Mycobacterium Abscessus in Bone: A Treatable Challenge?

Male patient CGBL, 80 years old. Immunocompetent and with heart disease. Femur fracture operated in another service in January 2022, with removal of the prosthesis due to drainage and persistence of infection ‒ M. abscessus isolated, resistant to clarithromycin. He came for a new hip arthroplasty in September 2022 after 9-months of treatment with tigecycline and clarithromycin. Before the procedure, he underwent joint fluid aspiration, with negative culture, according to information in a medical report. In the September intraoperative period, abundant whitish secretion adherent to the bone and surrounding tissue was observed. It was decided not to place a new prosthesis, and material was collected for culture. There was growth of M. abscessus. The Health Secretariat recommended amikacin three times per week, tigecycline, and linezolid as home care. Surgical debridements were scheduled as part of treatment. In November 2022 and January 2023, he underwent surgical procedures, again with intraoperative secretion; he reported hearing loss attributed to amikacin and nausea attributed to tigecycline ‒ his case was taken to the Ministry of Health mycobacteria committee, which recommended bedaquiline and clofazimine, in addition to IV linezolid. Culture was again positive. In March 2023 and later in June, he again underwent surgical debridements, with the same appearance and positive culture. We maintained the medication. In September 2023, he returned for surgery, which maintained the “candle wax dripping” appearance. Bedaquiline was discontinued according to the Committee’s guidance, and we maintained clofazimine and linezolid. Surgical procedures were performed again in December 2023 and February 2024. He developed thrombocytopenia, attributed to linezolid. We resumed tigecycline and maintained clofazimine. Cultures remained positive. In June 2024, already significantly debilitated, he died. M. abscessus is a rapidly growing mycobacterium belonging to the group of non-tuberculous mycobacteria (NTM). It is known to cause pulmonary, cutaneous, and soft tissue infections, especially in immunocompromised patients or those with chronic lung disease. It is described in aquatic environments and in soil. Infections occur through environmental exposure (contaminated water, invasive medical procedures). Treatment is challenging and involves multiple antimicrobials. In bone, it is rarely described in the literature and becomes even more challenging. It is expected to appear more frequently in medical practice with the increasing use of implants.