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| CASE REPORT |
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| Year : 2022 | Volume
: 5
| Issue : 4 | Page : 212-217 |
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Mesh infection of Mycobacterium fortuitum after inguinal hernia repair: A rare case report and literature review
Lu Chen, Gengwen Huang
Department of Hernia and Abdominal Wall Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China; Department of General Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| Date of Submission | 12-Aug-2022 |
| Date of Decision | 16-Sep-2022 |
| Date of Acceptance | 19-Sep-2022 |
| Date of Web Publication | 24-Dec-2022 |
Correspondence Address:
Gengwen Huang
Department of Hernia and Abdominal Wall Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, Hunan Province
China
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijawhs.ijawhs_39_22
PURPOSE: Inguinal hernia repair is one of the most common operations worldwide. The standard procedure now is tension-free hernioplasty with mesh implantation. Mesh repairs obviously reduce the rate of hernia recurrence and alleviate the pain. However, mesh infection is one of the most serious complications, which usually causes secondary operation. At present, no standard treatment measures of mesh infections, especially for rare pathogens such as nontuberculous mycobacteria (NTM), are available. MATERIALS AND METHODS: We present an unusual case of Mycobacterium fortuitum infection of implanted mesh after inguinal hernia repair. Medline and PubMed databases were searched using the keywords mentioned subsequently, and the literature on treatment measures of mesh infection of M. fortuitum and other subtypes of NTM after inguinal hernia repair is reviewed. RESULTS: Mesh infections of M. fortuitum are very rare after inguinal hernia repair. The infection is hard to diagnose and complex to treat. However, it has characteristic clinical manifestations. With early recognition and specific tests, clinicians can still confirm the infection. Treatments include antibiotics and surgical intervention. Mesh displantation is considered to be necessary and needs to be conducted as soon as possible. CONCLUSION: When a mesh infection is present, it is important to check the wound before obtaining bacteriological evidence. Once the mycobacteria infection is suspected, corresponding tests should be taken immediately. With appropriate treatment, patients will likely make a full recovery. Keywords: Inguinal hernia, mesh infection, Mycobacterium fortuitum
How to cite this article:
Chen L, Huang G. Mesh infection of Mycobacterium fortuitum after inguinal hernia repair: A rare case report and literature review. Int J Abdom Wall Hernia Surg 2022;5:212-7 |
| Introduction | |  |
Inguinal hernia repair is one of the most common operations worldwide, with more than 20 million people undergoing surgery every year.[1] Over the past few decades, the use of meshes has become the standard procedure for inguinal hernia repair. The implantation of mesh during surgery can significantly reduce the recurrence rate of hernia.[2] An earlier meta-analysis comparing mesh and non-mesh for inguinal hernia repair showed that mesh implantation significantly reduces the risk of recurrence by over 46%.[3]
However, mesh-related complications have become increasingly important. These complications include seroma, abdominal adhesions, chronic pain, mesh migration, mesh erosion, and mesh-related infections.[4] The most devastating one is mesh-related infections, which often lead to long-term use of antibiotics, repeated surgery, mesh removal, and potential hernia recurrence.[5] This process not only afflicts patients but also places a significant economic burden on the medical system. In a retrospective cohort study, for comparison of complete vs. partial mesh removal for the treatment of chronic mesh infection, 34 patients with chronic mesh infection underwent an average of 3.4 operations[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] until recovery, and the average delay from the first operation to cure is 2.8 years (0–6).[6]
Typically, the mesh-infection-related bacterium is mainly staphylococci. However, we found a rare case of M. fortuitum (one kind of nontuberculous mycobacteria [NTM])-related infection. Recently, a series of reports regarding pre-operative infections of NTM, including the outbreak of rapidly growing NTM wound infections among medical tourists undergoing cosmetic surgeries in the Dominican Republic,[7] the outbreak of life-threatening NTM infections in patients who had cardiothoracic surgery during which contaminated heater–cooler devices were used,[8] and an outbreak of NTM joint prosthesis infections,[9] have been reported. These cases have renewed the attention of the originally rare NTM infections. However, there are a few reports of mesh-related infections of NTM and no accepted treatment process. Here, we present a case of mesh infection of M. fortuitum after Lichtenstein’s operation for inguinal hernia.
| Case Report | | |
A 46-year-old female was admitted to our department on September 23, 2021, with complaints of a reducible bulge in the right groin area for more than 8 years. The bulge (about 1 cm × 1 cm in size) was first found 8 years ago. First, it only emerged during coughing or aggravating activities and resolved during rest or lying down. Thus, it was not given enough attention. In the last 6 months, the bulge could not be completely resolved, accompanied by swelling and pain in the right inguinal area. She had no significant medical background or family history. The physical examination revealed a soft right inguinal bulge with tenderness to palpation. It had a well-defined boundary. The bulge could not be completely resolved in the abdominal cavity. Ultrasound showed a cyst in the right groin area, which seemed to be connected to the abdominal cavity. Relevant examinations were improved, and there was no obvious operation contraindication. On September 24, 2021, the patient was operated with an open polypropylene, tension-free hernioplasty protocol, according to the Lichtenstein technique.
