Mycobacterium abscessus, a prominent pathogen among a diverse group of nontuberculous mycobacteria (NTM), is characterized by its accelerated growth kinetics and proclivity to instigate skin and soft tissue infections (SSTIs). Currently, there is mounting concern about the escalating incidence of atypical mycobacterial infections at injection sites, particularly in the context of cosmetic procedures, necessitating heightened vigilance. Prompt diagnosis based on clinical suspicion poses a challenge. However, an even greater obstacle lies in the complete eradication of the disease, further underscoring the need for intensive scrutiny [1].

M. abscessus is a rapidly growing mycobacterial species that has been increasingly recognized as a causative agent of SSTIs and respiratory diseases. As such, it poses a dual challenge to public health, with implications for both individual patient outcomes and the population-wide disease burden [2]. From 1993 to 2002, a study in Hong Kong provided a thorough retrospective examination of the incidence rate of atypical mycobacterial cutaneous infections, which was found to be less than 1% [3]. Between 2000 and 2008, the M. abscessus complex emerged as particularly common in East Asia, accounting for 17.2% of all clinically identified NTM isolates in the country, which is equivalent to an incidence rate of 1.7 cases per 100,000 people [4]. With respect to NTM infections, M. abscessus has assumed heightened significance owing to its steadily increasing incidence. By the end of the study period (2019), this species accounted for a substantial share of NTM infections, underlining its prominence as a clinically relevant pathogen [5].

M. abscessus-related SSTIs have been extensively shown to result from a wide variety of causes, with trauma (76%), injections (54%), acupuncture (26%), and plastic surgery (15%) being the leading contributors. These data are supported by a substantial body of research encompassing 60 studies that comprised 955 cases by 2020. Although the majority of patients (95%) achieved full recovery following appropriate treatment, a minority (5%) experienced severe disseminated infections that could ultimately prove fatal, as illustrated by two cases in the extant literature [6,7]. Individuals with open wounds or injuries are particularly vulnerable to M. abscessus infections, emphasizing the importance of stringent adherence to infection control protocols, particularly during invasive procedures and wound management [5].

In the summer of 2023, a group of infections was traced back to a well-known beauty service center chain administering mesotherapy fusion (F-XBC) for slimming between June and August. According to the product description, “F-XBC body is a mesotherapy treatment for slimming, reduces cellulite and activates lipolysis. The active ingredient consists of active ingredients including Caffeine, Carnitine, Taurine, Vectorized lipase, Vectorized hyaluronidase, Coumarin, Artichoke extract, Ginkgo extract, and Hydrocotyle (centella asiatica) extract.”

Nineteen patients ranging in age from 22 to 53 years, who sought similar treatment and presented with relevant symptoms, were identified through the Center of Health Protection in Hong Kong. All developed rashes or abscesses a few days to weeks following their injections and were confirmed to have a M. abscessus infection along the injected sites.

One of the patients presented at my clinic 3 months after her injection with tender and inflamed swelling that developed soon after her injections and progressively enlarged, reddened, and acutely painful nodules, predominantly at the sites where the mesotherapy solution (F-XBC) had been injected (Fig. 1, 2). Bedside ultrasound revealed multiple variably sized lesions ranging in diameter from 1 to 5 cm. Ultrasound-guided intralesional aspiration was performed on the affected nodules under strict aseptic precautions. The pus aspirated from the swelling included 1) 3 mL of pus admixed with blood from the right abdominal nodule, 2) 4 mL of pus and blood from the left abdominal nodule, and 3) 1 to 1.5 mL of a purulent sanguineous fluid obtained from small thigh nodules.

Figure 1. Tender abscess swelling on the right side of the abdomen.

Figure 2. Tender abscess swelling on the left side of the abdomen.

Owing to the clinical suspicion and history reported by the patient, she was made aware of two other clients from the same center who tested culture-positive for M. abscessus. Pus samples (3 and 4 mL) were promptly collected for microscopic evaluation, pus culture, including acid-fast bacilli (AFB) smear and culture, and antibiotic susceptibility testing. These specimens were then forwarded to the infection control team at a government healthcare facility for comprehensive analysis, and growth of M. abscessus was confirmed.

The incident was brought to the attention of the Department of Health, after which the patient was admitted and subsequently transferred to a public hospital. During this time, the patient underwent a daily regimen of intravenous antibiotics for approximately 2 to 3 months, coupled with multiple surgical incision draining procedures, and has been attending follow-up at the government outpatient clinic.

