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					LETTERS


 6. Masaki T, Ohkusu K, Hata H, Fujiwara            postsurgical wound infections caused                 scopic examination of specimens from
    N, Iihara H, Yamada-Noda M, et al. My-          by rapidly growing mycobacteria (2),                 days 21 and 27 yielded no bacteria in
    cobacterium kumamotonense sp. nov. re-
    covered from clinical specimen and the          particularly after breast surgery (with              Gram- and Ziehl-Nielsen–stained pus
    first isolation report of Mycobacterium          or without prosthetic implants) (3). M.              specimens, and standard bacteriologic
    arupense in Japan: novel slowly growing,        conceptionense, an emerging member                   cultures remained sterile. M. concep-
    nonchromogenic clinical isolates related        of the M. fortuitum complex, was ini-                tionense, identified by partial rpoB
    to Mycobacterium terrae complex. Micro-
    biol Immunol. 2006;50:889–97.                   tially described in a case of osteomy-               gene sequencing (100% identity with
 7. Telenti A, Marchesi F, Balz M, Bally F,         elitis that occurred after an open frac-             GenBank accession no. AY859695.1)
    Böttger EC, Bodmer T. Rapid identifica-          ture of the tibia (4). We report a case              (4), grew in both specimens after 8
    tion of mycobacteria to the species level       of M. conceptionense infection that                  days of incubation at 37°C under a 5%
    by polymerase chain reaction and restric-
    tion enzyme analysis. J Clin Microbiol.         occurred after breast surgery.                       CO2 atmosphere in Coletsos medium
    1993;31:175–8.                                        A woman 58 years of age had a                  (bioMérieux, La Balme-les-Grottes,
                                                    left mastectomy with lymph node dis-                 France). By the Etest method (4), both
Address for correspondence: M. Carmen               section and chemotherapy for breast                  isolates were susceptible to several an-
Menéndez, Department of Preventive Medicine,        carcinoma in March 2004. Three years                 timicrobial drugs, including clarithro-
Public Health and Microbiology, School of           later, she underwent breast reconstruc-              mycin, amikacin, ciprofloxacin, and
Medicine, Autonoma University of Madrid, St/        tion that used a cutaneomuscular                     doxycycline. The patient was treated
Arzobispo Morcillo s/n 28029, Madrid, Spain;        latissimus dorsi flap with a prosthetic               with ciprofloxacin, azythromycin, and
email: carmen.menendez@uam.es                       implant. Immediately after surgery, a                amikacin for 3 weeks, followed by
                                                    fever (39°C) developed, but 3 blood                  ciprofloxacin and azythromycin for 4
                                                    cultures remained sterile. No treat-                 weeks.
                                                    ment was administered, and she be-                         At patient’s relapse 3 months
                                                    came afebrile within 3 days.                         later, M. conceptionense exhibiting
                                                          At day 15 after surgery, a serous              identical antimicrobial drug suscepti-
                                                    discharge appeared in the tip of the                 bility pattern was again isolated from
      Mycobacterium                                 skin flap. By day 21, the patient was
                                                    again febrile, and the wound discharge
                                                                                                         the wound fluid. The patient was then
                                                                                                         treated with ciprofloxacin, azythro-
      conceptionense                                was swabbed for analysis. On day 27,                 mycin, and doxycycline for 6 months;
       Infection after                              she underwent surgical revision with                 subsequently, doxycycline alone was
      Breast Implant                                ablation of the breast implant, drain-
                                                    age, and sample collection. The leuko-
                                                                                                         given for a total of 18 months. Results
                                                                                                         from the 2-month follow-up examina-
      Surgery, France                               cyte count was normal. However, the                  tion were unremarkable.
                                                    C-reactive protein level was 99 mg/L,                      M. conceptionense was unambig-
     To the Editor: Mycobacterium                   and the erythrocyte sedimentation rate               uously identified by partial rpoB gene
fortuitum complex members are rap-                  was 111 mm (first hour). Treatment                    sequencing, a first-line tool for accurate
idly growing mycobacteria found in                  with intravenous amoxicillin/clavu-                  identification of nontuberculous myco-
water and soil (1). These opportunistic             lanic acid was started. Although the                 bacteria (5). A pathogenic role for M.
pathogens are responsible for posttrau-             biologic parameters normalized, the                  conceptionense was supported by 1)
matic skin and soft tissue infections.              serous discharge continued. Micro-                   its repetitive isolation from the wound;
They also account for 60%–80% of
 Table. Three cases of Mycobacterium conceptionense infection in female patients*
 Patient                                                                                           Treatment
 age, y          Clinical situation                 Identification                           Nature                        Duration, mo      Reference
 31            Posttraumatic osteitis        16S rRNA, soda, hsp65,             Antimicrobial drug therapy: AMC                  3              (4)
                                                     recA, rpoB†
 43           Subcutaneous abscess          partial 1,464-bp 16S rRNA            Surgery and antimicrobial drug                   5              (10)
                 without trauma                         gene‡                therapy: COT and CLA; then DOX and
                                                                                    CLA; then LIN and CLA
 58           Breast implant infection                 rpoB§                     Surgery and antimicrobial drug                  18          This report
                                                                             therapy: CIP and AZY; then CIP, AZY,
                                                                                      and DOX; then DOX
 *AMC, amoxicillin/clavulanic acid; COT, cotrimoxazole; CLA, clarithromycin; DOX, doxycycline; LIN, linezolid; CIP, ciprofloxacin, AZY, azythromycin. The
 outcome for all 3 patients was favorable.
 †GenBank accession nos.: 16S rRNA, AY859684; rpoB, AY859695; hsp65, AY859678; sodA, AY859708; recA, AY859690.
 ‡GenBank accession no. AM884289.1.
 §GenBank accession no. AY859695.1.


