case report

Total Hip Arthroplasty Infected with Mycobacterium Abscessus: A Unique Case Report

Authors: PA Baumann, BD Fishalow, AR Humphries, KA Burton

Introduction
Nontuberculous mycobacteria (NTM) have low virulence compared to their tuberculoid cousin, Mycobacterium tuberculosis. Many different species fall under NTM, with one category consisting of rapidly growing mycobacteria (RGM). RGM’s are found in soil and water (both sewage and drinking water) and consist mostly of Mycobacterium chelonae, -fortuitum, and –abscessus. 5,6  These three are known to cause subcutaneous abscesses and cellulitis following trauma and can be distinguished from each other by 16S ribosomal DNA sequencing.

There have been rare cases of joint prosthesis infections caused by RGM species.8 Those that do occur are caused in the majority by Mycobacterium fortuitum.  The most pathogenic of the RGM’s, Mycobacterium abscessus, is generally  seen clinically in pulmonary and cutaneous infections.6  To date, a literature search has shown only three arthroplasties infected by M. abscessus, two of which were found in knee prosthesis and one in a hip prosthesis.15 Our case report details a patient with a total hip arthroplasty infected with Mycobacterium abscessus making this, to our knowledge the second case reported on a hip prosthesis infected by this organism.

Case Report
A 58-year-old male presented with chronic left hip discomfort, instability, and limited range of motion since a fall 5 years previous. The patient has a history of hepatitis C and a protein S deficiency causing hypercoagulability, treated with chronic Coumadin and an inferior vena cava filter placement. He had fallen 9 feet off a balcony during a visit to Puerto Rico, from which he suffered a subtrochanteric fracture of his left femur and subdural hematomas. He underwent open reduction and internal fixation with hardware. At presentation, the patient exhibited a shortening of his left extremity by 1 inch compared to the right, with excessive external rotation of his affected hip and a decrease in mobility of the joint. 

 Although the patient initially was hesitant to have another surgery, he eventually agreed to have the original hardware removed and have a total left hip arthroplasty to correct his retroverted hip with degenerative joint disease. Following the procedure, the patient developed a pulmonary embolism and later, a large hematoma in the region of the incision site. The hematoma was surgically evacuated and lavaged while the patient’s anticoagulants were stopped temporarily.  Cultures were performed during the drainage of the hematoma and were gram stain negative.

About four years following his conversion to a total hip replacement, the patient was admitted to our facility with an eight month history of discomfort on hip flexion, abduction, internal rotation, and external rotation. He had three week history of erythema and abscess development over the hip. His sedimentation rate was 87 mm/h at this time. The patient was given oral antibiotics prior to admittance at our facility and these oral antibiotics did not resolve his pain and suspected infection.

The patient was taken to the operating room and the posterior lateral wound was incised, drained, and lavaged, and a wound drain was placed. Approximately three days later, the patient was taken to the operating room to undergo an incision and drainage with debridement and removal of hardware with placement of an antibiotic loaded spacer.  The intra-operative finding were necrotic tissue around the left hip. The hip was irrigated with six liters of antibiotic laden pulse lavage as well as one liter of Dakin’s solution, two bottles of chlorhexidine and one bottle of peroxide. An articulating cement spacer wasa utilized consisting of a cemented all-poly freedom constrained cup with PLR stem.  The cement for the stem was prepared with 2 bags of Cobalt G and 2 grams of Vancomycin per cement bag.  An additional bag of Colbalt G cement was prepared with 2 grams of Vancomycin and was used for fixation of the all-poly freedom constrained cup.

Post-operatively, the patient once again developed issues with bleeding and a new hematoma developed which was drained surgically. In the meantime, the patient had continued a regimen of vancomycin, piperacillin and tazobactam. During all these procedures cultures were performed but yielded no results. Due to vancomycin toxicity, the patient was later switched to daptomycin.

About three months later, the patient was readmitted from rehabilitation for drainage of the wound which now cultured Mycobacterium abscessus. He underwent another incision and drainage along with additional cultures. The spacer was retained. Intra-operatively it was noted that there was a sinus tract that tracked into the joint. Also, there appeared to be a piece of trochanteric bone which was nonviable. A second lavage procedure was performed again as explained above. The patient denied an offer to have a girdlestone procedure executed and instead, decided on a long-term course of oral azithromycin antibiotics.

