Mycobacterium chelonae abscesses associated with biomesotherapy, Australia, 2008.

Mycobacterium TheInStudy June 2008, the Communicable Disease Control Branch of the SA Department of Health received notifichelonae cation of 5 suspected and 1 laboratory-confirmed case of skin infection. All case-patients reported Abscesses mycobacterial having received biomesotherapy treatment from the same Practitioner A. Associated with person, An investigation team immediately inspected PractitioBiomesotherapy, ner A’s premises and found poor sanitation and infectionpractices in place. Equipment used for injections Australia, 2008 control at the clinic was seized, and Practitioner A was directed Mihaela Ivan, Craig Dancer, Ann P. Koehler, Michaela Hobby, and Chris Lease An outbreak of skin abscesses occurred in Adelaide, Australia, in association with biomesotherapy, an alternative therapy practice. Mycobacterium chelonae was identified in 8 patient and 3 environmental samples. Our findings show M. chelonae infection can be associated with alternative therapies when infection-control breaches occur. Tighter regulations of alternative therapy practices are needed. B iomesotherapy is marketed in Australia as a new therapy that combines homotoxicology, mesotherapy, and acupuncture. Saline solution and homeopathic formulations are injected subcutaneously at specific acupuncture or trigger points, and homeopathic formulations are administered orally during treatment sessions. Biomesotherapy is used for pain management and general well-being. Mycobacterium chelonae is a rapid-growing mycobacterium that occurs naturally in water sources and produces rare infections in humans. The bacterium can cause pneumonia and skin and ocular lesions, mostly following tissue trauma (1). M. chelonae is commonly present in tap water; however, it is not reliably removed by filtration or by boiling for short periods. Outbreaks and isolated cases of cutaneous infections caused by M. chelonae and other rapid-growing mycobacteria have been described in association with alternative therapies, hospital settings, and spas (2–8). Mycobacterial infections are notifiable in South Australia, a state in the southern central part of Australia. On average, 2 cases of nonpulmonary M. chelonae infection are reported in South Australia each year. Author affiliations: South Australia Department of Health, Adelaide, South Australia, Australia (M. Ivan, A. P. Koehler, M. Hobby, C. Lease); and SA Pathology, Adelaide (C. Dancer) DOI: http://dx.org/10.3201/eid1909.120898 to cease all practices related to injection of clients, including the preparation of formulations. A media release and a public health alert were issued to inform the community about the outbreak. Case finding was then initiated. A case-patient was defined as a person with “skin lesions compatible with mycobacterial infection at injection site and visit to Practitioner A since January 1, 2008.” A list of clients was assembled from Practitioner A’s patient records and appointment book, direct information from patients, and physician referrals. To identify possible case-patients and to collect relevant epidemiologic data, we developed a semistructured questionnaire for use during telephone interviews with Practitioner A’s clients; 43 clients completed the interview. At the end of interviews, clients were strongly advised to consult a general practitioner for clinical assessment and referral to an infectious diseases physician if they had skin lesions or other concerns. Through telephone interviews and doctor and laboratory notifications, we identified 27 case-patients, of whom 20 had completed the telephone interview. Abscesses (1–16/case-patient) had developed within days to several weeks after case-patients received biomesotherapy injections from Practitioner A (Figure 1). The mean age of casepatients was 47 years (range 27–77); 17 were female and 20 were male. Thirteen case-patients had visited a physician for their skin lesions, and 18 still had abscesses present at the time of the interview. Twelve case-patients reported that the same needle was used for all injections during a single treatment session. Three case-patients recalled that Practitioner A had washed his/her hands before the procedure; most other case-patients were unsure if this step had been taken. Twenty clinical samples from 14 case-patients and 36 environmental samples were sent for laboratory testing. The samples were stained (Gram and Ziehl-Neelsen stains) and cultured at 30°C and 35°C on routine agar media in MGIT Mycobacteria Growth Indicator Tube (Becton Dickinson Microbiology Systems, North Ryde, NSW, Australia) broth culture and on Lowenstein-Jensen slopes. The environmental samples were centrifuged and processed as described (9). We initially identified organisms by Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 19, No. 9, September 2013 1493 DISPATCHES from Practitioner A’s clinic. Isolates were susceptible to clarithromycin, amikacin, tobramycin, and tigecycline but resistant to cefoxitin. Figure 1. Mycobacterium chelonae abscesses associated with biomesotherapy, an alternative therapy practice, Adelaide, South Australia, Australia, 2008. The abscesses are at the biomesotherapy injection site. (Photo courtesy of Erina Gray.) conventional phenotypic methods (10). Molecular identification was performed on all isolates by sequencing 3 regions: 16S rDNA, 16S-23S rRNA internal transcribed spacer, and rpoB (11–13). Susceptibility testing was performed by using the disk diffusion test and Etest (bioMérieux, Baulkham Hills, NSW, Australia) (14). Histologic examination of clinical samples revealed inflammation and granulomata, and Ziehl-Neelsen staining of samples from 3 case-patients revealed acid-fast bacilli. Phenotypic testing of isolates showed that arylsulfatase activity was positive at day 3 (weakly positive in 1 isolate); p-aminosalicylic acid degradation was positive, but the organism was also tolerant to 5% sodium chloride (results uncertain for 1 isolate); and iron uptake was positive, all of which are suggestive of Mycobacterium abscessus. Molecular sequencing identified M. chelonae with identical genetic profiles in 8 patient samples and 3 therapeutic solutions, including a Coley toxin homeopathic formulation, Conclusions These 27 cases of a rare infection occurred in clients of Practitioner A while no other cases were reported elsewhere in South Australia, representing overwhelming epidemiologic evidence that the source of infection was Practitioner A’s clinic (Figure 2). Case-patients had received injections of an M. chelonae–contaminated Coley toxin formulation, and the same formulation had been included with colloidal silver in a spray solution that was used to “clean” patients’ skin before injections were administered. These 2 uses of the contaminated formulation constitute plausible routes of infection and the source of the outbreak. Practitioner A’s procedures demonstrated a profound lack of sterile injection techniques and infection- (...truncated)