Atypical Soft Tissue Infections Linked to Cosmetic Procedures and Acupuncture

Peggy Peck

October 10, 2003

Oct. 10, 2003 (San Diego) -- A trio of posters presented here at the 41st annual meeting of the Infectious Diseases Society of America (IDSA) confirm cosmetic injections and acupuncture as the source for Mycobacterium abscessus soft tissue infection, underlining the need to consider "injection procedures" as the source of atypical soft tissue infections, said Reina Turcios, MD, from the Centers for Disease Control and Prevention's National Center for Infectious Diseases in Atlanta, Georgia.

Dr. Turcios and colleagues reported an outbreak of M. abscessus linked to two providers of "unlicensed cosmetic injections." Twenty-four cases among women who underwent injections for wrinkles or breast or buttocks enhancement or to treat cellulite were identified during a six-month period in 2002. The injected substances were "imported, non-FDA approved substances" that included artichoke extract used to treat cellulite. Other injected substances included silicone, collagen, vitamin compounds, and lidocaine.

The injections were administered by unlicensed providers -- a Venezuelan couple who claimed to be physicians -- who operated "mobile clinics" from a series of apartments in different locations. These providers were eventually arrested, said Dr. Turcios.

The incubation period ranged from 2 to 80 days, and the median time to treatment was 15 days. Twelve patients required hospitalization; median length of stay was 23 days, Dr. Turcios said. Fifteen patients required surgical debridement of the infection, several patients required "six months of antibiotic therapy, and all patients had significant scarring."

Because the two providers "were a moving target" tracking the cases "was difficult and we have not been able to identify the source of the contamination," Dr. Turcios said.

A second poster described 51 cases of M. abscessus in Santiago, Chile, between July and December 2002, also among people who underwent treatment at cosmetic clinics. The patients -- 50 of whom were women -- underwent injections in the abdomen, back, buttocks, thighs, arms, and face to remove body fat in a procedure called mesotherapy. Carlos Perez, MD, director of the department of infectious diseases at Pontificia University, Catolica de Chile, in Santiago, reported that these patients also have developed extensive scars. Mesotherapy is a common practice in South America and may be gaining acceptance in North America as well. Dr. Perez noted that the five clinics identified with this outbreak have all closed.

The third paper reported an outbreak of M. abscessus among 29 people treated by an acupuncture specialist in Toronto, Ontario. In this case the infection was tracked to a breech in infection control practices, said Elizabeth J. Phillips, MD, consultant in infectious diseases at Sunnybrook and Women's College Health Sciences Center, Toronto.

In this case, as in the New York cases, the incubation period was long -- up to five months, Dr. Phillips said. Fortunately the infection was limited to the site of the acupuncture needles, but she said that "scarring is still a problem."

Christopher Karp, MD, professor of pediatrics and director of molecular immunology at the University of Cincinnati School of Medicine in Ohio, said the studies were significant because they represent a series of cases of skin or soft tissue infection in different parts of the world, yet in each case the infection is caused by a microbe related to tuberculosis.

"It just points out the risks of infection whenever the skin is pierced and with this infection there is an additional likelihood of extensive scarring. So you always want to be sure that whatever needles are being used for whatever procedure are, in fact, sterile," he said at an IDSA press conference Thursday. Dr. Karp was not involved in any of the studies.

"Of course, in these cases, these were all nonlicensed [providers]," which clearly increases risk, Dr. Karp said. In addition to risk associated with nonsterile needles, the infection could have originated in the substances injected. "So caution on every front is essential."

Dr. Phillips said the outbreaks should be a clear message to regulators about the need for "stringent regulation of alternative medicine practitioners."

IDSA 41st Annual Meeting: Posters 845, 846, 847. Presented Oct. 11, 2003.

Reviewed by Gary D. Vogin, MD



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