Cultures performed at National Jewish Health in Colorado showed that the Mycobacterium abscessus was susceptible to amikacin, kanamycin, cefoxitin, tigecycline, clarithromycin, and azithromycin. The patient was therefore initiated on IV Amikacin and oral azithromycin 500 mg once a day. About 15 days later, cefoxitin was added to the mix. The patient, however, had an increase in creatinine which was believed to be due to the Amikacin. It was discontinued and Tigecycline was added. The patient received an approximately one month course of Amikacin and Azithromycin.

Approximately three months following the last incision and drainage the patient underwent yet another hematoma evacuation on the left anterior thigh that was a result of interventional radiology doing a CT guided drainage. Vascular surgery at this time did a fasciotomy with incision and drainage and found no communication with the lateral hip wound or hip joint. 

The patient currently has no more evidence of drainage and has had serial negative cultures for M. abscessus. He will continue to undergo frequent appointments with infectious disease physicians and will remain on antibiotic suppressant (currently restarted on azithromycin).  If he begins to have cultures that are positive for Mycobacterium abscessus and he shows systemic signs of infections, he is aware he must undergo a girdlestone procedure.

Discussion

There are only a handful of cases reported of joints infected by nontuberculous mycobacterium, let alone rapidly growing mycobacterium. As mentioned before, there have only been three reported cases of Mycobacterium abscessus; two of which were found in the knees. The presented case exhibits a 4th case, but only the second case added to the previous single case found in the hip.

Mycobacterium abscessus resides in aqueous environments such as tap water, sewage, ice, and soil.9  In humans, it can be found in the respiratory tract with a rough colony morphology and in wounds with a smooth colony morphology.5 The method of transmission is unknown for this mycobacterium.  It may be due to hematogenous seeding, human contact, or environmental contact via a compromise of the skin barrier.

In this case, it is difficult to determine the source of infection. The patient did not have a respiratory tract infection nor did the prosthesis and surgical equipment knowingly come in contact with the environments that harbor Mycobacterium abscessus.  The patient also was not taking immunosuppressants nor using bezalkonium chloride which both would have made him more susceptible to acquiring an infection caused by RGM. 10,11,12 Mycobacterium, in general, have a hydrophobic lipid cell surface which allows them to adhere to smooth surfaces such as joint prosthesis.13 It can be difficult to determine precisely when a patient becomes infected with Mycobacterium abscessus as cultures may be negative even though the organism is actually present. It seems unlikely the patient acquired the infection from his initial fall as the infection presented 5 years later. It is also difficult to distinguish whether the patient had the infection after his first total hip arthroplasty or from his revision. It appears the revision is the most likely culprit as the cultures became positive for the mycobacterium following this event. Adding to this likelihood is that it is known that Mycobacterium abscessus thrives in inflamed environments that are neutrophil rich.13 Our patient had a previous infection from his first joint replacement, allowing for an ideal breeding ground for the M. abscessus to flourish.

The patient in the case was treated similarly to what has been recorded in the previous literature. First, it was key to remove the prosthetic as it was assumed this was the source of infection. The efficacy of the lavage and cement are unknown. The Mycobacterium abscessus in this case seemed to show little if any susceptibility to the antibiotics used in the Colbalt G cement and lavage. Perhaps, the lavage by itself was able to flush out some of the organism as well as the peroxide and Dakin’s solution causing the death of some of the bacteria. It would have been ideal to know the organism prior to inserting an antibiotic into the Cobalt G cement with Vancomycin, since other reports have shown that only clarithromycin, amikacin, and cefoxitin are the only ones that are consistently reliable against this organism. 15

A prolonged treatment of antibiotics is what was able to control the infection in our patient. In the presented case, it took approximately 6 months for the patient to have no more signs of infection. He will remain on the antibiotics indefinitely, until infectious disease believes the organism has been terminated in its totality or until there is a relapse in infection and the patient must undergo a girdlestone and be switched to another antibiotic.

