What happened, in summary

A 40-year-old woman was diagnosed with invasive ductal carcinoma of the right breast in April 2015. She received neoadjuvant chemotherapy, followed by right mastectomy with sentinel lymph node biopsy, tissue-expander placement, and radiation therapy. On 29 December 2015, she underwent prophylactic left mastectomy, bilateral DIEP-flap reconstruction, autologous fat transfer, and removal of the tissue expander.

About one month later, purulent drainage developed from the reconstruction site. Wounds along both breasts and the abdominal donor site failed to heal, and cultures grew the uncommon organism Mycobacterium mageritense. Courses of cephalexin and clindamycin did not help. Ciprofloxacin and doxycycline were started, but doxycycline caused nausea. Imipenem-cilastatin was added, yet drainage and new nodules continued. CT showed numerous fluid-filled nodules across both breasts, the abdomen, and the right flank.

Plastic surgeons performed wide debridement, finding connected abscesses throughout the abdominal and breast tissues. Wound-vacuum dressings were used before closure. Amikacin was added, and antibiotic substitutions were needed during a medication shortage. She then developed DRESS with fever, rash, low platelets, and liver injury, requiring all antibiotics to be stopped and carefully reintroduced. Ciprofloxacin was later withdrawn because of suspected tendinopathy, and tedizolid was added.

After debridement and the revised regimen, the wounds healed and CT showed resolution of the nodular infection. She completed an 11-month antibiotic course, including 24 weeks of imipenem-cilastatin, 10 weeks of amikacin, and 20 weeks of tedizolid. The infection had not recurred after three years of follow-up.