1180                              Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 7, July 2010
                                                                                                                                  LETTERS


2) the absence of any other pathogen;                 Sandrine Thibeaut,                         Address for correspondence: Michel Drancourt,
and 3) wound healing during appropri-                  Pierre-Yves Levy,                         Unité des Rickettsies, Faculté de Médecine,
ate, long-term antimicrobial drug treat-             Marie-Laure Pelletier,                      Université de la Méditerranée, 27 Blvd Jean
ment. However, the source of infection               and Michel Drancourt                        Moulin, 13385 Marseille CEDEX 5, France;
remained unknown. The patient had            Author affiliations: Université de la Méditer-       email: michel.drancourt@univmed.fr
a tattoo on the skin flap used for the        ranée, Marseille, France (S. Thibeaut, P.-Y.
breast reconstruction, and ink has been      Levy, M. Drancourt); and Clinique la Casa-
shown to be a source for rapidly grow-       mance, Aubagne, France (P.-Y. Levy, M.-L.
ing mycobacteria other than M. con-          Pelletier)
ceptionense (6). However, the tattoo
                                             DOI: 10.3201/eid1607.090771
was 5 years old and clinically safe.
      Recent reports have identified 12
                                                                                                   Rapid Diagnostic
                                             References
M. conceptionense isolates from wa-
ter collected in a cooling tower (7)
and 9 isolates from various freshwater
                                              1.   Primm TP, Lucero CA, Falkinham JO III.
                                                   Health impacts of environmental myco-          Tests and Severity
fish species (8). The type strain of M.             bacteria. Clin Microbiol Rev. 2004;17:98–         of Illness in
                                                   106.
conceptionense had been isolated af-          2.   Brown-Elliott BA, Wallace RJ Jr. Clini-        Pandemic (H1N1)
ter prolonged exposure of the patient
to fresh water (4). These observations
                                                   cal and taxonomic status of pathogenic
                                                   non-pigmented or late-pigmented rap-             2009, Taiwan
suggest that water is a potential source           idly growing Mycobacteria. Clin Micro-
                                                   biol Rev. 2002;15:716–46. DOI: 10.1128/             To the Editor: The recent pan-
for M. conceptionense. In this patient,            CMR.15.4.716-746.2002                         demic (H1N1) 2009 (1) demonstrates
use of contaminated aqueous solutions         3.   Vinh DC, Rendina A, Turner R, Embil JM.       the need for more sensitive rapid di-
or inadequately rinsed surgical equip-             Breast implant infection with Mycobacte-
                                                                                                 agnostic tests (RDTs) to distinguish
ment (9) was unlikely the source of in-            rium fortuitum group: report of case and
                                                   review. J Infect. 2006;52:e63–7. DOI:         between influenza and other respira-
fection because further investigations             10.1016/j.jinf.2005.07.004                    tory viruses, enhance influenza sur-
indicated proper use of sterilized, non-      4.   Adékambi T, Stein A, Carjaval J, Raoult D,    veillance, and institute early antiviral
reusable surgical equipment. At home,              Drancourt M. Description of Mycobacte-
                                                                                                 therapy for patients who are severely
the patient used well water, but results           rium conceptionense sp. nov., a Mycobac-
                                                   terium fortuitum group organism isolated      ill or at high risk (2). In anticipation of
of tests used to detect M. conception-             from a posttraumatic osteitis inflamma-        the global spread of pandemic (H1N1)
ense by culture and the presence of                tion. J Clin Microbiol. 2006;44:1268–73.      2009, on August 15, 2009, the gov-
