Management of tattoo-associated Mycobacterium abscessus skin infections by surgery and observation

Mycobacterium abscessus, a rapidly growing and frequently multidrug-resistant non-tuberculous mycobacterium, has been linked to cutaneous infections in both immunocompetent and immunocompromised individuals through inoculation via skin-traumatizing procedures such as tattooing. Here we describe two patients with culture-confirmed M. abscessus cutaneous infections acquired from the same tattoo studio in Calgary, Canada. Both patients developed dozens of erythematous papules at the site of inoculation within 2 weeks of a new tattoo using the same grey-wash ink. Despite recommendation for antimicrobial therapy, both patients independently elected to pursue surgical excision and observation. Following excision of multiple papules, both patients showed evidence of infection resolution within 10 weeks, without any evidence of relapsed infection. Conventional treatment of M. abscessus skin and soft tissue infections typically involves susceptibility-guided multidrug regimens for several months and is commonly associated with significant medication toxicity. These cases demonstrate that observation, potentially augmented with surgical removal, may be effective alternatives, especially in immunocompetent individuals with localized infections, and thereby avoiding the need for antibiotics.