Chronic Fistulas after Breast Augmentation Secondary to Mycobacterium abscessus

Sir: There has been an increase in the incidence of nontuberculous mycobacterial infections after breast augmentation and other procedures over the past several years.1–5 We present a case of bilateral mycobacterial infection after transareolar subpectoral breast augmentation with occurrence of chronic draining fistulas at the incision sites after implant removal so as to alert surgeons to this unexpected complication. An otherwise healthy 44-year-old woman underwent transareolar subpectoral breast augmentation with 500-cc saline implants. Four weeks later, she developed slight swelling of her right breast, with no fever, erythema, pain, or tenderness. The patient was placed on oral linezolid (600 mg twice daily). Ten days later, an area of erythema developed on the inferomedial aspect of the right breast, prompting implant removal through an inframammary crease incision. Approximately 200 ml of turbid fluid was drained, the Gram stain of which showed a white blood cell count of 4+ and no bacteria. Results of routine cultures were negative. Although closed tube drainage was used, the patient developed serous drainage through the inframammary incision site. The amount of drainage diminished slowly and the fistula closed spontaneously within 3 months. Two weeks after removal of the right implant, the patient became febrile and developed pain and erythema over the inferolateral aspect of the left breast. These symptoms prompted immediate removal of the left breast implant, again through an inframammary crease incision. Approximately 100 ml of turbid material was removed and submitted for Gram stain and cultures. As it was noted during this—and the previous, right-sided—explantation that the tissues surrounding the implant appeared normal without detectable capsule formation, no attempt was made to excise any granulation tissue or perform capsulectomy. Closed tube drainage was again performed. Gram stain showed a white blood cell count of 2+ with no organisms. The final bacteriology report indicated Mycobacterium abscessus. The patient showed improvement of her signs and symptoms within 2 to 3 days after explantation. A new antibiotic regimen was initiated by the infectious disease consultant that was continued for 6 months. Approximately 1 week after implant removal, the patient developed a fistula tract similar to the one on the right breast involving the left inframammary crease incision. This fistula closed spontaneously within 3 weeks. Because of the recent rise in outbreaks of mycobacterial infections1–5 and because clinical diagnosis of mycobacterial infection after breast augmentation may be delayed,5 we strongly recommend laboratory staining for acid-fast bacilli in addition to routine Gram stain and culture studies in all patients who undergo implant removal. A standard Gram stain frequently fails to identify acid-fast bacilli. Furthermore, we bring attention to the occurrence of a chronic fistula as a potential complication of atypical mycobacterial breast implant infection. The treatment goal should involve controlling the infection medically, without necessarily removing the periprosthetic granulation tissue or the capsule at the time of explantation or when a fistula has formed. David J. Jackowe, M.D. Daniel Murariu, M.D. Department of Surgery Natalie N. Parsa, M.D. Department of Family Practice F. Don Parsa, M.D. Department of Surgery John A.