This case report highlights the escalating prevalence of M. abscessus infections associated with cosmetic procedures, underscoring the criticality of heightened vigilance in aesthetic medicine. The standard diagnostic protocol for M. abscessus infections typically includes an AFB smear, culture on specialized media, and antibiotic susceptibility testing [5].

However, the slow growth rate of the bacteria can lead to delayed detection, particularly in cases of persistent inflammation [6]. This underscores the significance of maintaining a high index of suspicion for unconventional pathogens and employing rapid diagnostic techniques such as polymerase chain reaction, loop-mediated isothermal amplification, and matrix-assisted laser desorption ionization time-of-flight mass spectrometry [7]. These technologies, though promising, require broader implementation in clinical settings to enhance the diagnostic precision and expedite effective interventions.

The therapeutic landscape for M. abscessus infections is fraught with complexities owing to the organism’s low susceptibility to standard treatments, biofilm formation, and the resultant poor treatment success rates, often below 50% [5]. Our case exemplifies the challenges in managing such infections, necessitating a nuanced multidisciplinary approach that balances conventional wisdom with emerging strategies.

Our patient’s journey began with meticulous aspiration of the lesion fluid under aseptic conditions, followed by comprehensive microbiological analysis incorporating AFB smears, culture, and advanced molecular techniques for rapid detection. Empirical combination therapy with clarithromycin and rifampin was promptly initiated and guided by broad-spectrum coverage until definitive culture results were available. This aligns with the multidrug regimen advocated by leading health societies, which acknowledges the need for individualized adjustments based on susceptibility profiles (Table 1) [8-13].

Table 1 . List of antibiotic regimen for Mycobacterium abscessus.

Drug therapy	Rationale	Reference
Amikacin, Cefoxitin, Imipenem, Clarithromycin	Part of the recommended multidrug regimen by expert panels for initial therapy	Daley et al. (2020) [9]
Macrolides (e.g., Clarithromycin)	Central to M. abscessus treatment plans due to their activity against the bacterium, though inducible resistance via erm41 gene is a concern	Nash et al. (2009) [8], Daley et al. (2020) [9] Pennington et al. (2021) [10]
Omadacycline	Newer agent showing effectiveness against pulmonary M. abscessus infections, with potential for skin applications	Rizzo et al. (2022) [13]
Bacteriophage therapy	Targets biofilms and intracellular bacteria; efficacy varies with conditions	Wang et al. (2023) [12]
Thiostrepton	Novel anti-M. abscessus agent with additional anti-inflammatory properties	Wang et al. (2023) [12]
Azithromycin+Rifampicin	Novel synergy discovered by DiaMOND analysis, suggesting reassessment of conventional therapies	Van et al. (2023) [11]
Debridement	Surgical intervention to physically remove infected tissue and reduce bacterial load	Shen et al. (2024) [7]

Innovation in M. abscessus management extends beyond traditional antibiotics, with omadacycline featuring potential for dermatological applications, bacteriophage therapy targeting biofilms, and thiostrepton’s dual anti-M. abscessus and anti-inflammatory properties. The DiaMOND paradigm shift in the assessment of drug interactions promises to refine therapeutic strategies, reveal unexpected synergies, and necessitate tailored strain-specific treatment plans [11,14].

Surgical interventions such as incisions and drainage have become indispensable, complementing medical therapy by facilitating bacterial clearance and improving antibiotic efficacy. Emphasizing the environmental factors and stringent infection control measures, our case reinforces the importance of preventing M. abscessus transmission through adherence to aseptic procedures, use by qualified practitioners, and patient education.

In conclusion, this case report not only highlights the potential dangers of cosmetic procedures but also elucidates the intricate dance of diagnostic acumen, therapeutic innovation, and infection control required to mitigate the threat posed by M. abscessus. By integrating the latest diagnostic advancements, exploring novel therapeutic avenues, and emphasizing the centrality of infection prevention strategies, this narrative contributes to the ongoing dialogue on combating antibiotic-resistant pathogens in aesthetic medicine. Ultimately, this underscores the necessity for a multifaceted strategy that acknowledges the unique challenges of M. abscessus infections and strives for personalized, evidence-based care [5,13].

The authors have nothing to disclose.