Subcutaneous infection caused by Mycobacterium abscessus following cosmetic inje

lNTRODUCTlON

Nontuberculous mycobacteria (NTM) refer to mycobacteria other thanandwith the common involved organs of the lung, bone, soft tissues, skin, and lymph nodes[1].() is one of the common pathogens in NTM, which is a fast-growing mycobacterium causing skin and soft tissue infections. Meanwhile, the atypical mycobacterial infections are increasing at injection-related sites as the informal cosmetic treatments are performed, which deserves the attention of the cosmetic and medical supervision[2-4]. The case presented here is a subcutaneous infection caused byfollowing cosmetic injections of botulinum toxin.

CASE PRESENTATlON

Chief complaints

文中介绍了一种基于Android平台的高血压监测预警系统设计方案，为用户提供血压、心率监测、智能预警以及健康指导等功能，对于缓解医疗资源紧张、辅助家庭监护系统、降低患者病死病残率，提高生活质量等方面具有一定的作用。同时，为高血压移动医疗软件的设计与开发提供了新的思路。

History of present illness

The lesions initially presented with erythema after 10 d of the injection then developed to nodules and abscesses after half a month. The patient did not have any concomitant symptoms such as fever, cough,fatigue, sweats, or diarrhea. She was prescribed with antibiotics for 2 wk without alleviation of the lesions.

History of past illness

Nothing special.

Personal and family history

The patient did not have any underlying disease or take any drugs in the past.

Physical examination

Physical examination indicated multiple red papules, nodules, and abscesses on the forehead and both temporal sites with a diameter of 1-3 cm.

Laboratory examinations

The routine blood, urine, and stool tests as well as kidney and liver function tests were in normal levels.The levels of C3, C4 and C-reactive protein were normal. The patient was negative for syphilis, HIV,antinuclear antibodies, and rheumatoid factor. CD3 and CD4 counts were done to check for any immunodeficiency and were within normal limits (Supplementary Table 1).

Imaging examinations

Computed tomography (CT) of the whole body did not find any systemic infection or diseases.

FlNAL DlAGNOSlS

The patient underwent skin biopsy on the nodules of left temporal site. The pathology of skin tissue showed a large number of inflammatory cells including neutrophils, lymphocytes, and multinucleated giant cells distributed in the derma (Figure 2A and 2B). However, periodic acid Schiff (PAS) and acidfast staining were negative. Meanwhile, the skin tissue did not yield any microbiome after culture on different media for bacteria, fungus, or mycobacterium. Considering the low biopsy- and culturepositive rate of some microorganisms, a puncture on abscess of right temporal site was further performed. Gray-white colonies were yielded after being cultured on Mycobacterium Roche's Medium(MRM) for 5 days at 35 °C (Figure 3A). Meanwhile, the pus was positive for acid-fast staining andwas identified by DNA sequencing (Figure 3B). The drug sensitivity test indicated that the microbiome was sensitive to clarithromycin, moxifloxacin, azithromycin, cefoxitin, and amikacin, and was resistant to isoniazid, streptomycin, dapsone, and rifampicin (Supplementary Table 2).

TREATMENT

The patient was initially intramuscularly injected with amikacin 0.2 g and given oral clarithromycin 0.25 g twice a day for 2 wk and then adjusted to moxifloxacin 0.4 g per day and clarithromycin 0.25 g twice a day because of dizziness and vomiting caused by amikacin.

The patient did not show any side effects and presented complete remission of the lesions during the subsequent treatment for 7 mo (Figure 1D-F).

OUTCOME AND FOLLOW-UP

对于陶瓷器物来说，瓷器上的纹饰不仅仅是重要装饰手段，更是时代审美与人文风气的缩影。陶瓷器物的绘画装饰的手法起源于新石器时代。新石器时代的图案源自于人们在长期的劳动时间活动中对事物的认识，在经过当时人们的主观的感想和艺术处理而形成的图腾形象。在后来的发展中，器物上的纹饰时代气息更加明显，文化内涵也发生了翻天覆地的变化，这些纹饰已经不仅仅带给人视觉上的享受，其中还有耐人寻味的艺术价值。

DlSCUSSlON

With the development of un-standard invasive performance in cosmetic industry, related iatrogenic complications are increasing in the last two decades. Injection pain, local edema, erythema, and transient nausea are common complications with mild symptoms. Life-threatening complications are rarely seen, while severe idiosyncratic reactions can cause patients to die from shock and pseudoaneurysm of the superficial temporal artery may break and cause bleeding to death[5]. Infections are also common complications, which usually can be easily cured with empiric antibiotic therapy. However,atypical mycobacterial infections are increasing these years and resistant to regular antibiotic treatment.To meet the challenge of NTM diagnosis and management, we should learn more about it. In Table 1,previous cases of mycobacterial infections caused by cosmetic performance are reviewed[2-4,6-14], the results of which are consistent with the previous studies[1]. It is common to be seen in female patients aged 25 to 45 years. This phenomenon can be attributed to the fact that these people are more often seeking invasive cosmetic performance.

