Cutaneous Atypical Mycobacteriosis After Ultrasound Hydrolipoclasia Treatment

Abstract

Ultrasound hydrolipoclasia is a form of mesotherapy in which physiological solution is injected subdermally before ultrasound application; it is an off-label treatment for localized fatty areas. A 28-year-old white woman presented with painful erythematous-secreting nodules in her abdomen for 1 week. The nodules were located where a non-physician performing another service had applied an ultrasound hydrolipoclasia treatment 1 month before (Figure 1). She reported that four other women who had received this sort of intervention on the same day and in the same aesthetic clinic were presenting with the same symptoms. The patient did not experience systemic symptoms. Erythematous nodules and abscesses in the abdomen. The diagnostic hypothesis was atypical mycobacteriosis. A biopsy of one lesion was performed, and cultures of the smear and of the biopsy specimen were prepared. The culture of the smear isolated Mycobacterium fortuitum, and a histologic examination revealed dermal chronic inflammation with alcohol-acid-resistant bacilli present at the Ziehl-Nielsen stain. Treatment was performed with 100 mg of doxycycline twice a day for 6 months, resulting in complete remission of the erythema and secretions and involution of the lesions. Because skin palpation demonstrated remaining nodules, a topical betamethasone dipropionate ointment was prescribed during the last month of antibiotic treatment, which resulted in improvement of the skin texture. Six months after the final treatment, the lesions were atrophic, with an appearance resembling stretch marks (Figure 2A). To improve this condition, we submitted the scars to five weekly sessions of intradermotherapy with 0.5% silanol salicylate. Injections were performed beginning with 1 mL of silanol salicylate, in consecutively decreasing amounts, until filling of the scar was visually evident. (A) The lesions became atrophic scars after the end of antibiotic treatment. (B) The appearance of scars after five sessions of intradermotherapy. Some improvement can be noted. After the intradermotherapy treatment, some improvement in skin texture was noted (Figure 2B), and the patient was satisfied. Ultrasound hydrolipoclasia is an off-label procedure for treatment of localized fatty areas and cellulite that consists of injections of physiologic solution into the subdermic tissue followed by ultrasound applications.1 This procedure has little scientific documentation, and unlicensed medical personnel sometimes perform it, as was the case with our patient. Advocates of this procedure state that, because the substance being injected is a 0.9% physiologic solution, it is a safe procedure, and for this reason it is popular in Brazilian esthetic clinics, but this report indicates that this technique can cause undesirable complications and that it should not be performed until clinical testing has been conducted and conclusive evidence found. To the authors' knowledge, this is the first article to be published in an indexed journal reporting ultrasound hydrolipoclasia complications. Intradermotherapy is a treatment that is slightly different from ultrasound hydrolipoclasia. It consists of the injection of specific drugs into the upper dermis. Mycobacterial infections and distressing complications of mesotherapy are common. Some authors contend that these complications are due to aseptic measures during the sessions or contamination of the injected substances. In either case, resulting infections require extensive multi-antibiotic treatments and often lead to scarring at the affected site.2-5 Although our patient did not have mycobacterial abscesses caused by mesotherapy itself, the assumption can be made that the infection in this case study followed the same progression reported previously as intradermotherapy complications. The infection developed after an esthetic injection procedure, indicating that mycobacteria were inoculated into the subcutis. The interval between injection and development of symptoms and the clinical appearance were the same as with mesotherapy infections, which led the authors to believe that, once a mycobacteria is inoculated in the skin, the resulting infection will be similar, whether in the dermis or the subcutaneous tissues. Treatment of atrophic scars is difficult, and there are some reports about the use of fat injections, 1,064-nm neodymium-doped yttrium aluminium garnet laser and fractional photothermolysis for this condition.6-8 Our decision to treat the atrophic scars with silanol salicylate was based on previous reports about its beneficial effects on regenerating and altering the architecture of the dermis.9 In Brazil, silanol is an active ingredient in oral dermatologic supplements, topical creams, and injectable intradermotherapy drugs; recent reports demonstrate its role in improving dermal texture and increasing dermal fiber content.10-12