Mycobacterial Infection after Cosmetic Procedure with Botulinum Toxin A

Abstract

A 45-year-old woman presented to the dermatology clinic complaining of lesions that had appeared soon after the injections of botulinum toxin A, at the sites of the injections. Gradually the lesions increased in size. The injections had been administered for cosmetic proposes five months before.Physical examination showed erythematous, swollen, warm, and tender plaques and nodules at the points of injection: the procerus muscle zone and the pars externa of the orbicularis oculi muscle [Table/ Fig-1]. One of the lesions was aspirated with a fine needle, obtaining a yellowish, purulent liquid, which was sent for microbiological culture with negative results for common bacteria and mycobacteria. An empiric treatment with clarithromycin plus azithromycin was established, and a punch biopsy was obtained from the lesion on the muscle procerus region. The biopsy showed a granulomatous infiltrate in the deep dermis and the hypodermis [Table /Fig-2a]. The granulomas were epithelioid, irregularly shaped, and without giant cells [Table/ Fig-2b]. There was no central necrosis; instead, the epithelioid cells appeared admixed, and the center of the granuloma was occupied by an abscess . Fungal forms were not identified after histochemical staining with Grocott and periodic-acid Schiff (PAS). Ziehl-Neelsen and Fite-Faraco stainings showed small amounts of acid-fast positive bacilli [Table/ Fig-2d].An investigation for the possible source of the infection was conducted. The infection was a unique case among all the patients of this specific dermatologist. The botulinum toxin vials were sterile and directly provided by the manufacturer. We did not identify any other cases of mycobacterial infection among other dermatological and cosmetic consultancies in the city that were supplied by the same manufacturer of the botulinum toxin A. The dermatologist confirmed that all the materials and instruments used by the (including syringes, gauzes, and anesthetics) were sterile and disposable. The patient admitted to having used some cosmetic facial creams on the areas of injection immediately after the procedure for several days. She was asked to bring these facial creams to the clinic, and some samples were sent for microbiological cultures with negative results. Therefore, we were not able to identify the source of infection in this case and have placed the botulinum toxin A as a possible etiology (Score 1 of Naranjo algorithm).Due to the morphologic evidence of acid-fast bacilli, rifampicin was added to clarithromycin and azathioprine. The lesion cleared in 40 d, leaving residual postinflammatory pigmentation. DisCussionNon-tuberculosis mycobacteria (NTM) are usually acquired through environmental exposure rather than through person-to-person contact. NTM are ubiquitous and are mainly present in soil and water from rivers or lakes. However, the microorganism is resistant to the standard levels of chlorination; therefore, it can be found in tap water. The main mechanisms of infection are aerosol route, dust, water, ingestion, and inocul...

Subcutaneous infection caused by Mycobacterium abscessus following botulinum toxin injections: A case report and literature review

“…A total of 24 cases across 18 studies of cutaneous NTM infection after cosmetic injections reported from 2013 to 2023 were identified in the search 4–21 …”

“…A total of 24 cases across 18 studies of cutaneous NTM infection after cosmetic injections reported from 2013 to 2023 were identified in the search. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] The characteristics of the included studies are summarized in Table 1. The majority of the patients were female (23 out of 24 patients), with ages ranging from 28 to 56 years old.…”

“…Incision and drainage 3 months M. abscessus [17] Clarithromycin, azithromycin, and rifampicin None 40 days Histopathologically confirmed [18] Doxycycline 100 mg bid and ciprofloxacin 750 mg q4h 5 m Debridement 5 months Mycobacterium. wolinskyi (M. wolinskyi) [19] Ciprofloxacin 500 mg bid and clarithromycin 500 mg bid 6 m Excision 6 months Mycobacterium.…”

Infraorbitale granulomatös-purulente Läsion vermeintlich unklarer Ätiologie

“…Granulome nach BoNT-A-Injektionen treten mit einer großen Spannbreite an klinischer Latenz auf: zwischen zwei Tage und bis zu sechs Jahre nach BoNT-A-Injektion wurden beschrieben, die Diagnose wird oft mittels Biopsie gestellt [ 3 ]. Nur wenige Veröffentlichungen beschreiben purulente Granulome, wobei bei diesen, im Gegensatz zu unserem Fall, Mykobakterien nachgewiesen worden waren [ 4 , 5 ].…”

Surgical Treatment for Cutaneous Mycobacterium abscessus Infection Caused by Injections of Hyaluronic Acid

“…2 Skin and soft tissue infections caused by NTM have been increasingly described as a complication associated with cosmetic procedures. 3 Cases or outbreaks are therefore reported after mesotherapy, 4 hair transplant, 2 injection of botulinum toxin A, 5,6 illicit intramammary injections of silicone, 7 liposuction, 8 face lift, 9 piercing, 10 and tattooing. 11 However, few cases of secondary NTM infections after injection of hyaluronic acid filler have been reported.…”