Facial Skin and Tissue Infection After Cosmetic Procedures
A 56-year-old Asian female patient was admitted to Jeju National University Hospital with persisting edema that evolved from a small indurated nodule on the right cheek over the course of 3 months (Figure 1). The patient had received multiple AccuSculpt™ laser procedures (1444 mm Nd:YAG) for facial pigmentation removal and lipolysis, and repeated filler injections for cosmetic purposes at a local clinic since 2011. In August 2012, a subcutaneous indurated nodule approximately 1 to 2 cm in diameter developed on the right side of the face. She was injected with hyaluronidase and triamcinolone weekly for subcutaneous nodule. However, swelling at the site of erythema progressively developed. Although a local physician prescribed antibiotics with suspected facial cellulitis, the patient's condition did not improve.
(Enlarge Image)
Figure 1.
Small indurated nodules with persisting edema on the right cheek.
The patient did not have any previous surgical and medical history of tuberculosis or diabetes mellitus, but was controlled for hypertension. Physical examination indicated stable vital status. The right facial lesion was generally edematous without a definitely elevated margin in addition to a heating sensation and tenderness at the site of swelling (Figure 1). Initial laboratory findings did not indicate any abnormal results other than elevated C-reactive protein (CRP) 7.13 mg/dL and erythrocyte sedimentation rate (ESR) of 69 mm/h. Human-immunodeficiency virus was negative. Chest radiography revealed no apparent active lesions.
Facial computed tomography (CT) indicated multiple metallic foreign bodies, soft tissue infection, and fatty infiltration (Figure 2). Since the patient had a history of cosmetic procedures, and steroid injections and showed no apparent improvement of symptoms in response to β-lactam antibiotic, pus was collected for acid fast bacilli (AFB) stain, mycobacterium culture, Mycobacterium tuberculosis/NTM polymerase chain reaction (TB/NTM PCR), gram staining, and culture. The results indicated the presence of AFB positive and NTM PCR positive organisms. According to the test results, the antibiotic treatment regimen was changed to clarithromycin (500 mg every 12 h), amikacin (200 mg every 8 h), and ciprofloxacin (400 mg every 6 h), and NTM culture for pus was performed. Pain at the site of the lesion was improved, but the patient still complained of continuous pus formation. Meanwhile, M. fortuitum complex (MFC) was isolated from the NTM pus culture. The results from the antibiotic susceptibility tests are shown in Table 1. The subsequent rpoB gene sequencing identified M. wolinskyi with an accuracy of 99%.
(Enlarge Image)
Figure 2.
Facial computed tomography. A: shows swelling of soft tissue with fatty infiltration on the right side on the axial image B: scattered longitudinal tube-like shaped lesions of 0.5 to 1 cm with high density at right mandibular area on the coronal image as well as at the contralateral side.
Since metal foreign body and abscess had been confirmed by radiologic and pathologic images, incision and drainage was performed to eliminate granulation tissue, metallic foreign bodies, and thread remnants (Figures 3 and 4). At the same time, the patient was treated with oral doxycycline (100 mg every 12 h) and ciprofloxacin (750 mg every 4 h) for 5 months. Subsequently, the facial abscess and erythematous swelling were resolved with minor dermatologic sequelae.
(Enlarge Image)
Figure 3.
Postoperative images after incision and drainage.A: granulation tissue and B: Metal foreign body (F/B 1). Remnant thread of previous cosmetic procedure (F/B 2).
(Enlarge Image)
Figure 4.
Postoperative histology findings.A: Foreign body in dermis; B: Lymphocytic infiltration surrounding the foreign body; and C: Granulomatous inflammation with multinucleated giant cells (H&E stain, magnification × 100).
Case Presentation
A 56-year-old Asian female patient was admitted to Jeju National University Hospital with persisting edema that evolved from a small indurated nodule on the right cheek over the course of 3 months (Figure 1). The patient had received multiple AccuSculpt™ laser procedures (1444 mm Nd:YAG) for facial pigmentation removal and lipolysis, and repeated filler injections for cosmetic purposes at a local clinic since 2011. In August 2012, a subcutaneous indurated nodule approximately 1 to 2 cm in diameter developed on the right side of the face. She was injected with hyaluronidase and triamcinolone weekly for subcutaneous nodule. However, swelling at the site of erythema progressively developed. Although a local physician prescribed antibiotics with suspected facial cellulitis, the patient's condition did not improve.
(Enlarge Image)
Figure 1.
Small indurated nodules with persisting edema on the right cheek.
The patient did not have any previous surgical and medical history of tuberculosis or diabetes mellitus, but was controlled for hypertension. Physical examination indicated stable vital status. The right facial lesion was generally edematous without a definitely elevated margin in addition to a heating sensation and tenderness at the site of swelling (Figure 1). Initial laboratory findings did not indicate any abnormal results other than elevated C-reactive protein (CRP) 7.13 mg/dL and erythrocyte sedimentation rate (ESR) of 69 mm/h. Human-immunodeficiency virus was negative. Chest radiography revealed no apparent active lesions.
Facial computed tomography (CT) indicated multiple metallic foreign bodies, soft tissue infection, and fatty infiltration (Figure 2). Since the patient had a history of cosmetic procedures, and steroid injections and showed no apparent improvement of symptoms in response to β-lactam antibiotic, pus was collected for acid fast bacilli (AFB) stain, mycobacterium culture, Mycobacterium tuberculosis/NTM polymerase chain reaction (TB/NTM PCR), gram staining, and culture. The results indicated the presence of AFB positive and NTM PCR positive organisms. According to the test results, the antibiotic treatment regimen was changed to clarithromycin (500 mg every 12 h), amikacin (200 mg every 8 h), and ciprofloxacin (400 mg every 6 h), and NTM culture for pus was performed. Pain at the site of the lesion was improved, but the patient still complained of continuous pus formation. Meanwhile, M. fortuitum complex (MFC) was isolated from the NTM pus culture. The results from the antibiotic susceptibility tests are shown in Table 1. The subsequent rpoB gene sequencing identified M. wolinskyi with an accuracy of 99%.
(Enlarge Image)
Figure 2.
Facial computed tomography. A: shows swelling of soft tissue with fatty infiltration on the right side on the axial image B: scattered longitudinal tube-like shaped lesions of 0.5 to 1 cm with high density at right mandibular area on the coronal image as well as at the contralateral side.
Since metal foreign body and abscess had been confirmed by radiologic and pathologic images, incision and drainage was performed to eliminate granulation tissue, metallic foreign bodies, and thread remnants (Figures 3 and 4). At the same time, the patient was treated with oral doxycycline (100 mg every 12 h) and ciprofloxacin (750 mg every 4 h) for 5 months. Subsequently, the facial abscess and erythematous swelling were resolved with minor dermatologic sequelae.
(Enlarge Image)
Figure 3.
Postoperative images after incision and drainage.A: granulation tissue and B: Metal foreign body (F/B 1). Remnant thread of previous cosmetic procedure (F/B 2).
(Enlarge Image)
Figure 4.
Postoperative histology findings.A: Foreign body in dermis; B: Lymphocytic infiltration surrounding the foreign body; and C: Granulomatous inflammation with multinucleated giant cells (H&E stain, magnification × 100).
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