Conclusions
M. wolinskyi has been reported in only 13 cases since its first categorization within the M. smegmatis group in 1999. Contrary to several reported cases of SSTI caused by other NTM species, previously reported cases of M. wonlinskyi-related SSTI mostly described incidences following surgical procedures including hip prosthesis, peritoneal dialysis, transplantation, and heart surgery and posttraumatic events. Infections have also been observed in immunocompromised patients and in some cases of tissue necrosis involving subjacent bone. However, M. wolinskyi infection complicating facial cosmetic procedure has not hitherto been reported, although there are increasing reports of SSTI caused by other RGM species involving cosmetic therapy such as M. fortuitum, M. abscessus, M. jacuzzi and M. concepcionense (Table 2).
In this case, we describe a facial SSTI associated with M. wolinskyi, presumably due to invasive cosmetic procedures. The exact route and time of the infection is currently unclear because the patient had received multiple cosmetic procedures involving filler injection, and lipolysis over the course of 2 years. One possible route of infection includes a failure to maintain aseptic procedure during the invasive procedures. Furthermore, the patient also has a history of receiving facial acupuncture procedures in the childhood. Multiple acupuncture needle insertions tend to leave needle remnants at the site of procedures, and would allow M. wolinskyi to invade dermis and grow along the existing metal fragments more rapidly than without any foreign bodies. Facial acupuncture is a widely-performed childhood ritual on Jeju Island for health and longevity.
Culture and laboratory identification of NTM can be a time consuming process because the process relies on growth rate, pigmentation, and several biochemical tests. Molecular analysis using 16S rRNA and rpoB gene sequencing and TB/NTM PCR screening has made the identification process more rapid and accurate. In the current case, since PCR and culture results indicated the presence of NTM, rpoB gene sequencing analysis was performed using primers MF (5′-CGACCACTTCGGCAACCG-3′) and MR (5′-TCGATCGGGCACATCCGG-3′). The isolate was identified as M. wolinskyi, whose sequence similarity was 99% with M. wolinskyi ATCC 700010. Since the rpoB gene sequence is more divergent and discriminable for identification of RGM species than 16S rRNA sequence, we only performed rpoB sequence analysis for prompt identification of NTM species to prevent further delay in diagnosis and treatment in this case.
RGM organisms are generally known to be resistant to standard anti-tuberculosis agents, and treatment for each RGM species differs depending on the susceptibility to antibiotics. In this case, the patient had frequent exposure to medical procedure-related contamination, and the SSTI did not improve with antibiotics and remained for a long duration. Due to its chronic condition and procedure-related infection, not only bacterial but also NTM infections were suspicious. Since Korea is a known tuberculosis endemic area, when infection persists and is resistant to standard antibiotic treatment, tuberculosis infection is more likely than NTM infection. However, failure of standard anti-tuberculosis agents is strongly suggestive of NTM infection. It was also notable that there have been five cases of NTM infection in the Jeju area within a recent year.
Treatment regimen with clarithromycin, amikacin, and ciprofloxacin was effective in controlling the infection according to the laboratory results and this patient's condition. The metallic foreign materials embedded at the site of abscess made the progression of NTM SSTI more severe and rapid than expected. When SSTI is associated with foreign materials, the progression of the clinical course of infection could be unusual and faster. In addition, surgical interventions like incision and drainage in addition to medical treatment is highly recommended for better prognosis when NTM infection is associated with foreign body materials.
Increased public desire to attain and accentuate perceived physical beauty have motivated development of various cosmetic techniques that include lipolysis, acupuncture, and laser therapy. However, the possible risks and side effects of repetitive cosmetic procedures remain unclear. Infection, one of most critical side effects after cosmetic practices, can cause both physical and emotional distress. Bacterial infection goes through a natural course of acute exacerbation and recovery with antibiotics. However, in chronic infection, diagnosis and following treatments tend to be delayed, resulting in permanent sequelae. Therefore, in case of chronic infection, resistant to usual antibiotics regimen, it is helpful to consider the possibility of NTM infection for prompt diagnosis and treatment, and ultimately for a better quality of life in patients.
Consent
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.