Age: 64.0
Sex: F
Vaccine: FLUX
Symptoms: Abscess limb, Antimicrobial susceptibility test sensitive, Atypical mycobacterium test positive, Computerised tomogram abdomen abnormal, Culture wound positive
Clinical narrative: M. abscessus/chelonae; Skin necrosis on the lateral aspect; Left buttock abscess; Syncopal episode; This literature case was received on 29-Nov-2023 and concerned a 64-year-old female patient.   This case report presented a female patient with left buttock wound, following an influenza vaccination administration who was diagnosed with mycobacterium chelonae infection and was treated with empiric antimicrobial therapy.  The patient's medical history and concomitant medications were not reported.   On an unspecified date, the patient was vaccinated with influenza vaccine (brand not specified; dose, route of administration, anatomical location, and indication: not reported). The batch number was not reported.   On an unspecified date, two months after receiving influenza vaccine, the patient noticed that her left buttock became more swollen and red. The patient was followed up with her primary care specialists, who gave her a course of oral cephalexin without improvement.  On an unspecified date, six months after receiving influenza vaccine, the patient with left buttock wound was presented to the hospital after a syncopal episode in her surgeon's outpatient office. The patient was referred to the hospital for computed tomography (CT) abdomen/pelvis, which showed a 3.3 x 6.7 x 9.7 cm fluid collection within the subcutaneous fat of the left buttock with no abscess in the muscle. On physical exam, there was a 7 x 5 cm eschar over an area of fluctuance with associated purulent drainage. The patient underwent excisional debridement of the left buttock abscess. Ten mL of purulent fluid was evacuated and sent for culture. A wound vac was placed, and the patient was discharged with surgical follow-up  On an unspecified date, one week later, the patient returned for further excisional debridement and closure of the wound. In the operating room, the patient was found to have a 7 x 3 cm wound with skin necrosis on the lateral aspect. The wound was irrigated, and specimens were sent for culture. The culture grew M. abscessus/chelonae. The patient was amenable to transitioning care to the OPAT unit to receive empiric antimicrobial therapy pending susceptibilities. The treatment included azithromycin with a dose of 500 mg, PO, daily, levofloxacin with a dose of 750 mg, PO, daily, tigecycline reported as 'tigecycyline' with a dose of 50 mg intravenously (IV), daily, and amikacin with a dose of 1475 mg (IV), three times weekly.   On an unspecified date, the patient was discharged from the hospital.   On an unspecified date, reported as four days after hospital discharge, the patient was readmitted due to gastrointestinal (GI) intolerance to tigecycline therapy. Susceptibility testing revealed a macrolide-susceptible strain.   On an unspecified date, the treatment with Levofloxacin was discontinued, and the patient remained on azithromycin, tigecycline, and amikacin. As the patient continued to have GI intolerance, the decision was made to substitute omadacycline (MIC returned at 0.12 ug/mL for tigecycline). The patient was instructed to continue with azithromycin and per os (PO) omadacycline was added. The patient completed a total six-month course of therapy with complete wound healing.  On an unspecified date, the patient recovered from 'skin necrosis ' and 'abscess on buttock' as reported that the patient completed a total 6-month course of therapy with complete wound healing.  The outcome of the events of 'mycobacterium chelonae infection' and 'syncope' was not reported.  The reporter did not provide a causality assessment.   In conclusion, given its favourable in vitro activity and synergy data, oral availability, long-term tolerability, and safety data, it was a promising agent to consider in combination for the treatment of M. abscessus infections. More studies were needed to confirm the optimal combination, dose, timing of initiation, duration of treatment and applicability to all sources of infection and subspecies of M. abscessus.   The events of mycobacterium chelonae infection and syncope were considered as serious due to the seriousness criteria of hospitalization. Additionally, the events of mycobacterium chelonae infection and syncope were considered to be medically significant by Physician within Seqirus's Pharmacovigilance Department.   The literature citation   Company comment: Reportedly, two months after receiving influenza vaccine, the patient noticed that her left buttock became more swollen and red. The patient was followed up with her primary care specialists, who gave her a course of oral cephalexin without improvement. Six months after receiving influenza vaccine, the patient with left buttock wound was presented to the hospital after a syncopal episode in her surgeon's outpatient office. The patient underwent excisional debridement of the left buttock abscess. One week later, the patient returned for further excisional debridement and closure of the wound. In the operating room, the patient was found to have a skin necrosis on the lateral aspect. The wound was irrigated, and specimens were sent for culture. The culture grew M. abscessus/chelonae. Although, limited information about anatomical location of vaccination and alternative aetiology, causal role of the vaccine is assessed as possibly related for abscess on buttock, Mycobacterium chelonae infection and skin necrosis. The event of syncope is assessed as not related to the vaccine, based on implausible temporal relationship and since it was considered as a consequence of undelaying infection.; Sender's Comments: Reportedly, two months after receiving influenza vaccine, the patient noticed that her left buttock became more swollen and red. The patient was followed up with her primary care specialists, who gave her a course of oral cephalexin without improvement. Six months after receiving influenza vaccine, the patient with left buttock wound was presented to the hospital after a syncopal episode in her surgeon's outpatient office. The patient underwent excisional debridement of the left buttock abscess. One week later, the patient returned for further excisional debridement and closure of the wound. In the operating room, the patient was found to have a skin necrosis on the lateral aspect. The wound was irrigated, and specimens were sent for culture. The culture grew M. abscessus/chelonae. Although, limited information about anatomical location of vaccination and alternative aetiology, causal role of the vaccine is assessed as possibly related for abscess on buttock, Mycobacterium chelonae infection and skin necrosis. The event of syncope is assessed as not related to the vaccine, based on implausible temporal relationship and since it was considered as a consequence of undelaying infection.