Nontuberculous mycobacterial infection after frontalis sling surgery using silicone rod
© The Author(s) 2012
Received: 19 February 2012
Accepted: 22 March 2012
Published: 5 April 2012
The purpose of this study is to report a case of nontuberculous mycobacterial infection after frontalis sling surgery.
A 65-year-old man presented with bilateral painful, erythematous lesions in the brow and upper eyelids. He had a history of frontalis sling surgery for myopathic ptosis 2 years back and all lesions were found localized to the tract of the silicone rod used in the previous frontalis sling surgery.
Incision and drainage of the lesions with microbiological analysis revealed significant growth of coagulase negative staphylococcus and Mycobacterium fortuitum. Sensitivity-based antibiotic treatment with intravenous amikacin was started, but poor response necessitated eventual explantation of both silicone rods for relief of symptoms. Culture of the explanted rods revealed similar results of M. fortuitum infection. Five months after the acute presentation, the patient is asymptomatic.
Nontuberculous mycobacterial infection may be a delayed onset complication in frontalis sling surgery using silicone rods.
KeywordsNontuberculous mycobacteria Frontalis sling surgery Silicone
Frontalis sling surgery is the treatment option for myopathic blepharoptosis with poor levator muscle action . Infections associated with the silicone rod after frontalis sling surgery have been reported . Nontuberculous mycobacterial infections in the periocular region are rare and are usually caused by organisms belonging to Runyon group IV including Mycobacterium chelonae and Mycobacterium fortuitum . Chang et al. reported six cases of nontuberculous mycobacterial infection and found an association with nasolacrimal duct obstruction, implantation of foreign body, history of recent surgery, and immunosuppression . Mauriello found implantation of a foreign body in 5 out 13 patients of nontuberculous mycobacterial infections of the periocular region . Treatment of nontuberculous mycobacterial infections can be difficult because of their multi-drug resistance . Treatment usually involves surgical debridement with removal of infected foreign body and a prolonged course of antibiotics like amikacin, clarithromycin, ciprofloxacin, and doxycycline . We report a rare case of nontuberculous mycobacterial infection of the silicone rod after frontalis sling surgery.
Several authors have reported about nontuberculous mycobacterial infections after periocular surgery [3, 4]. The median time interval between prior surgery and onset of infection in these reports was 6 weeks (range 0.5–11 months) [3, 4]. In our patient, multiple erythematous nodules with suppuration along the tract of the silicone rod more than 2 years after surgery led to the suspicion and eventual diagnosis of nontuberculous mycobacteria. Some aspects in our patient need to be highlighted.
First is that a bilateral infection by nontuberculous mycobacteria involving the silicone rod after frontalis sling surgery has not been reported earlier. The lodgement of nontuberculous mycobacteria in the brow region in our case may be related to the persistent irritation from the silicone rod and its predeliction for fat [4, 5]. Sequestration of nontuberculous mycobacteria with fat allows its growth without detection by normal immunosurveillance [4, 5]. In our patient, sequestration of nontuberculous mycobacteria in the brow fat may have been responsible for delayed and bilateral infection involving the silicone slings. Further, Fitzgerald et al. found nontuberculous mycobacteria in 82 % of fat globules in their series of 71 cases .
Second is the chronic persistence of M. fortuitum infection after treatment with sensitive antibiotics. Complete resolution in our case occurred only after silicone slings were removed from both eyes.
Finally, removal of the silicone sling did not result in a recurrence of blepharoptosis. This phenomenon is postulated to be due to scarring and fibrosis along the tract of the silicone rod .
Nontuberculous mycobacterial may be responsible for bilateral delayed infection after frontalis surgery with silicone slings in an immunocompetent adult. Surgical removal of infected slings and prolonged course of antibiotics are required for complete resolution.
Hyderabad Eye Research Foundation, Hyderabad, India
The authors do not have any financial interest or any conflicting relationship in any of the issues or products referred to in the manuscript.
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