Correspondence

Acupuncture Mycobacteriosis

N Engl J Med 2001; 345:842-843September 13, 2001

Article

To the Editor:

A 79-year-old woman presented with induration of the right leg three months after undergoing acupuncture for osteoarthritis of the knees. The induration was centered around the acupuncture point that lies along the gallbladder meridian (site GB 38, or Yangfu) (Figure 1AFigure 1Site of Acupuncture along the Gallbladder Meridian (Panel A) and Anteroposterior Radiographs of the Patient's Right Leg (Panels B and C).). Radiographs of the right leg showed focal dystrophic calcification below this point. The underlying fibula was intact except for periosteal bone formation along the lower half (Figure 1B and Figure 1C). The findings were consistent with the presence of a chronic soft-tissue infection that extended along the muscle compartments over the fibula. There were no other signs of trauma or foci of infection, and the findings on chest radiography were normal. Histologic studies of the biopsy specimen showed suppurative granulomatous inflammation with microabscesses, caseous necrosis, and acid-fast bacilli. The isolate was identified as Mycobacterium chelonae. The infection responded to three weeks of treatment with imipenem, clarithromycin, and amikacin, followed by a six-month regimen of clarithromycin and minocycline.

This woman had acupuncture-induced mycobacteriosis. The acupuncture procedure required insertion of the needle 4 in. above the lateral malleolus, at the anterior margin of the fibula (the point at which the induration developed), which overlay the focus of dystrophic calcification. The needle had to penetrate the skin, subcutaneous tissue, extensor digitorum longus and extensor hallucis longus muscles, and interosseous membrane, to a depth of 7.5 to 12.5 mm (0.3 to 0.5 in.).1 This depth is similar to the depth of the chronic infectious process, as suggested by the finding of periosteal bone formation.

There was a long delay in establishing the diagnosis of acupuncture mycobacteriosis. The patient delayed seeking medical advice because the symptoms were relatively mild and indolent. Furthermore, she failed to associate the acupuncture procedure with the clinical illness because the infection had a relatively long incubation period.2-4 The attending clinicians also did not recognize the source of the mycobacteriosis. The diagnosis was made by the infectious-disease consultant, after the patient recalled having undergone acupuncture when she was asked whether a sharp object had penetrated the involved site in the preceding months.

Patrick C.Y. Woo, M.B., B.S.
Jimmy H.C. Li, M.B., B.S.
Wai-man Tang, M.B., B.S.
Kwok-yung Yuen, M.D.
University of Hong Kong, Hong Kong, China
hkumicro@hkucc.hku.hk

4 References

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   Camargo D, Saad C, Ruiz F, et al. Iatrogenic outbreak of M. chelonae skin abscesses. Epidemiol Infect 1996;117:113-119
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   Clegg HW, Foster MT, Sanders WE Jr, Baine WB. Infection due to organisms of the Mycobacterium fortuitum complex after augmentation mammaplasty: clinical and epidemiologic features. J Infect Dis 1983;147:427-433
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