Question

Read this furunculosis article then answer questions:

From

The New England Journal of Medicine

May 2, 2002 (Volume 346, Number 18)

An Outbreak of Mycobacterial Furunculosis Associated With Footbaths at a Nail Salon

Winthrop KL, Abrams M, Yakrus M, et al.
The New England Journal of Medicine. 2002;346(18):1366-1371

There is no arguing that over the past few years in the United States, people have increasingly been using the services of pedicurists and nail salons. As with any social trend, there was bound to be a downside, and as often happens, it showed up first in California. The investigators, public health authorities from the CDC and the California Department of Human Services, describe a large outbreak of leg abscesses from contaminated whirlpool footbaths at a single salon. This epidemic is a warning to clinicians to inquire about cosmetic practices in the evaluation of patients with cutaneous infections.

The epidemic came to light when an alert physician noted her fourth case of enigmatic lower-extremity furunculosis in 6 months. Interestingly, it took a female physician to first recognize the problem and report it to the health department. Through various active and passive methods, the investigators identified 110 patients who met their case definition of leg infection lasting more than 2 weeks after a salon visit between April and October 2000. The team also compiled clinical and microbiological data on these cases after encouraging physicians to perform punch biopsy cultures for acid-fast bacilli. The epidemiologists compared the first 48 of these patients to 56 uninfected control patients who also had similar nail services at the salon during the period in question. Finally, the investigators performed environmental cultures of salon equipment and subjected isolates to molecular identification.

All but 1 patient was female, with median age of 36 years. A total of 34 patients (31%) had isolates of rapidly growing mycobacteria from skin biopsies. Of these, 32 were M fortuitum and 2 were not identified. Fourteen of these 32 isolates were sent for pulse-field gel electrophoresis and shown to be identical. All 6 footbath drain screens also had isolates of M fortuitum, and 3 were identical to the 14 human isolates. Most patients had more than 1 boil, were treated with a multiplicity of antibiotics for many weeks to months, and were left with disfiguring scars. Leg shaving (OR = 4.8, 95% CI = 2.1-11.1) appeared to be the only factor separating cases from controls. (an OR (odds ratio) >1 at the 95% confidence level shows a very strong correlation)

Since M fortuitum is a normal constituent of tap water, it is not surprising that it was found in the pedicure whirlpool baths. The particular strain in this outbreak probably was more pathogenic than usual, exhibiting impressive virulence in these immunologically normal women. Shaving prior to the bath probably increased the risk of establishing infection due to microtrauma, and failure to adequately clean debris from bath equipment facilitated high titers of bacilli. Clinicians are encouraged to be alert for similar infections with Pseudomonas and other mycobacteria.

In response to the outbreak, the CDC posted the following:

Our findings document the ubiquitous presence of potentially pathogenic mycobacteria among footspas of nail salons in California. The 2000 outbreak might have been a warning of what can happen again if this emerging infection is not adequately addressed. In 2004, a case report documented 2 cases of M. mageritense furunculosis associated with using footbaths at a nail salon in Georgia (14).

The California Board of Barbering and Cosmetology adopted new regulations in May 2001 requiring nail salons to follow specific cleaning and disinfection procedures to ensure that their footspa equipment is properly cleaned and maintained. Since our survey was conducted before these new regulations were implemented, further monitoring and research are needed to determine whether complying with the regulations will decrease the potential risk for mycobacterial cutaneous infections among pedicure customers.

Two stories from 205 students about M. fortuitum infections:

(sp08): A student of mine went to a salon in Phoenix for her birthday and had shaved her legs right before a pedicure. She obtained a lesion – the first doctor did not want to do a biopsy or anything – and she was put on antibiotics for a Gram -/ Gram+ infection. The antibiotics did not work. In the meantime she found out she was pregnant. Since her lesion was not resolving she went to another more helpful physician, a biopsy was done and Mycobacterium fortuitum was indicated. She was told she needed to take antibiotics for 6 months. She said no way while she was pregnant. Her lesion eventually resolved on its own but she said it took over a year and she has a nice scar.

(sp15): Cousin of my student bought his wife a spa package for her 50^th bday – 3^rd of January (farm on Bismark, never had a pedicure). She had to use the coupon and it was getting close to the expiration date but she could not spend an entire day doing the following, she had to come in a couple of different times close together.

Dermabrasion on face

Pedi/mani

Full body mud/seaweed wrap

She ended up with a boil on her face and it wouldn’t heal, it kept getting worse. The doctor figured she got it from the farm via dermabrasion. That is, the bacterium is in the environment, probably on her skin. Her primary recommended a dermatologist who was flippant and gives her abx for gram +/-. 7weeks later sends pic to my student – looks like furuncle and not getting better. Student suggests get a second opinion based on this case study, telling her it could be Mycobacterium

2^nd opinion – female dermatologist. Had a biopsy (bx) done, came back as M. fortuitum; progressed into a secondary staph – MRSA sepsis, had to get IV vancomycin. Still resolving after several months.

Question:

1. Write a case definition using the info in the article.

2. What was the portal of entry for this bacterium?

3. What were two reasons investigators believed helped the organism establish infections and caused an outbreak?

4. In both stories the students received antibiotics. Why didn’t the antibiotics cure their infections?

Answer 1

1. The case is about the Mycobacterium infection on salon customers. The scientist identified a large outbreak of rapidly growing mycobacterial infections among persons who had had footbaths and pedicures at one nail salon. Physicians should suspect this cause in patients with persistent furunculosis after exposure to whirlpool footbaths.

2. Mycobacterium fortuitum can be found in natural and processed water, sewage, and dirt. Healthy people usually do not get Mycobacterium fortuitum infections. in the salon, they might use sewage and dirty water. it easily affects the immune suppressed people.

3. The first reason is the epidemic disease came to light when an alert physician noted her fourth case of enigmatic lower-extremity furunculosis in 6 months. Interestingly, it took a female physician to first recognize the problem and report it to the health department.

The second reason is through various active and passive methods, the investigators identified 110 patients who met their case definition of leg infection lasting more than 2 weeks after a salon visit between April and October 2000. The team also compiled clinical and microbiological data on these cases after encouraging physicians to perform punch biopsy cultures for acid-fast bacilli. The epidemiologists compared the first 48 of these patients to 56 uninfected control patients who also had similar nail services at the salon during the period in question.

4. The two students had biopsy and found they are infected with MRSA. MRSA, (methicillin-resistant staphylococcus aureus), is a form of contagious bacterial infection that is resistant to numerous antibiotics including methicillin, amoxicillin, penicillin, and oxacillin. This resistance makes it challenging to treat.