Infection with Mycobacterium fortuitum during acupoint embedding therapy
Authors: Tai Kyung Noh, Chong Hyun Won, Mi Woo Lee, Jee Ho Choi, Sang Oh Lee, Sung Eun Chang
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: Acupoint embedding therapy (AET), also known as needle embedding therapy, embeds absorbable foreign substances such as polydioxanone sutures in acupoints to achieve their long-term stimulation. AET has been used to treat chronic and painful disorders, particularly in traditional oriental medicine,1Zhang X.P. Jia C.S. Wang J.L. Shi J. Zhang X. Li X.F. et al.Acupoint catgut-embedding therapy: superiorities and principles of application.Zhongguo Zhen Jiu. 2012; 32 ([article in Chinese]): 947-951PubMed Google Scholar and is currently also used for aesthetic purposes (eg, reducing facial wrinkles). However, little is known about the adverse effects of this therapy. Here, we report a patient with nontuberculous mycobacteria (NTM) infection induced by AET. A healthy 44-year-old woman presented with multiple tender erythematous papules and nodules on both cheeks (Fig 1). She had recently undergone 2 courses of AET separated by an interval of 1 month. Needles were used to embed sterile polydioxanone sutures in acupoints of lower aspects of both cheeks and nasolabial folds. After the second course, multiple oozing erythematous papules and tender nodules appeared, the locations of which corresponded with the points at which the sutures had been embedded. The patient did not have a fever or lymphadenopathy, and responded poorly to acupuncture performed by the oriental medicine doctors who performed the AET. The patient underwent a 1-month course of combined minocycline and cefixime therapy at another dermatology clinic. A skin biopsy specimen revealed a dermal abscess comprising lymphocytes, neutrophils, and histiocytes without foreign body granulomas or suture materials (Fig 2). Dermal tissue culture revealed atypical mycobacteria, which were identified as Mycobacterium fortuitum by polymerase chain reaction hybridization using the rpoB gene. The isolate was susceptible to doxycycline, ciprofloxacin, amikacin, and clarithromycin. The patient responded well to combination therapy with oral doxycycline, ciprofloxacin, and clarithromycin. After 3 months of treatment, the lesions continued to improve and a 6- to 12-month course of combination therapy was recommended.Fig 2Mycobacterium fortuitum infection associated with acupoint embedding therapy. Acute mixed inflammation composed of lymphocytes, neutrophils, and histiocytes involving the entire dermis. (Hematoxylin-eosin stain; original magnification: ×100).View Large Image Figure ViewerDownload Hi-res image Download (PPT) AET is thought to work by inducing the release of neurochemicals in response to the application of pressure or needles to acupoints.1Zhang X.P. Jia C.S. Wang J.L. Shi J. Zhang X. Li X.F. et al.Acupoint catgut-embedding therapy: superiorities and principles of application.Zhongguo Zhen Jiu. 2012; 32 ([article in Chinese]): 947-951PubMed Google Scholar AET is increasingly used for gradual face lifts and skin tightening, especially among oriental medicine doctors in Korea. AET is advertised as a nonsurgical procedure that uses natural materials; therefore, many patients assume it is safer than filler or botulinum toxin treatments. However, AET can cause iatrogenic infections. As with other strains of NTM, M fortuitum infections are generally associated with the use of contaminated solutions and/or equipment during medical procedures. In the case presented here, the source of contamination responsible for the NTM infection could not be identified. However, because disposable needles and threads were used, we suspected that mycobacteria on the patient’s skin may have been the source of the infection. The patient was treated with minocycline, which might have a lower benefit/risk ratio than doxycycline.2Lebrun-Vignes B. Kreft-Jais C. Castot A. Chosidow O. Comparative analysis of adverse drug reactions to tetracyclines: results of a French national survey and review of the literature.Br J Dermatol. 2012; 166: 1333-1341Crossref PubMed Scopus (43) Google Scholar Until the causative organisms are isolated, empirical antibiotics should be used carefully. There are reports of NTM infections being contracted after tattooing3Mitchell C.B. Isenstein A. Burkhart C.N. Groben P. Morrell D.S. Infection with Mycobacterium immunogenum following a tattoo.J Am Acad Dermatol. 2011; 64: e70-e71Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 4Kappel S. Cotliar J. Inoculation of Mycobacteria chelonae from a tattoo.J Am Acad Dermatol. 2011; 64: 998-999Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar and acupuncture.5Guevara-Patino A. Sandoval de Mora M. Farreras A. Rivera-Olivero I. Fermin D. de Waard J.H. Soft tissue infection due to Mycobacterium fortuitum following acupuncture: a case report and review of the literature.J Infect Dev Ctries. 2010; 4: 521-525PubMed Google Scholar However, to our knowledge, this is the first reported case of M fortuitum infection associated with AET. Thus, practitioners should suspect mycobacterial infection in patients presenting with nodules and abscesses in areas that have been treated with AET. Such infections should be treated promptly to minimize further disfigurement.