Relatively Alcohol-Resistant Mycobacteria Are Emerging Pathogens in Patients Receiving Acupuncture Treatment

Abstract

Acupuncture has been gaining popularity as a form of alternative medicine. In the past, only blood-borne viruses and anecdotal reports of bacterial infections have been associated with acupuncture. We report on four patients with mycobacterial infections complicating acupuncture who were encountered in a 2-year period. All had clinical and/or radiological lesions at acupuncture point-and meridian-specific locations. There was no other history of trauma or other clinical foci of infections, and the chest radiographs were normal. Histological studies of biopsy specimens of all four patients showed changes compatible with chronic inflammation, with granulomatous inflammation present in three patients and acid-fast bacilli present in two. Conventional biochemical tests and whole-cell fatty acid analysis for identification were inconclusive for all four nonpigmented mycobacteria recovered from tissue biopsies. 16S rRNA gene sequencing showed that the strains from two patients were Mycobacterium chelonae and that those from the other two were Mycobacterium nonchromogenicum. Alcohol resistance assay using the quantitative suspension test revealed that all four strains showed prolonged survival in 75% alcohol compared to other skin flora. Mycobacterial infections transmitted by acupuncture are an emerging problem. A high index of suspicion is essential to recognize this clinical syndrome, and strict implementation of proper infection control guidelines for acupuncture is mandatory.Acupuncture has been gaining popularity as a form of alternative medicine in both Asian and Western countries for chronic pain problems, digestive disorders, allergic disorders, psychosomatic problems, menstrual disorders, and drug and alcohol rehabilitation. However, in most countries, monitoring and control over the practice and its associated complications are far from adequate. Although infection control guidelines for acupuncture are available (1), the implementation, especially in developing countries where acupuncture is very popular, is far from ideal. In the past, needles used for acupuncture were usually reused and often inadequately sterilized. Such inadequate disinfection has led to the transmission of infectious diseases from patient to patient. The best-documented acupuncture-transmitted microorganisms are the blood-borne viruses, including human immunodeficiency virus, hepatitis B virus, and hepatitis C virus (13,32,44). Apart from blood-borne infections due to patient-to-patient transmission, acupuncture can also be complicated by infections caused by environmental microorganisms or the patient's own skin flora, as the most commonly used skin disinfectant in acupuncture clinics is alcohol. There have been case reports of such bacterial infections as well as abscess formation without proven microbiological causes complicating acupuncture (4,10,11,12,14,16,19,24,26,45).Mycobacteria are well known to be relatively resistant to disinfectants, and the mechanism of disinfectant resistance has been described for some mycobacteria (18)...

Outbreak of persistent cutaneous abscesses due to Mycobacterium chelonae after mesotherapy sessions, Lima, Peru

“…Similar infections have also been reported acupuncture treatment and insulin injections. 3,7 A similar outbreak was documented during the same time period in the District of Columbia, United States. Cutaneous lesions were similar to the ones described in this report and M. chelonae was also isolated from biological samples.…”

Acupuncture Transmitted Infections

“…In contrast to pyogenic bacterial infections, only eleven sporadic cases of acupunctureassociated mycobacteriosis have been reported in the English literature (Woo et al, 2001(Woo et al, , 2002Ara et al, 2003;H.J. Cho et al, 2010; W.J.…”

“…Furthermore, failure of the attending clinicians to recognize acupuncture-associated mycobacteriosis as a cause of indolent skin and soft tissue infection due to a lack of awareness of such a disease entity, as well as the assumption of "adequate" skin disinfection with alcohol and the use of disposable acupuncture needles, have also resulted in delay in diagnosis. In the four sporadic cases of mycobacterial infections associated with acupuncture reported earlier in the year 2001 and 2002, the diagnosis was made during subsequent infectious disease consultations, when the patients recalled the history of acupuncture only on direct questioning of whether the involved site has been penetrated by sharp objects in recent months (Woo et al, 2001(Woo et al, , 2002.…”

“…The reported cases of acupuncture mycobacteriosis were caused by both rapidly and slow growing mycobacteria, as recovered in biopsy specimens of the lesions, which responded to the anti-mycobacterial treatment for the corresponding mycobacteria with or without surgical excision. In the three large outbreaks, Mycobacterium abscessus was the causative microbe isolated (Ryu et al, 2005;Song et al, 2006;Tang et al, 2006;Koh et al, 2010), whereas in the sporadic cases, a wider variety of mycobacteria were recovered, including Mycobacterium chelonae, Mycobacterium nonchromogenicum, Mycobacterium abscessus, Mycobacterium avium complex and Mycobacterium haemophilum (Woo et al, 2001(Woo et al, , 2002Ara et al, 2003;H.J. Cho et al, 2010; W.J.…”

Atypical mycobacterias associated to acupuncuture: an integrative review

“…This practice has been used to treat digestive (2) , psychosomatic, menstrual, allergy, alcohol and drugs rehabilitation problems (3) . It is considered a complementary health therapy (CHT) that makes use of an invasive intervention and for this reason some concern is necessary in relation to skin antisepsis.…”