on september 15 , 2009 , a 29-year - old woman , 61 kg , 1.69 m stature , caucasian , with no comorbidities , post - graduated , brazilian , from recife - pe was submitted to an elective bilateral reductive mammoplasty on a private hospital of recife - pe to remove 200 ml of each breast using the l technique for resections of excess of skin and breast tissue . then an ampoule of adrenaline was infiltrated into her breasts , the bandage was realized using saline and polivinilpirrolidone - iodine . the patient made her bandages at home using water , soap and an antiseptic solution of chlorhexidine gluconate . one year after surgical procedure , on october 17 , 2010 , the patient referred edema , heat and pain on her left breast . although left breast presented no blush and normal aspect of scar . it was requested a breast ultrasonography ( usg ) and it was prescribed a non - hormonal anti - inflammatory , nimesulide 100 mg , one pill a day for 5 days , with no improvement of the signs and symptoms . usg revealed an image of a fluid collection filled by thin echoes , extending from 9 oclock to 3 oclock , with an antero - posterior diameter with approximately 2.3 cm , far around 2 cm of the skin with an increase of the echogenicity of the subcutaneous tissue on the region ( figure 1 ) . it was then prescribed treatment with cephalexin , 500 mg every six hours and nimesulide , 100 mg , one pill a day for 5 days . as there was no improvement of the clinical conditions , an aspiration of the fluid collection was performed in november 23 , 2010 on patient s left breast with an entry on the intern superior upper quadrant , obtaining a greenish secretion which was sent for automatized culture and antibiogram , both negative for bacterial growth . after the procedure , it was prescribed ciprofloxacin , 500 mg , 2 pills every twelve hours for 2 days and one pill every twelve hours totaling 10 days , without improvement of the condition . on november 30 , 2010 , the patient was submitted to a surgery to drain the breast s abscess , maintaining ciprofloxacin 500 mg , one pill every twelve hours , diclofenac sodium , 100 mg one pill a day and dipyrone one pill every six hours for 7 days . the sample collected in this procedure was sent for automatized culture with antibiogram and for smear tests on acid fast bacilli ( afb ) , both showing negative results . after the end of the treatment with antibiotics , on december 13 , 2010 an usg showed an increase of the echogenicity on the cellular subcutaneous tissue and on the breast s fat , associated with 2 collections which presented debris in suspension and irregular and inaccurate contours , measuring : 8.83.11.7 cm ( vol = 24.2 cm ) , located on the superior upper quadrants of the left breast and another with 2.21.20.8 cm ( vol=1.1 cm ) ; deeper than the previous one , which was located on the transition of the left lower quadrants , presenting 2 reactive lymph nodes on the left axilla , measuring 1.8 cm and the 1.4 cm , respectively . after confirming the presence of the collections , another aspiration was performed using usg , on the same breast in december 14 , 2010 , and it was also requested in a private laboratory of the city . another culture and cytological exam of the collected sample , showed one inflammatory cyst and growth of afb on a specific culture medium , but the mycobacterium specie was not identified due to fungus contamination on the sample . a chest x - ray was requested , and it did nt show abnormalities , another usg was performed on january 24 , 2011 , which revealed a new fluid collection , homogeneous , measuring : 2.00.71.5 cm located on the internal superior upper quadrant of the left breast . it was then prescribed vibramycin , 100 mg , one pill every twelve hours and trimethropim sulfamethoxazole , 400/160 , one pill every twelve hours for 6 months , and it was also requested a new drainage . the drained material was sent to the public health s central laboratory  dr . milton bezerra sobral ( lacen - pe ) , being isolated non - tuberculous mycobacteria in the culture medium . mycobacterium wolinskyi was identified by sequencing specific genes ; this technique was performed at aggeu magalhes research center , fiocruz - pe . as the patient presented an evident improvement of the clinical conditions , the treatment scheme proceeded for more 6 months , independent on the antibiogram s result ( table 1 ) remaining asymptomatic for almost 11 months . after this period , on january 9 , 2012 , the inflammatory signs and symptoms reappeared on the left breast , an usg showed 4 cystic images , the biggest at 12 oclock measuring : 0.70.6 cm ; the second had slightly thick walls associated with hyperechogenicity of the cellular subjacent subcutaneous tissue at 1 oclock , measuring : 0.70.60.5 cm , far 1 cm of the skin and about 4 cm of the nipple ; the third cyst presented an heterogeneous content with two adjacent