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Infection with emerging atypical pathogen leaves scarring after resurfacing

Dr. Al Dabagh
Washington — An isolated case of a patient who developed infection with Mycobacterium massiliense after undergoing CO2 fractional laser resurfacing should remind dermatologists to consider atypical pathogens in patients with a skin infection that does not respond to standard antibiotics, say Bishr Al Dabagh, M.D., and Claude Burton III, M.D.

In a poster presented at the 2011 meeting of the American Society for Dermatologic Surgery, Dr. Al Dabagh, dermatology resident, and Dr. Burton, professor of dermatology, Duke University Medical Center, Durham, N.C., reported on a 53-year-old woman admitted to the hospital with painful, erythematous, eroded papules and pustules involving the chest, neck and face. Her history included nonablative radiofrequency treatment for rejuvenation of the face and neck, followed two weeks later by CO2 fractional laser resurfacing of the face, neck and chest.

She had received antiviral prophylaxis pre- and post-resurfacing and reported the appearance of itchy pustules around her eyes and upper lip four days after the procedure. She was started on trimethoprim-sulfamethoxazole and showed a partial response, but she had to discontinue the antibiotic because of intolerability. Her eruption then worsened.

Treatment with a topical corticosteroid and oral fluconazole, acyclovir and doxycycline was started, but the patient was admitted to the hospital due to lack of response. Skin biopsies were taken and histopathology showed suppurative granulomatous inflammation and acid-fast bacilli. Eventually, M. massiliense was identified based on speciation from tissue culture.

Based on the initial histopathology, therapy was changed empirically to azithromycin, moxifloxacin and tigecycline, and it was maintained for five months with azithromycin only after the antimicrobial susceptibility test results were received. The infection resolved, but the patient had residual scarring of the neck and chest. She is being treated with pulsed dye laser.

M. massiliense facts

"M. massiliense was first validated as a species in 2006 and has become recognized as an emerging pathogen based on several reports in the literature describing outbreaks and individual cases of skin/soft tissue and other infections caused by this atypical microorganism," Dr. Al Dabagh says. "Overall, atypical mycobacterial infections are rare. However, based on personal communication with dermatologists and other physicians, they are frequent enough to be recognized as a real concern.

"The experience with this patient underscores the importance of maintaining an index of suspicion for atypical mycobacteria in a patient with a skin infection that does not respond to an initial course of therapy with standard antibiotics, regardless of immune status. In this case, threshold for biopsy should be low," he adds. "It also highlights the need for beginning empiric therapy with multiple antimicrobial agents and for prolonged therapy to clear the infection. In addition, we feel it is important that the risk of atypical mycobacterial infections and the possibility of residual scarring be mentioned in the informed consent for patients undergoing cosmetic or medical dermatologic surgery procedures."

Dr. Al Dabagh says that scarring as a result of the ongoing host inflammatory response can occur even with more timely initiation of effective therapy.

Based on a literature review, Drs. Al Dabagh and Burton believe this is the first case of M. massiliense infection after laser resurfacing reported in the U.S. The source of the pathogen in this patient was not determined, but Dr. Al Dabagh says M. massiliense and related species are ubiquitous in the environment. Water is a particular reservoir. Infection may occur during or post-procedure from an exposure.

In other reported cases and series, infection with M. massiliense and related organisms has been traced to contaminated medications, surgical instruments, footbaths, spa beds, tattoo dyes and ink in surgical marking pens.

"It is important to recognize that M. massiliense is very resistant to some chemical disinfectants that are used for surgical instrument sterilization, including glutaraldehyde and quaternary ammonium compounds, possibly because of the organism's enhanced ability to form a biofilm," Dr. Al Dabagh says.

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