Atypical mycobacterium infection following upper eyelid Müller's muscle-conjunctival resection - case report

Periorbital non-tuberculous mycobacterium (NTM) infections are uncommon. To the best of our knowledge, NTM infection as a complication following Müller's muscle-conjunctival resection (MMCR) surgery has not been reported before. We report a case of left upper lid M. Chelonae infection following MMCR surgery. A 61-year-old lady presented with left upper lid swelling and nodular mass 4 weeks after bilateral MMCR surgery for aponeurotic ptosis. Past medical and ocular history include systemic lupus erythematosus (SLE), chronic hepatitis B infection, bilateral cataract operation done 14 years ago and right eye Fuch's dystrophy with Descemet stripping automated endothelial keratoplasty done 3 years ago. She was initially treated with topical and oral antibiotics, as well as repeated incision and curettage and intralesional steroid injection with limited improvement. Seven months post-MMCR, repeated biopsy and nodule debulking were performed. Biopsy revealed granulomatous inflammation with mycobacterial infection and PCR identified M. Chelonae. A total of 6 months course of combination systemic antibiotics were given, with good response. Limited blepharoplasty with repeat nodular excision was performed 15 months after the initial MMCR surgery, and biopsy culture and PCR were both negative. No relapse of symptoms was noted and good lid height was maintained at 30 months of follow-up. Management of periorbital NTM infections can be challenging. Clinicians should consider early diagnostic workup with mycobacterial culture and PCR in suspicious cases, followed by prompt initiation of empiric treatment with systemic macrolides. A combination of surgical excision of nodules and prolonged systemic antimicrobial treatment is needed for complete organism eradication.