A Subtle Adversary: Mycobacterium avium-intracellulare Infection of the Surgical Site Years After Bilateral Lung Transplantation.

Mycobacterium avium-intracellulare complex is a nontuberculous Mycobacterium that has been associated with a wide range of infections, including the skin and soft tissues, central nervous system, and pulmonary system. We discuss the case of a 66-year-old male with a history of coal worker's pneumoconiosis who had undergone a bilateral lung transplant eight years prior and presented with drainage from his right chest incision site. He underwent operative exploration and drainage of the wound. Cultures returned with M. avium-intracellulare complex. He was initially treated with rifabutin, ethambutol, and azithromycin for a planned 12-month course. Ethambutol was subsequently discontinued due to a suspected drug fever. At this time, he is recovering appropriately and doing well on his antibiotic course. While still a rare cause of infection within the Mycobacterium genus, it has been increasingly recognized. Recognition is important due to the antimicrobial drug-resistant characteristics of nontuberculous​​​​​​​ Mycobacterium. They have also been found to be resistant to disinfectants, making them an important source of postsurgical infection. Skin and soft tissue infections are commonly associated with direct contact with contaminated material and an open wound or secondary to disseminated disease. Susceptibility testing is a necessity to determine the appropriate treatment. Clarithromycin, amikacin, and cefoxitin have shown the best activity in in vitro studies. Prevention of contamination via control of the water supply and medical devices is an important measure. This case demonstrates that nontuberculous​​​​​​​ Mycobacterium infections may present in at-risk patients remotely following surgery and require a high level of clinical suspicion for diagnosis and treatment.