ONLINE CASE REPORT Ann R Coll Surg Engl 2013; 95: e12–13 doi 10.1308/003588413X13511609955175 Mycobacterium fortuitum skin infection as a complication of anabolic steroids: a rare case report R Pai, U Parampalli, G Hettiarachchi, I Ahmed Medway NHS Foundation Trust, UK ABSTRACT Mycobacterium fortuitum is a rare cause of recurrent skin abscesses in an immunocompetent person. We report the case of a 37-year-old man presenting with multiple recurrent non-healing skin abscesses. Culture of the abscess wall yielded growth of M fortuitum. In our case, we highlight the association of anabolic steroids with non-tuberculous mycobacterial skin abscesses that fail to resolve despite repeated drainage. KEYWORDS Mycobacterium fortuitum – Cutaneous abscess – Anabolic steroids Accepted 15 August 2012; published online 21 December 2012 CORRESPONDENCE TO Roshanne Pai, F1 Doctor, Medway Maritime Hospital, Windmill Road, Gillingham, Kent ME7 5NY, UK E: [email protected] Abscesses requiring incision and drainage present to sur- the abscess cavities. On this occasion, a tissue sample was geons frequently. However, it is important to be aware of sent for histology and microbiology analysis. The impres- unusual presentations of abscesses. Those that do not re- sion at this time was one of hidradenitis suppurativa (Fig 1). solve following a surgical procedure or multiply without an These indurated and multiple abscesses required a obvious cause must be investigated with tissue cultures and fourth round of surgery. The histology was reported as wound swabs in order to obtain an accurate diagnosis as ‘chronic inflammation with multinucleate giant cells along inoculation with mycobacteria could be a rare cause. with foci of caseating necrosis surrounded by granulomas’ (Fig 2). There were no acid-fast bacilli demonstrated on special staining. However, the diagnosis was thought to be Case history probable tuberculosis. A 37-year-old Caucasian man working as a mechanic pre- The patient was referred to the respiratory physicians sented to the emergency department with a solitary swelling for treatment of tuberculosis. However, the tissue culture on the right side of his chest wall. He had previously had an isolated a very resistant Mycobacterium fortuitum, and incision and drainage of the abscess on the same site while so he was treated with ciprofloxacin 750mg twice daily working in the Middle East. He was not diabetic and was im- and doxycycline 200mg daily. He was unable to tolerate munocompetent. He had injected anabolic steroids in the ciprofloxacin and was switched to a second line quinolone pectoral muscles for body building in the past. On examina- in the form of moxifloxacin 400mg daily and continued on tion, he had a 5cm x 5cm abscess in the right axilla. It was doxycycline 200mg daily. Unfortunately, he developed incised and drained under general anaesthesia and he was side effects with the second quinolone and this was also discharged home with a course of oral amoxicillin and cla- discontinued. The extensive antibiotic resistance pattern vulanate 625mg three times a day for seven days. A routine meant there were few oral treatment options. Computed bacterial culture of the wound showed no significant growth. tomography of the chest excluded secondary pulmonary in- The patient presented again a week later with recur- volvement. The respiratory physician referred him back for rence of the abscess. Further incision and drainage was further surgical excision with a view to obtain clear mar- performed and again the swabs did not yield any bacterial gins. He was reviewed in the surgical clinic a few weeks growth. A week later, he presented for a third time with yet later. The wound had healed completely (Fig 3). Histology another recurrence. The abscesses were erythematous, ten- revealed only fibrous scar tissue and no evidence of any der and discharging pus. He underwent further drainage of granulomatous inflammation. e12 Ann R Coll Surg Engl 2013; 95: e12–13 PAI PARAMPAllI HEttIARACHCHI AHMED MYCOBACTERIuM fORTuITuM SKIN INfECTION AS A COMPLICATION Of ANABOLIC STEROIDS: A RARE CASE REPORT androgens such as testosterone and nandrolone may focus preferentially on altering immune function by reducing nat- ural killer cell activity and inhibiting the maturation of stem cells into B lymphocytes. At supraphysiological doses, they influence cytokine production directly. All these effects in combination affect immunocompetence although long-term figure 1 the incised and drained abscesses prior to the effects are still unproven.9 administration of antibiotic therapy M fortuitum is mostly sensitive to amikacin, cefotaxime, gentamicin quinolones and tetracyclines. Although mac- rolide sensitivity is often detected in vitro, M fortuitum con- tains an inducible resistant gene. Ciprofloxacin and doxy- cycline are therefore the most common antibiotics used to treat this type of infection. In the majority of cases, dual therapy is recommended. The course of antibiotics should be continued for 4–6 months.10 In cases where antibiotic re- sistance is detected or when the patient is unable to tolerate antibiotics, surgical excision should be considered. If abscesses are thought to be due to mycobacterial in- fection, it is important to institute a two-step treatment: figure 2 Histology slides: granulomatous inflammation with incision and drainage of the abscess, and appropriate anti- central necrosis (40x magnification; left) and granuloma in the microbial therapy.11 The surgeon operating on the abscess centre of the picture and caseation in the bottom right (200x should be careful to remove as much tissue from the site as magnification; right) possible to reduce the burden of infection. Conclusions To our knowledge, this is the first reported case of an asso- ciation between anabolic steroid injection and M fortuitum infection. In this case, surgical excision and prompt antimi- crobial treatment achieved a local cure. 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