The patient received a skin preparation of a pre-operative soap shower and pubic hair shaving the night before the surgery in the ward. Then, the operation area was disinfected with iodine by senior residents in the operating room three times. Antibiotics were not used during the perioperative period.
The operation went well with no intra-operative complications. On post-operative day (POD) 1, the patient appeared well with minimal groin pain and was able to ambulate and tolerate diet. The incision was clean and dry, with no drainage or signs of infection. The patient was discharged on POD 2.
At home, the patient complained of discomfort in the right groin area 1 week after discharge, accompanied by a burning feeling, but without any change in shape from the time of appearance. Three weeks after discharge, the patient developed fever and swelling in the surgical site. A single nodule appeared above the top of the wound. Four weeks after discharge, purulent material was draining from the upper part of the wound. It appeared that this patient developed a chronic infection and sinus tract formation.
An abdominal ultrasound scan showed few accumulating fluids below the wound. A subsequent CT scan displayed a deep collection with a small amount of gas surrounding the mesh. The diagnosis was confirmed as mesh infection. One month after the initial procedure (October 23, 2021), the patient consented to further surgery. During the operation, the mesh was completely free of tissue incorporation, and there were caseous necrosis and a little pus around the mesh. Wide debridement of the wound was made, and the prosthesis was completely removed. The pus and part of the prosthesis were reserved for examination. After culture, M. fortuitum was isolated from the pus and the prosthesis. The post-operative wound swelling did not improve significantly. After consulting the infection control center of our hospital, prescriptions with multiple antibiotics were given: cefoxitin sodium (2.0 g IVGTT Q8H), amikacin (300 mg IVGTT q12h), doxycycline (100 mg oral BID), and levofloxacin tablets (500 mg oral QD). During the next 4 weeks, the patient markedly improved. Then, the patient was discharged with advice to continue doxycycline and levofloxacin tablets for 2–6 months and was followed up at regular intervals on the ward and in the outpatient department. For now, the patient has been treated orally for 4 months, and the wound has completely healed.
| Discussion | | |
Deep mesh infection should be distinguished from superficial incision infection. Although they all belong to surgical site infection (SSI),[10],[11] data from the US Nationwide Inpatient Sample showed that SSI has become the second most common hospital-acquired infection, leading to significant poor outcome, prolonged hospitalization, and increased treatment costs.[12] Superficial SSIs are limited to the skin or subcutaneous tissue, whereas deep infections extend to the underlying fascia or muscle.[13] For inguinal hernia surgery, deep mesh infections tend to present after a delayed period following mesh repair and usually require mesh removal. Antibiotics and local debridement are not enough to eradicate the infection in most cases.[14],[15],[16] The true incidence of chronic mesh infections is not clear and varies in different operation methods. A recent large cohort of male inguinal hernia repair in 2015 compared the incidence of SSI and mesh infection after total extraperitoneal hernioplasty (TEP) and Lichtenstein surgery. The incidence of SSI after Lichtenstein surgery was significantly higher than that after TEP surgery (0.35% vs. 0.07%; P < 0.001), and the mesh infection rate had similar results (0.26% vs. 0.06%; P = 0.003).[17]
The common pathogens associated with mesh infections are Staphylococcus spp., especially Staphylococcus aureus; Streptococcus spp. (including group B streptococci); Gram-negative bacteria (mainly Enterobacteriaceae); and anaerobic bacteria (including Peptostreptococcus spp.).[4] A very small part of mesh infections is caused by mycobacterium. However, in recent years, the infection caused by mycobacteria in hospital-associated infections, mainly NTM, has shown an increasing trend.[18] In our case, the bacteria of mesh infection were M. fortuitum, a subtype of NTM. This is the first NTM mesh infection after inguinal hernia repair in our center. However, NTM is highly resistant to antibiotics, resulting in difficult treatment, prolonged course of disease, and low cure rate. Thus, it is important to further study this kind of bacterial infection. After a detailed literature review, there were only seven cases of M. fortuitum infections after ventral hernia repair and only two after inguinal hernia repair.[19],[20],[21],[22],[23] The details of the cases are summarized in [Table 1].
NTM, also known as environmental mycobacterium or atypical mycobacterium, encompasses all mycobacteria species other than those in the M. tuberculosis complex and M. leprae, the agent of leprosy.[24] More than 190 species have been identified, of which about 40 are considered pathogenic.[25]Mycobacterium is ubiquitous in natural and constructed environments. They can be found in soil, natural, or treated water all over the world.[26],[27],[28] They are now often found in the hospital environment and have been associated with outbreaks of nosocomial infections following surgery or other invasive procedures.[29],[30],[31]
NTM can be categorized into rapidly growing mycobacteria (RGM) and slowly growing mycobacteria according to the growth rate on the nutrient medium. The M. fortuitum group is the most commonly isolated RGM in human infection.[32]
Many infections caused by M. fortuitum have been reported to be associated with surgical procedures using devices such as orthopedic prosthesis, peritoneal dialysis catheters, vascular catheters, and prosthetic heart valves.[33] In our case, it involved mesh implantation. Given that it is still rare and surgeons do not know enough about this kind of infection, diagnosis and treatment are often delayed.