the rpoB gene in well water remained               DOI: 10.1128/JCM.44.4.1268-1273.2006
                                                                                                 ernment of Taiwan began perform-
negative.                                     5.   Adékambi T, Drancourt M, Raoult D. The
                                                   rpoB gene as a tool for clinical microbiol-   ing RDTs at clinics and hospitals for
      Because M. conceptionense is an              ogists. Trends Microbiol. 2009;17:37–45.      patients with influenza-like illness.
emerging pathogen with only 2 re-                  DOI: 10.1016/j.tim.2008.09.008                This initiative was based in part on the
ported cases of infection (4,10), the         6.   Preda VA, Maley M, Sullivan JR. Myco-
                                                                                                 notion that patients with higher viral
optimal treatment is unknown (Table).              bacterium chelonae infection in a tattoo
                                                   site. Med J Aust. 2009;190:278–9.             loads would be more likely to have a
Current recommendations for breast            7.   Pagnier I, Merchat M, Raoult D, La Scola      positive RDT result and more severe
implant infection from M. fortuitum                B. Emerging Mycobacteria spp. in cooling      disease. We report that RDTs may
include 6 months of appropriate anti-              towers. Emerg Infect Dis. 2009;15:121–2.
                                                                                                 have paradoxically lower sensitiv-
microbial drug treatment in addition to       8.   Pourahmad F, Thompson KD, Taggart JB,
                                                   Adams A, Richards RH. Evaluation of the       ity for pandemic (H1N1) 2009 virus
implant removal because surgery alone              INNO-LiPA mycobacteria v2 assay for           for patients with respiratory failure
yields relapse within 4–6 weeks (2,3).             identification of aquatic mycobacteria. J      requiring mechanical ventilation, ex-
Increased worldwide use of breast im-              Fish Dis. 2008;31:931–40. DOI: 10.1111/
                                                                                                 tracorporeal membrane oxygenation
plants is likely to increase the number            j.1365-2761.2008.00968.x
                                              9.   Phillips MS, von Reyn CF. Nosocomial          (ECMO) or both than for those with-
of M. conceptionense infections and                infections due to non tuberculous myco-       out respiratory failure.
will raise questions about the optimal             bacteria. Clin Infect Dis. 2001;33:1363–            National Taiwan University Hos-
management of these infections.                    74. DOI: 10.1086/323126
                                                                                                 pital is a 2,200-bed teaching hospi-
                                             10.   Liao CH, Lai CC, Huang YT, Chou CH,
                                                   Hsu HL, Hseuh PR. Subcutaneous abscess        tal in Taiwan. This hospital provides
    This work was supported by Unité de            caused by Mycobacterium conception-           primary and tertiary care and ECMO.
                                                   ense in an immunocompetent patient. J         All patients admitted with presumed
Recherche sur les Maladies Infectieuses et
                                                   Infect. 2009;58:308–9. DOI: 10.1016/j.
Tropicales Emergentes UMR CNRS 6236                jinf.2009.02.012
                                                                                                 severe influenza were immediately
IRD 198.                                                                                         treated with oseltamivir during the
                                                                                                 2009 pandemic. From July 25 through

                             Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 7, July 2010                                 1181

				
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