cysts , located at 10 oclock and measuring : 1.41.31 cm and 1.31.10.8 cm , far 3 cm of the nipple and 2 cm of the skin ; and the fourth image was located at 5 oclock measuring : 2.91.91 cm , far 1 cm of the skin and 4 cm of the nipple . the patient was then submitted to a new surgical procedure to drain the collection and to withdraw the necrotic tissue . this tissue culture revealed one more time the presence of mycobacterium wolinsky , identified by sequencing specific genes . the prescribed therapy was an association of antibiotics , initially under hospital regimen , amikacin 1 g injectable per day with ciprofloxacin 500 mg every twelve hours and doxycycline 100 mg . amikacin was maintained for 10 weeks under domiciliary regimen , 1 g intramuscular 3 times a week . after this period the patient was released from the therapeutic scheme with complete regression of the clinical symptoms . the culture on lwenstein - jensen medium revealed afb growth on less than 7 days , suggesting rgm . the colonies did not show any coloring , they were resistant to the para - nitrobenzoic acid ( pnb ) and to the hydrazide of the 2-carboxilic acid ( tch ) ; they did not show rope spoilage and the test for the presence of niacin was negative . a 764-bp fragment was amplified and sequenced with primers mycof ( 5_-gcaaggtcaccccgaaggg-3 _ ) and mycor ( 5_-agcggctgctgggtgatcatc-3 _ ) . a total of 5 l of each dna solution ( 50 g / ml ) was added to 45 l of a pcr mixture containing 50 mm kcl , 20 mm tris - hcl ( ph 8.4 ) , 2.5 mm mgcl2 , 200 m each dntp , 1 m primers , and 1.0 u of taq dna polymerase ( promega ) . pcr mixtures were heated at 95c for 1 min and then subjected to 35 cycles of denaturation at 94c for 30 s , annealing at 64c for 30 s , and extension at 72c for 90 s , with a final step of 72c for 5 min . amplicons were purified with gfx pcr dna and a gel band purification kit ( g&e ) and sequenced in an abi prism 3100 sequencer with a bigdye terminator cycle sequencing kit ( applied biosystems ) . the sequences found were edited and aligned by analyzing the sequencing electropherograms using the program bioedit v7.0.9 . the sequences obtained were compared with those deposited in the genbank database by using blast ( http://www.ncbi.nlm.nih.gov/blast ) . the isolate had partial sequence of the rpob gene with 99% ( 683/689 ) similar to genbank accession number ay262743 , which corresponds to mycobacterium wolinskyi type strain atcc 700010 . the in vitro susceptibility test to antibiotics was performed using the microdilution broth assay ( mic ) ( table 1 ) . the bacilloscopy performed with the samples was negative for afb . the culture on lwenstein - jensen medium revealed afb growth on less than 7 days , suggesting rgm . the colonies did not show any coloring , they were resistant to the para - nitrobenzoic acid ( pnb ) and to the hydrazide of the 2-carboxilic acid ( tch ) ; they did not show rope spoilage and the test for the presence of niacin was negative . a 764-bp fragment was amplified and sequenced with primers mycof ( 5_-gcaaggtcaccccgaaggg-3 _ ) and mycor ( 5_-agcggctgctgggtgatcatc-3 _ ) . a total of 5 l of each dna solution ( 50 g / ml ) was added to 45 l of a pcr mixture containing 50 mm kcl , 20 mm tris - hcl ( ph 8.4 ) , 2.5 mm mgcl2 , 200 m each dntp , 1 m primers , and 1.0 u of taq dna polymerase ( promega ) . pcr mixtures were heated at 95c for 1 min and then subjected to 35 cycles of denaturation at 94c for 30 s , annealing at 64c for 30 s , and extension at 72c for 90 s , with a final step of 72c for 5 min . amplicons were purified with gfx pcr dna and a gel band purification kit ( g&e ) and sequenced in an abi prism 3100 sequencer with a bigdye terminator cycle sequencing kit ( applied biosystems ) . the sequences found were edited and aligned by analyzing the sequencing electropherograms using the program bioedit v7.0.9 . the sequences obtained were compared with those deposited in the genbank database by using blast ( http://www.ncbi.nlm.nih.gov/blast ) . the isolate had partial sequence of the rpob gene with 99% ( 683/689 ) similar to genbank accession number ay262743 , which corresponds to mycobacterium wolinskyi type strain atcc 700010 . the in vitro susceptibility test to antibiotics was performed using the microdilution broth assay ( mic ) ( table 1 ) . the bacilloscopy performed with the samples was negative for afb . the culture on lwenstein - jensen medium revealed afb growth on less than 7 days , suggesting rgm . the colonies did not show any coloring , they were resistant to the para - nitrobenzoic acid ( pnb ) and to the hydrazide of the 2-carboxilic acid ( tch ) ; they did not show rope spoilage and the test for the presence of niacin was negative . a 764-bp fragment was amplified and sequenced with primers mycof ( 5_-gcaaggtcaccccgaaggg-3 _ ) and mycor ( 5_-agcggctgctgggtgatcatc-3 _ ) . a total of 5 l of each dna solution ( 50 g / ml ) was added to 45 