The typical mesh infections caused by M. fortuitum have a long incubation period, which is characterized by delayed wound infection.[34] Although the manifestations of M. fortuitum are highly variable, common clinical manifestations include nodules, abscesses, ulcers, draining sinus tracts, and atypical cellulitis at the surgical site. These symptoms can occur within 4–6 weeks after infection. In our case, initially, the post-operative wound seemed to have healed. However, 3 weeks later, there was a single nodule, and obvious pus outflow began about 1 month later. We found typical indurated plaque with peripheral papules around the wound, which is different from other bacterial infections. Strong clinical suspicion of NTM is very helpful to determine the diagnosis. Chronic non-healing wounds should alert clinicians to the possibility of NTM infection. Because the diagnosis and treatment of NTM infection are different from ordinary bacteria, early identification and intervention can greatly improve the prognosis.
Normally, acid-fast bacilli (AFB) smear is performed to identify mycobacteria. However, AFB is not always positive in all cases. In a study in India, only 10 of 25 patients with post-operative wound NTM infection were AFB-positive at first.[35] Most of the NTM are cultivable in Lowenstein–Jensen, Middlebrook, Dubos Broth, and Agar.[36] However, because of the extremely slow nature of traditional biochemical tests, these tests have now been replaced by molecular tests for NTM species and subspecies identification, such as line probe hybridization, PCR-restriction fragment length polymorphism analysis, real-time PCR, DNA sequencing, and matrix-assisted laser desorption ionization–time of flight spectrometry.[37]
Although drug susceptibility testing for NTM is controversial because of discrepancy between in-vitro susceptibility and treatment response,[36] it is still recommended for NTM, especially RGM, and used as a clinical guide for treatment.[33] The antimicrobials recommended by the Clinical and Laboratory Standards Institute (CLSI) for NTM susceptibility testing include amikacin, cefoxitin, ciprofloxacin, clarithromycin, doxycycline (or minocycline), imipenem, linezolid, moxifloxacin, trimethoprim-sulfamethoxazole, and tobramycin.[32]
Compared with M. tuberculosis, there is no standard antimicrobial treatment for NTM infection. Therefore, treatment decisions are largely based on case studies and expert opinions published in guidelines.[26],[38],[39],[40],[41],[42]M. fortuitum is resistant to tuberculosis drugs but usually susceptible to several traditional antibiotics. Empirical therapy was suggested first until susceptibilities are known.[37] The key to NTM treatment lies in combination medication and long course of treatment.[26]M. fortuitum has been shown to be sensitive in vitro to oral antibiotics such as clarithromycin, azithromycin, ciprofloxacin, levofloxacin, moxifloxacin, doxycycline, minocycline, linezolid, and trimethoprim-sulfamethoxazole.[26],[43] In our case, the patient was given cefoxitin sodium, amikacin, doxycycline, and levofloxacin. After discharge, the prescription of doxycycline and levofloxacin tablets was continued for 6 months. The patient made a complete recovery.
When a mesh-related infection occurs, most scholars insist a combined medical and surgical approach involving antimicrobial agents, and complete surgical removal of the mesh is the preferred management strategy.[37] Monotherapy with antibiotics has been reported to have a poor outcome. A Turkish study reviewed 15 cases of chronic mesh infection after open inguinal hernia repair from 2000 to 2012. All patients underwent mesh removal after conservative approaches failures. The infection was finally controlled without recurrence.[44] Therefore, to control the infection and shorten the treatment time, most scholars believe that the infection mesh should be taken out in time and completely. Conservative surgical methods, such as abscess drainage, sinus resection, or partial patch resection, may fail and lead to the recurrence of mesh infection.[45]
As for NTM infection, more active surgical measures should be taken. Once the diagnosis is determined, complete mesh removal and strong debridement should be carried out as soon as possible, including all infected subcutaneous tissues and skin.[46] However, due to the progress of detection methods and antibiotics, radical debridement is no longer necessary unless the infection is extensive or is a relapse infection.[26] In our case, due to the immediate removal of mesh when the diagnosis was suspected and combined with antibiotic treatment, extended debridement was avoided.
| Conclusion | | |
Although NTM infection of mesh after inguinal hernia surgery is rare, it is different from ordinary mesh infection, which is difficult to diagnose, is complex to treat, and has a long treatment course. Moreover, it is easy to relapse once the treatment is not complete. However, as long as we recognize the possibility of mycobacterial infection in the early stage, timely and actively remove the mesh, and combine with appropriate antibiotics for long-term treatment, NTM infection can be cured.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1]
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