The rare pathogen ofis the main mycobacteria isolated from lesions cultured, which can involve the skin, soft tissue, and lymph nodes in immunocompetent or immunosuppressed patients[1,15]. The cutaneous infection caused bygenerally occurs following surgery, subcutaneous injection, or acupuncture[16]. Becausehas a hydrophobic biofilm, by whichcan be resistant to disinfectants and heavy metals, and lead to nosocomial infections[17]. The lesions of the patient presented here develop at the injected point of botulinum toxin. We suspected that the infection may be caused by the non-standard aseptic operation and injection, surgery, equipment contamination,or intraoperative infection. Iatrogenic infections have become one of the common causes of fast-growing mycobacterial infection because of the unstandardized aseptic operation during injection and surgery causing an increase in opportunistic infections and great pain to patients. Therefore, when managing such cases, attention should be paid to these agents.

The skin lesions can be the initial symptoms or secondary to disseminated infections, which often present with multiple papules, herpes, nodules, erythema, or abscesses[1]. The initial symptoms of our patient presented as multiple erythema then developed to nodules and abscess. She was prescribed with multiple antibiotics but without remission of the lesions. The unspecific infection caused by fungus,, or NTM was suspected. Finally, the patient was diagnosed as having subcutaneous infection caused by. The golden standard for diagnosing NTM infections is histopathology and mycobacteria culture. Acid-fast staining is the most convenient and common laboratory test, while PCR sequencing and DNA chip technology have emerged as fast and accurate methods in identifying NTM[15]. However, the acid-fast staining of nodule of this patient was negative and did not yield any culture on MRM. Fortunately, the puncture fluid of abscess was positive for acid-fast staining andwas yielded and identified by PCR sequencing. Therefore, once NTM infection is clinically suspected, multiple specimens should be tested by histopathology, culture, and molecular biology identification. The successful diagnosis of this patient depended on the awareness of mycobacterial infections and attitude of insistence.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

CONCLUSlON

NTM infection should be aware in patients with refractory lesions, particularly followed by cosmetic procedure. Moreover, the drug sensitivity test needs to be performed to obtain early diagnosis and appropriate treatment to avoid dissemination and deformity.

Informed consent was obtained from the patient for publication of this case report.

FOOTNOTES

Yu XH and Deng L were the patient’ dermatologists; Deng L collected the data; Luo YZ and Liu F contributed to manuscript drafting and literature review.

“以癌症为例，中国人非常恐癌。”周岱翰说，国际抗癌联盟曾公布的一项调查数据显示，面对癌症，中国人持消极态度的高达43%。其实，良好的心理、精神状态对治疗调养有很大作用。

The authors declare that they have no conflicts of interest to disclose.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

NTM are intracellular colonies whose high hydrophobicity on the cell surface and cell wall permeability barrier make them resistant to traditional anti-tuberculosis drugs and difficult to treat[17].is the most resistant strain of mycobacterium, and is highly resistant to traditional antituberculosis drugs; hence, it needs to be tested for drug susceptibility when yielding positive cultures.is often sensitive to clarithromycin, amikacin, and cefoxitin. However, a single drug is easy to induce drug resistance according to the guidelines of the American Thoracic Society and the American Society of Infectious Diseases, therefore the combination of two kinds of sensitive drugs is recommended for treatment until the lesions are completely healed[18]. Meanwhile, drug susceptibility testing needs to be performed once culture of NTM is yielded to ensure the effective treatment.

目前，市场上周氏啮小蜂蛹售价一般为5.5元/个，考虑到释放45～120枚/hm2的寄生率及防治效果差异不大，如果为节省成本，一般可采用60枚孕蜂蛹/hm2的释放量。

近年来,人们对于健康的认识也越来越深,在此背景下,护理工作的重要性已经被人们所广泛认知和接受。经过多年的发展,传统的单一护理工作已经逐渐演变成为如今以人为本的新型人性化护理,其给医院的护理工作增添了新的含义,同时也给处在病症中的患者带来了强烈的人文关怀。本文的研究结果显示,对妇产科患者采用人性化护理可以改善心理状况。此外,由于人性化护理能够及时解答患者家属的疑问,讲解相关的健康知识,安抚他们的情绪,并及时通过交流了解患者的心理活动,因而也得到了家属的强烈支持与赞同能够有效提升患者抗击病痛的信心和毅力,同时也可以提高患者对医护人员的信任,从而更好地提升护理效果。

China

Lin Deng 0000-0001-9574-4632; Ying-Zhi Luo 0000-0002-9662-2562; Fang Liu 0000-0001-6961-0219; Xiao-Hong Yu 0000-0001-8932-499X.

Xing YX

(2)语言神态描写：①他对人说话，总是满口之乎者也，教人半懂不懂的。说明他以读书人自居，卖弄学问。迂腐可笑的性格。②孔乙己睁大眼睛说，“你怎么这样凭空污人清白……”说明他死要面子，怕人嘲笑。③孔乙己便涨红了脸，额上的青筋条条绽出，争辩道，“窃书不能算偷……窃书!……读书人的事，能算偷么？”说明他自命清高、迂腐不堪、自欺欺人，死要面子的性格。④孔乙己看着问他的人，显出不屑置辩的神气。说明孔乙己自命清高。⑤“孔乙己立刻显出颓唐不安模样。脸亡笼上了一层灰色，嘴里说些话；这回可是全是之乎者也之类，一些不懂了。说明孔乙己深受封建科举制度毒害，至死不悟。

Wang TQ

Xing YX