l of a pcr mixture containing 50 mm kcl , 20 mm tris - hcl ( ph 8.4 ) , 2.5 mm mgcl2 , 200 m each dntp , 1 m primers , and 1.0 u of taq dna polymerase ( promega ) . pcr mixtures were heated at 95c for 1 min and then subjected to 35 cycles of denaturation at 94c for 30 s , annealing at 64c for 30 s , and extension at 72c for 90 s , with a final step of 72c for 5 min . amplicons were purified with gfx pcr dna and a gel band purification kit ( g&e ) and sequenced in an abi prism 3100 sequencer with a bigdye terminator cycle sequencing kit ( applied biosystems ) . the sequences found were edited and aligned by analyzing the sequencing electropherograms using the program bioedit v7.0.9 . the sequences obtained were compared with those deposited in the genbank database by using blast ( http://www.ncbi.nlm.nih.gov/blast ) . the isolate had partial sequence of the rpob gene with 99% ( 683/689 ) similar to genbank accession number ay262743 , which corresponds to mycobacterium wolinskyi type strain atcc 700010 . the in vitro susceptibility test to antibiotics was performed using the microdilution broth assay ( mic ) ( table 1 ) . among the rapidly growing mycobacteria ( rgm ) , m. wolinskyi belongs to m. smegmatis group ; it was identified for the first time by brown et al . rgm are broadly distributed on the environment , particularly on soil and water , including potable water , biofilms on water distribution piping , swimming pools , sewage and surfaces . since its taxonomic description , 19 cases of human infections all over the world were described until now . the majority of infections are post - traumatic and post - surgical , there are no reports of infection after breast aesthetics surgery . over the last few decades , the majority of the notified cases after infection post mammoplasty are associated with mycobacterium fortuitum ( 57% ) and with mycobacterium abscessus ( 15.2% ) . mycobacterium wolinskyi was isolated in only 2 notified cases , representing 2% of all breast infections . the infection caused by these microorganisms can appear weeks or months after the surgery , with no standard scheme to treat the infection by rgm due to in vitro variability and susceptibility of bacteria species . therefore , it is necessary to identify properly every sample and to determine its sensitivity to antimicrobial agents . the choice of the most suited treatment depends on the mycobacteria species involved in the infection , on the clinical presentation and on the patient s immunological condition . these bacteria are capable of producing biofilms , which makes their resistance to antibiotics easier . in general , procedures of drainage , the typical profile of the in vitro susceptibility of mycobacterium wolinskyi is : susceptibility to amikacin , imipenem and trimethropim sulfamethoxazole ; resistance to tobramycin ; intermediate susceptibility to doxycyclin and ciprofloxacin ; and susceptibility to cefoxitin and clarithromycin . its resistance to tobramycin is a feature that distinguishes mycobacterium wolinskyi from the other members of mycobacterium smegmatis group . the present case is the first report of infection by mycobacterium wolinskyi after mammoplasty in brazil . there was no notification of outbreaks during this period at the hospital where the surgical procedures were performed . it is more likely that the bacteria infected the breast at the moment of the mammoplasty , since the presence of inflammatory signs ( edema and pain ) and abscesses were detected one year after the surgery , with no breast trauma or piercing in the region in this period . it was also observed the absence of comorbidities , presenting similar evolution with the cases which are associated with this type of mycobacterium described on literature . to achieve cure , it was necessary to perform several drainage procedures of the abscesses combined with long term therapy using antibiotics , anti - inflammatories and analgesics . this case reassures the occurrence of postsurgical infections by non - tuberculous mycobacteria which must be considered , by health professionals , an important cause of morbidity for human beings .
mycobacterium wolinskyi is a rapidly growing mycobacterium , first described in 1999 as a member of the group mycobacterium smegmatis ( mycobacterium smegmatis , mycobacterium wolinskyi and mycobacterium goodii ) . 
 only 19 case reports all over the world have been described on literature , none of them in brazil . on this report 
 , it is described one case of infection after a mammoplasty procedure performed in a private health service in the county of recife , pernambuco , brazil , in 2009 . 
 the mycobacteria specie was identified using biochemical tests and sequencing the specific gene rpob . to treat the infection by mycobacterium wolinskyi it was necessary to combine antibiotics for a long period of time associated with surgical procedures of the breast abscesses .