Kulkarni Siddhesh, Menon Aditya, Rodrigues Camilla, Soman Rajeev, Agashe Vikas M
Department of Orthopaedics, PD Hinduja Hospital and Medical Research Centre, Mahim, Mumbai, Maharashtra, India.
Consultant, Infectious Diseases Jupiter Hospital, Pune, Maharashtra, India.
J Orthop Case Rep. 2022 Aug;12(8):9-13. doi: 10.13107/jocr.2022.v12.i08.2944.
Non-tuberculous mycobacteria (NTM) infections of the musculoskeletal system are commonly missed due to their rarity and the absence of systemic symptoms. Here, we present a rare case of NTM infection following repair of an avulsed pectoralis major tendon in an immunocompetent host managed by a multi-disciplinary team specializing in musculoskeletal infections.
A 23-year-old male patient presented with discharging sinus in the right axilla for 6 months. He sustained the right pectoralis major muscle avulsion following an accident which was surgically repaired using FiberWire® and endo buttons. He developed a discharging sinus 4-month post-surgery. He presented with persistent infection in spite of empirical antibiotics elsewhere. Radiographs and MRI sonogram showed intra-medullar endo buttons in the proximal humerus with marginal pus collection in the axillary region with minimal medial extension into pectoralis major and minor muscles along the superior aspect. A detailed plan was made with inputs from a multidisciplinary bone infection team. Wound was radically debrided, implants and sutures removed, humerus scraped, and tissues sent for microbiology and histopathology. Extended incubation of deep tissue culture as suggested by ID specialists grew Rapidly growing mycobacteria, a type of NTM 3 weeks after surgery. Patient was started on intravenous amikacin along with oral clarithromycin and linezolid based on antibiotic susceptibility. Wound discharge persisted for almost 5-week post-surgery and stopped 2 weeks after initiation of appropriate antibiotics. Amikacin was given for 1 month and oral antibiotics were continued for 6 months. The pectoralis major function was unaffected after surgery and patient returned to normal activities 3 months after debridement. Patient has an infection free follow-up of 4 years.
This case outlines the importance of having a high degree of suspicion for the diagnosing orthopedic NTM infections. In addition, it showcases the advantages of having good communication between surgeons, infectious disease specialist, and microbiologist for achieving good functional outcomes.
肌肉骨骼系统的非结核分枝杆菌（NTM）感染通常因罕见且无全身症状而常被漏诊。在此，我们报告一例免疫功能正常宿主在修复撕脱的胸大肌腱后发生NTM感染的罕见病例，该病例由一个专门处理肌肉骨骼感染的多学科团队进行管理。
一名23岁男性患者，右腋窝有排脓窦道6个月。他在一次事故后发生右胸大肌撕脱，手术采用FiberWire®和内固定纽扣进行修复。术后4个月出现排脓窦道。尽管在其他地方接受了经验性抗生素治疗，但仍存在持续感染。X线片和MRI超声显示肱骨近端髓腔内有内固定纽扣，腋窝区域有边缘性脓肿形成，沿上缘向胸大肌和胸小肌内侧有轻微延伸。在多学科骨感染团队的参与下制定了详细的治疗方案。对伤口进行彻底清创，取出植入物和缝线，刮除肱骨病变组织，并将组织送去做微生物学和组织病理学检查。按照感染病专家的建议延长深部组织培养时间，术后3周培养出快速生长分枝杆菌，这是一种NTM。根据药敏结果，患者开始静脉使用阿米卡星，同时口服克拉霉素和利奈唑胺。术后伤口持续排脓近5周，在开始使用合适的抗生素2周后停止。阿米卡星使用1个月，口服抗生素持续使用6个月。术后胸大肌功能未受影响，清创术后3个月患者恢复正常活动。患者已无感染随访4年。
本病例强调了对骨科NTM感染保持高度怀疑的重要性。此外，它还展示了外科医生、感染病专家和微生物学家之间良好沟通对于实现良好功能结局的优势。