Conclusion
We report the second case of Mycobacterium abscessus found in a total hip arthroplasty. This report highlights the rare presentation of such an infection and demonstrates a method of treatment. It seems that the diagnosis must be made with high clinical suspicion and treated, ultimately, with the removal of the infected hardware.

References

  1. Eid AJ, Berbari EF, Sia IG, et al. Prosthetic joint infection due to rapidly growing mycobacteria: Report of 8 cases and review of the literature. Clin Infect Dis 2007;45:687-94
  2. Septic Arthritis Caused by Mycobacterium fortuitum and Mycobacterium abscessus in a Prosthetic Knee Joint:Case Report and Review of Literature
    Shu-Xiang Wang 1, Chang-Jen Yang 2,Yu-Chuan Chen 3, Chorng-Jang Lay 4,5 and Chen-Chi Tsai 4,5
  3. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections.
    N Engl J Med 2004;351:1645-54.
  4. Bernard L, Hoffmeyer P, Assal M, et al. Trends in the treatment of orthopaedic prosthetic infections. J Antimicrob Chemother 2004;53:127-9.
  5. Jonsson BE, Gilljam M, Lindblad A, et al. Molecular epidemiology of Mycobacterium abscessus, with focus on cystic fibrosis. J Clin Microbiol 2007;45:1497-504.
  6. Petrini B. Mycobacterium abscessus: an emerging rapid-growing potential pathogen. APMIS 2006;114:319-28.
  7. Mueller PS, Edson RS. Disseminated Mycobacterium abscessus infection manifesting as fever of unknown origin and intraabdominal lymphadenitis: Case report and literature review. Diagn
    Microbiol Infect Dis 2001;39:33-7.
  8. Springer B, Bottger EC, Kirschner P, et al. Phylogeny of the Mycobacterium chelonae-like organism based on partial sequencing of the 16S rRNA gene and proposal of Mycobacterium mucogenicum sp. nov. Int J Syst Bacteriol 1995;45:262-7.
  9. Covert, T. C., M. R. Rodgers, A. L. Reyes, and G. N. Stelma, Jr. 1999. Occurrence of nontuberculous mycobacteria in environmental samples. Appl. Environ. Microbiol. 65:2492-2496. 
  10. Rodriguez G, Ortegon M, Camargo D, et al. Iatrogenic Mycobacterium abscessus infection: histopathology of 71 patients. Br J Dermatol 1997;137:214-8.
  11. Tiwari TS, Ray B, Jost KC, Jr., et al. Forty years of disinfectant failure: Outbreak of postinjection Mycobacterium abscessus infection caused by contamination of benzalkonium chloride. Clin Infect Dis
    2003;36:954-62.
  12. Villanueva A, Calderon RV, Vargas BA, et al. Report on an outbreak of postinjection abscesses due to Mycobacterium abscessus, including management with surgery and clarithromycin therapy and comparison of strains by random amplified polymorphic DNA polymerase chain reaction. Clin Infect Dis
    1997;24:1147-53.
  13. Bendinger B, Rijnaarts HH, Altendorf K, Zehnder AJ. Physicochemical cell surface and adhesive properties of coryneform bacteria related to the presence and chain length of mycolic acids. Appl Environ Microbiol 59: 3973-3977, 1993.
  14. Mycobacterium abscessus Induces a Limited Pattern of Neutrophil Activation That Promotes Pathogen Survival Kenneth C. Malcolm,#1,3,* E. Michelle Nichols,#1 Silvia M. Caceres,1 Jennifer E. Kret,1 Stacey L. Martiniano,4 Scott D. Sagel,4,5 Edward D. Chan,1,3,6 Lindsay Caverly,2,5 George M. Solomon,1,3 Paul Reynolds,1,2,7 Donna L. Bratton,2Jennifer L. Taylor-Cousar,1,3 David P. Nichols,2,4 Milene T. Saavedra,1,3 and Jerry A. Nick1,3
  15. Successful treatment of a prosthetic joint infection due to Mycobacterium abscessus
    Andrew Petrosoniak1, Paul Kim2, Marc Desjardins3, B Craig Lee1

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