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in our daily clinical work we have noted an increasing number of cosmetic surgeries performed abroad in eastern and southern europe for financial reasons , similar to american lipotourism , or liposurgery performed abroad , mostly in latin america and the caribbean . in our opinion
this cosmetic - surgery tourism will lead to an increasing number of cases of rare infections in europe , as has been observed in the united states [ 13 ] .
we report a case of a 30-year - old woman , a german of turkish origin , who was admitted to our hospital in february 2014 for recurrent infections of the abdominal wall .
three months after surgery , in january 2013 , she first noticed skin lesions near the incision lines . in the meantime , before she was admitted to our hospital , she had consulted several physicians regarding various abscesses of the left abdominal wall , but the abscesses always recurred after a short period of time .
the patient was a nonsmoking woman with a normal body mass index of 21 kg / m and without a history of any serious disease or immunosuppression .
abdominal examination revealed extensive phlegmon and several locular abscesses in the abdominal wall ( fig . 
we decided to relieve the largest abscess under local anesthesia , took a swab sample from an inner wound for microbiologic analysis , initiated antibiotic therapy with clarithromycin 500 mg twice a day and scheduled an extensive surgical debridement of the wounds with the patient under general anesthesia . before surgery we performed magnetic resonance tomography ( mrt ) to exclude any deeper infections of the abdominal wall and to estimate the extent of the infection .
the mrt revealed no infiltrations of the abdominal muscles ; the two largest abscesses measured 9    1  cm and 5    2 cm . during the inpatient treatment we performed a surgical debridement of the wound and initiated a vacuum - assisted closure ( vac ) therapy . in the following
the patient was discharged with inconspicuous wounds and in overall good health . in the meantime
antimicrobial susceptibility testing by the gradient diffusion method found the following minimum inhibitory concentrations : amikacin 1.0  g / ml , levofloxacin 0.125  g / ml , moxifloxacin 0.047  g / ml , clarithromycin 1.5 g / ml , linezolid > 256 g / ml , rifampin > 32 g / ml , tetracycline 0.064  g / ml , imipenem 4 g / ml , meropenem 3  g / ml , ampicillin > 256  g / ml and amoxicillin / clavulanic acid > 256  g / ml .
two weeks after discharge the patient again presented with abdominal wall pain and indurations of the skin ( fig . 
we reinitiated antibiotic therapy with clarithromycin 500 mg twice a day and reevaluated the surgical and medical treatment options in close cooperation with the institute of medical microbiology of the university hospital mnster .
the swab sample taken from the wound at this time again grew m.  fortuitum .
additionally , multiple flora were identified , including prevotella bergensis , actinomyces europaeus , staphylococcus epidermidis , micrococcus luteus , lactobacillus sp . and
because of the continuous progression of the disease over the last months and the proximity to the internal abdominal organs , interdisciplinary discussion led to the conclusion that the case was a potentially life - threatening illness .
it was decided that inpatient treatment with radical debridement of the infected abdominal soft tissue , in combination with targeted antimicrobial therapy according to the results of susceptibility testing , was necessary .
for antimicrobial therapy we decided to treat the patient intravenously for 14 days with amikacin ( 15 mg / kg ) and moxifloxacin 400  mg once per day , clarithromycin 500 mg twice a day and ampicillin / sulbactam 3 g every 8 hours .
after that she received oral antimicrobial therapy with moxifloxacin 400 mg once a day and clarithromycin 500 mg twice a day for 3 months .
we began the hospital treatment with this extended antibiotic therapy and radical debridement ( fig . 
1c ) , initiating vac therapy followed by several revisions with continued vac therapy to prepare the wound for skin grafting .
the patient was discharged from hospital with prescribed oral antibiotics and was regularly followed up . at the 1-year follow - up
there was no sign of reinfection , and no pathologic findings were found in the blood tests .
m.  fortuitum is a rapidly growing mycobacterium that can cause severe infections leading to unsuccessful wound healing , wound dehiscence and infection recurrence .
suspicion arises with a lack of response to conventional antibiotic regimens and if standard bacterial cultures remain negative .
m.  fortuitum is found in lakes , rivers , tap water , wastewater , and dust and dirt , and it can infect a wound when exposed to contaminated tap water . hospital - acquired disease caused by poor hygiene of sanitary facilities has previously been reported , but these infections usually present as disseminated skin lesions and soft tissue lesions , predominantly occurring in the setting of severe immunosuppression , especially in aids [ 68 ] .
it can be the cause of multiple types of infections such as sternal wound infections after cardiothoracic surgery or after breast augmentation surgery , e.g. due to contamination of the wound with contaminated tap water .
recent outbreaks have also been described in immunocompetent hosts after use of contaminated whirlpool foot baths in nail salons .
m.  fortuitum infections after liposurgery have been reported in different continents   but to our knowledge not yet in europe .
there have been reported outbreaks of mycobacterium abscessus wound infections in lipotourists from the united states who underwent abdominoplasty in the dominican republic . travelling to foreign countries , with their supposedly lower costs for cosmetic surgery , is relatively common in the united states ; these cosmetic surgeries are performed mostly in latin america and the caribbean [ 13,11 ] . in recent years
this kind of tourism seems to have recruited an increasing number of patients in europe too , which may confront physicians with uncommon disease patterns , especially physicians in private practice and those practicing in general medicine .
therefore , it is important to execute a full history of the patient and to know the significant signs of this rare infection . in particular , a negative standard bacterial culture ,
a lack of response to conventional antibiotic regimens and infection recurrence , particularly months after surgery , should set physicians ' alarm bells ringing .
we report a successful surgical and antibiotic treatment of a m.  fortuitum infection after abdominoplasty . in our case
awareness among physicians will , we hope , result in faster identification and treatment of these cases .
it is important to make patients appreciate the higher standards of hygiene and the more skilled performance of these procedures even though they are associated with higher cost .
bargain hunters should be made aware that in the end the price of their abdominoplasty may be higher than expected .
we report a case of a 30-year - old woman who experienced recurrent infections of the abdominal wall after travelling to turkey from germany to undergo abdominoplasty for aesthetic reasons . 
 the patient 's mycobacterium fortuitum infection was successfully treated by surgery and antibiotic therapy . 
 surgical tourism  in this case , lipotourism  is resulting in an increasing number of patients in europe who may present uncommon disease patterns .