Li, JHC

Tang, WM

Woo, PCY

Yuen, KY

New England Journal of Medicine

Patrick C.Y. Woo

Jimmy H.C. Li

Wai-man Tang

Kwok-yung Yuen

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Acupuncture Mycobacteriosis

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Title Acupuncture mycobacteriosis [6]Author(s) Woo, PCY; Li, JHC; Tang, WM; Yuen, KYCitation New England Journal Of Medicine, 2001, v. 345 n. 11, p. 842-843Issued Date 2001URL http://hdl.handle.net/10722/43132Rights New England Journal of Medicine. Copyright © MassachusettsMedical Society.842 · N Engl J Med, Vol. 345, No. 11 · September 13, 2001 · www.nejm.orgThe New England Journal  of  Medicinesition espoused in the coeditors’ letter. The idea of applyingsocial, political, and economic analysis to the understandingof medical illness is excellent, as is much of the material inthe book. However, the use of expressions such as “socialconstruction of illness” implies something more: that so-ciety creates illness as such, rather than modifies the mean-ing and impact of biologic events.Regarding the relative roles of treatment and prevention,the coeditors state in the book, “Indeed, taken together,the chapters make clear the need for fundamental socialchange. Such change would include reframing how scien-tific research is conducted, making prevention rather thancure the goal of both research and clinical practice.” I agree,as I state in my review, that prevention is always preferable,whenever possible. The benefits of primary prevention canbe enormous, but detecting them always requires a theoret-ical inference — the identification of a decrease in the in-cidence of new cases in the population — rather than a moreobvious and immediately rewarding scenario, the cure of anidentified patient of a specific disease and its consequences.This necessary abstraction — the detection of the absenceof a disease rather than the treatment of it — is one imped-iment to the implementation of prevention programs inmedicine.I welcome the coeditors’ current emphasis on the rela-tions among social and biomedical analysis, prevention, andtreatment. Such broad mobilization of all available resourc-es in collaboration rather than in competition is the surestpath toward our common goal of eliminating the sufferingcaused by breast cancer.DAVID SPIEGEL, M.D.Stanford University School of MedicineStanford, CA 94305-5718dspiegel@leland.stanford.eduAcupuncture MycobacteriosisTo the Editor: A 79-year-old woman presented with in-duration of the right leg three months after undergoingacupuncture for osteoarthritis of the knees. The indurationwas centered around the acupuncture point that lies alongthe gallbladder meridian (site GB 38, or Yangfu) (Fig. 1A).Radiographs of the right leg showed focal dystrophic calci-fication below this point. The underlying fibula was intactexcept for periosteal bone formation along the lower half(Fig. 1B and 1C). The findings were consistent with the pres-ence of a chronic soft-tissue infection that extended alongthe muscle compartments over the fibula. There were noother signs of trauma or foci of infection, and the findingson chest radiography were normal. Histologic studies of thebiopsy specimen showed suppurative granulomatous inflam-mation with microabscesses, caseous necrosis, and acid-fastbacilli. The isolate was identified as Mycobacterium chelonae.The infection responded to three weeks of treatment withimipenem, 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 nee-dle 4 in. above the lateral malleolus, at the anterior marginof the fibula (the point at which the induration developed),which overlay the focus of dystrophic calcification. The nee-dle had to penetrate the skin, subcutaneous tissue, extensordigitorum longus and extensor hallucis longus muscles, andinterosseous membrane, to a depth of 7.5 to 12.5 mm (0.3to 0.5 in.).1 This depth is similar to the depth of the chronicinfectious process, as suggested by the finding of periostealbone formation.There was a long delay in establishing the diagnosis ofacupuncture mycobacteriosis. The patient delayed seekingmedical advice because the symptoms were relatively mildand indolent. Furthermore, she failed to associate the acu-puncture procedure with the clinical illness because the in-fection had a relatively long incubation period.2-4 The at-tending clinicians also did not recognize the source of themycobacteriosis. The diagnosis was made by the infectious-disease consultant, after the patient recalled having un-dergone acupuncture when she was asked whether a sharpFigure 1. Site of Acupuncture along the Gallbladder Meridian(Panel A) and Anteroposterior Radiographs of the Patient’s RightLeg (Panels B and C).The acupuncture site is referred to as GB 38, or Yangfu (Panel A).The radiographs (Panels B and C) show osteoarthritis of the rightknee joint, focal dystrophic calcification (DC) in soft tissues deepto GB 38 (denoted by the asterisk), and a periosteal reaction (ar-rowheads) in the underlying fibula.A BCGB 38Copyright © 2001 Massachusetts Medical Society. All rights reserved. Downloaded from www.nejm.org at UNIVERSITY OF HONG KONG on January 24, 2007 . CORRESPONDENCEN Engl J Med, Vol. 345, No. 11 · September 13, 2001 · www.nejm.org · 843object had penetrated the involved site in the precedingmonths.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 KongHong Kong, Chinahkumicro@hkucc.hku.hk1. Chen E. Cross-sectional anatomy of acupoints. London: Churchill Liv-ingstone, 1995.2. Safranek TJ, Jarvis WR, Carson LA, et al. Mycobacterium chelonae wound infections after plastic surgery employing contaminated gentian vi-olet skin-marking solution. N Engl J Med 1987;317:197-201.3. Camargo D, Saad C, Ruiz F, et al. Iatrogenic outbreak of M. chelonae skin abscesses. Epidemiol Infect 1996;117:113-9.4. Clegg HW, Foster MT, Sanders WE Jr, Baine WB. Infection due to or-ganisms of the Mycobacterium fortuitum complex after augmentation mam-maplasty: clinical and epidemiologic features. J Infect Dis 1983;147:427-33.Correspondence Copyright © 2001 Massachusetts Medical Society.Copyright © 2001 Massachusetts Medical Society. All rights reserved. Downloaded from www.nejm.org at UNIVERSITY OF HONG KONG on January 24, 2007 . 

Acupuncture mycobacteriosis

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Acupuncture mycobacteriosis [6]

Acupuncture mycobacteriosis [6]

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