Surgical Wound Infection:

Mycobacterium
tuberculosis

A case close to the heart

Case #1

A 57-year-old Chinese woman who had

undergone Coronary Artery Bypass

Grafting (CABG) by median sternotomy

for triple-vessel disease 8 months

beforehand, presented to the hospital

Patient History

The patient has a history of:

• Hypertension

• Hyperlipidemia

• Insulin-dependent diabetes mellitus 

o Diabetic nephropathy

o Continuous ambulatory peritoneal

dialysis (CAPD)
Clinical Symptoms

6 months after surgery developed:

• purulent discharge from a nodular lesion
over the sternotomy
 
• Two 1 1.5-cm nodular lesions discharging
serosangious fluid
 
• Mild erythema over the lower half of
sternotomy wound
 
• Fever = 37'C
 
Clinical Syndrome
Conditions Patient Normal
WBC count 5900 cells/ mm3 4,300 -10,800
cells/mm3
Neutrophils 83.4% 33%

Lymphocytes 13.2% 20 – 40%

Monocytes 1% 2 – 8%

Hemoglobin level 8.3 g/dL 12 – 18 g/dL

Platelet count 155 000 cells/mm3 150000 - 450000

cells/ mm3
Erythrocyte >130 mm/h 130 mm/h
sediment rate
Diagnosis
Common causative organisms in surgical site infections:
• Staphylococcus aureus
• Enterobacteriaceae
o Escherichia coli and Enterobacter spp.

Occasional organisms:
• rapidly growing mycobacteria have caused infection of
sternum after open heart surgery
o Mycobacterium fortuitum
o Mycobacterium chelonae

Rare organisms:
• Mycobacterium tuberculosis
Laboratory Detection
• Wound Cultures
o Gram Stain
o Aerobic and anaerobic bacterial cultures

• Expectorate sputum samples

o Gram Stain
o Ziehl–Neelsen stain
o Aerobic and anaerobic bacterial cultures
o Polymerase Chain Reaction (PCR)
Laboratory Results

• Wound Cultures
o Gram Stain
 Gram Positive Cocci (Chains)

o Aerobic and anaerobic bacterial cultures

 Positive Growth on both

• Methicillin-sensitive Staphylococcus
aureus
Laboratory Results
• Expectorate sputum samples:
o Gram Stain
 Negative Growth

o Ziehl–Neelsen stain
 Acid-fast bacilli

o Aerobic and anaerobic bacterial

cultures
 Negative Growth on Both
Laboratory Results
Gram stain Acid fast Stain
•Staphylococcus aureus • Acid-fast bacilli

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08/Images/fig2grampos_cocci.jpg s/zn.jpg
Case #2

 An 80 year old female presented an epigastric mass

which

appeared in Novemeber 2007 and slowly grew over 4

weeks.

She has had two coronary artery bypass grafts

performed;

The first being in 1998 and the second in 2006.

Patient History

The patient has a history of:

• Cardiovascular and Valvular disease

• Mitral, aortic and tricupsic valve replacement

• During the second CABG, in anticipation of a

biventricular

pacemaker the patient had pacing wires installed

• She had migrated from SEA to United States in 1981

Clinical Symptoms

• Epigastric mass formation 11 months after CABG

•Subcutaneous abscess over the pacemaker site

• Inferior aspect of sternal incision wound

• No erythema

• No wound dehiscence
Laboratory Detection

CT scan revealed fluid collection extending from the

sternal cerclage wire into the peritoneum

Fluid collection was performed by a needle aspiration

which was then tested bacterial cultures
Negative for gram stain as well as routine bacterial
cultures

Debridement of Fluid cavity revealed fibrinous, purulent,

abscess surrounding the pacing wires
Laboratory Detection

• Needle aspirated fluid collection

• Gram strain
• Bacterial cultures
– Anaerobic and aerobic

• Debridement of Fluid cavity

• Aerobic and anaerobic bacterial
cultures
• Acid fast bacilli and fungal cultures
• Liquid chromotography
Lab Results

Needles aspirated fluid collection

Negative for bacteria

Debridment of Fluid Cavity

Negative for bacteria

TB was only considered when AFB

cultures grew

Mycobacterium Tuberculosis 5 weeks

after initial testing. Liquid

chromatography was performed as a

About Mycobacterium tuberculosis

Acid-fast, non-motile bacilli.

Obligate aerobes.
Non-spore forming.
Very slow growing; divides every 15-20
hours.
1.5-3 μm long
Humans = only reservoir
Virulence Factors

Factor Action

Mycolic Acid Increases resistance.

HBHA Promotes dissemination and cell binding.

ICL Mediates intracellular survival.

PGL Suppresses immune response (only

hypervirulent strains).
Epidemiology
Normal TB Symptoms

Usually pulmonary; productive prolonged cough, coughing up

blood, fever, weight loss.
Can progress to extrapulmonary forms EG miliary and
meningeal TB.

Cutaneous/wound infections are EXTREMELY RARE.

 Immune response
• Prevents fusion of phagosome with
lysosomes.
– Avoids being killed by badass
proteins.
• APCs secrete IL-12 and TNF-α.
– Recruit T cells, NK cells
– IFN-γ produced, macrophage activation
• Infection not cleared = tissue
necrosis
• Infection cleared = granuloma
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 Radiology

57 y/o Chinese woman 80 y/o pacemaker woman

Treatments

Antibiotics:
• isoniazid (IHD)
• rifampin
• pyrazinamide
• ethambutol
• streptomycin
Surgical debridement of wound.
Treatment of Case #1

• Initial treatment of Staph. aureas with cloxacillin.

• Wound debridement revealed necrosis of xyloid cartilage

• Discovery of TB waranted antituberculous chemotherapy:

o isoniazid 200 mg daily
o pyrazinamide 1 g daily
o ethambutol 1000 mg 3 times per week
o levofloxacin 500 mg 3 times per week
Treatment of Case #2

• She was initially treated daily with:

o isoniazid (INH) 300 mg
o rifampicin 450 mg
o ethambutol 800 mg

• Switched after 16 weeks to INH 900 mg and rifapentine 600

mg weekly.

• Pyrazinamide was excluded.

Sources of Infection

• In both cases patients were from TB endemic areas, but had

no history of TB infection.

• Surgery may have re-activated latent infection

• Equipment may have been contaminated

• Medical staff may have been infected (not likely)

Implications

• Pyrazinamide prophylaxis?
Outcome of Patients

1. The patient received 3 months of antituberculous

treatment and showed no evidence of relapse.
2. She responded well to treatment and has
completed 25 of 39 weeks of DOT.
Before After
References