suite 2290, Houston, TX 77030, USA Sean G. Boutros Division of Plastic Surgery, Department of Surgery, The University of Texas School of Medicine at Houston, TX, USA Houston Plastic & Craniofacial Surgery, 6400 Fannin, Suite 2290, Houston, TX 77030, USA Westside Surgical Hospital, USA E-mail address: [email protected] Jason A. Hall Division of Plastic Surgery, Department of Surgery, The University of Texas School of Medicine at Houston, TX, USA Houston Plastic & Craniofacial Surgery, 6400 Fannin, Suite 2290, Houston, TX 77030, USA 14 November 2013
Please cite this article in press as: Martinez CA, et al., Pasteurella multocida infection of a tissue expander following breast reconstruction, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.01.023
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, e1ee2
CORRESPONDENCE AND COMMUNICATION Pasteurella multocida infection of a tissue expander following breast reconstruction
Dear Sir, A 50-year-old woman with history of left-sided lobular breast cancer presented seeking reconstructive options following planned mastectomies. She was scheduled to undergo bilateral mastectomy and reconstruction with the deep inferior epigastric perforator (DIEP) flap assuming a negative sentinel node or unilateral mastectomy and expander placement if there was nodal disease. During the initial procedure, a large sentinel lymph node was found. Pathology analysis showed metastatic carcinoma. The decision was made to place a tissue expander with an acellular dermal matrix sling. Jackson-Pratt (JP) drains were placed. Her hospital stay remained uneventful. Eighteen days following surgery, the patient was seen for postoperative evaluation. No complaints were reported. There was approximately 25 cc in each breast drain. No sign of infection was present. The following day she complained of an odor and a worsening erythema on the lateral surface of her breast; prophylactic ciprofloxacin was started. Over the next 24 h she noted episodes of fever, with a sensation of “pressure and engorgement”. At that time, the patient sent us several pictures of the affected area that were taken with her handheld device (Figures 1 and 2). On subsequent evaluation, she indicated that while sleeping two days prior onset of symptoms, one of her cats had chewed through the drainage tubing on the affected side. She cut and removed the bitten segment, plugging back the remainder of the tube to the suction bulb of the JP drain. On physical examination, the patient had frank erythema to the anterolateral portion of the breast, which was warmth and tender to light palpation, with prominent edema of the affected area; the drainage contained a serosanguineous fluid, without purulent discharge. She was admitted to the hospital for intravenous antibiotics. In an attempt to salvage the expander-based reconstruction, she underwent uncomplicated debridement of granulation tissue and thorough lavage with a triple antibiotic solution of
gentamicin, bacitracin and tobramycin. A pediatric feeding tube was placed for continuous antibiotic (Bacitracin) irrigation of the superior pocket with a drainage tube in the inferior aspect. She was discharged home after 5 days on oral doxycycline. Final results from fluid cultures taken during surgery yielded Pasteurella multocida. The patient completed oral antibiotic therapy and was seen at our office one week following discharge. P. multocida is a Gram-negative, aerobic coccobacillus that colonizes the oral cavity and upper respiratory tract of a wide variety of animals, including dogs and cats. Zoonosis with these bacteria remains a sporadic event, with the majority of the cases associated with animal bites. An acute onset of erythema, inflammation and pain is characteristic of pasteurellosis, with symptoms manifesting within 3e6 h of the initial infection. Purulent or serosanguineous discharge can develop within 24e48 h. Soft tissue and integument infections are common manifestations; tenosynovitis and abscess formation are frequent complication of soft tissue infection, with a complication rate of 39%.1 Despite its low virulence, reported cases of bacteremia with Pasteurella spp. can reach a mortality rate as high as 37%, especially in patients with comorbidities such as liver dysfunction or respiratory compromise.2
Figure 1 The drainage tubes can be seen in the bottom of the image.
1748-6815/$ - see front matter ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.023
Please cite this article in press as: Martinez CA, et al., Pasteurella multocida infection of a tissue expander following breast reconstruction, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.01.023
+
MODEL
e2
Correspondence and communication
Conflict of interest/funding None.
References
Figure 2
Erythema to the inferolateral region of the breast.
Tissue expander infections caused by Pasteurella spp. are extremely rare. Johnson et al.3 and Mathieu et al.4 reported the only two other cases of expander infection caused by P. multocida. In both cases, patients stated living with dogs or cats, although neither recalled been scratched or bitten. Moreover, both cases accounted for loss of the prosthesis despite aggressive therapy with IV antibiotics. Our case is the third event in the literature, and was likely caused by transmission due to an infected fomite. It is also important to remark the surgical approach as an option complimentary to antibiotic therapy; salvage of the prosthesis can be achieved with prompt diagnosis and meticulous intraoperative lavage of the expander. Postoperative wound infections by Pasteurella spp. must be considered as a potential complication if the patient is in close contact with pets. Appropriate counseling in relation with the safety around animals, potentially modifies the outcome of the surgery, especially if we recommend basic rules of hygiene and avoid wound or devices (in our case the JP drain) contact by animals.
1. Weber DJ, Wolfson JS, Swartz MN, et al. Pasteurella multocida infections. Medicine 1984;249:514e5. 2. Pestana AO. Mycotic aneurysm and osteomyelitis secondary to infection with Pasteurella multocida. Am J Clin Pathol 1974;62: 355e60. 3. Johnson LB, Busuito MJ, Khatib R. Breast implant infection in a cat owner due to Pasteurella multocida. J Infect 2000;41: 110e1. 4. Mathieu D, Rodriguez H, Jacobs F. Breast prosthesis infected by Pasteurella multocida. Acta Clin Belg 2008;63:351.
Carlos A. Martinez Houston Plastic & Craniofacial Surgery, 6400 Fannin, Suite 2290, Houston, TX 77030, USA Sean G. Boutros Division of Plastic Surgery, Department of Surgery, The University of Texas School of Medicine at Houston, TX, USA Houston Plastic & Craniofacial Surgery, 6400 Fannin, Suite 2290, Houston, TX 77030, USA Westside Surgical Hospital, USA E-mail address: [email protected] Jason A. Hall Division of Plastic Surgery, Department of Surgery, The University of Texas School of Medicine at Houston, TX, USA Houston Plastic & Craniofacial Surgery, 6400 Fannin, Suite 2290, Houston, TX 77030, USA 14 November 2013
Please cite this article in press as: Martinez CA, et al., Pasteurella multocida infection of a tissue expander following breast reconstruction, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.01.023
