Nontuberculous Mycobacterial Infection After Fractionated CO2 Laser Resurfacing

Donna A. Culton; Anne M. Lachiewicz; Becky A. Miller; Melissa B. Miller; Courteney MacKuen; Pamela Groben; Becky White; Gary M. Cox; Jason E. Stout


Emerging Infectious Diseases. 2013;19(3) 

In This Article

Case-Patient 1

A 53-year-old woman had multiple erythematous papules and pustules densely distributed over her face, neck, and chest (Figure 1, panel A) 2 weeks after receiving fractionated CO2 laser resurfacing (Solta Medical Inc., Hayward, CA, USA). Before laser resurfacing, the patient began a prophylactic 7-day course of valacyclovir because of a history of recurrent herpes labialis. Immediately before the procedure, the patient's skin was cleansed with 70% isopropanol. Topical lidocaine/tetracaine ointment was applied to the skin for topical anesthesia, followed by intraoral nerve block and tumescent anesthesia for the face only. The neck and chest were treated at 40 mJ (treatment level 7 mJ) and 25% coverage, the forehead at 60 mJ (treatment level 9 mJ) and 35% coverage, and the nose and cheeks at 70 mJ (treatment level 9 mJ) and 35% coverage (total 10.46 kJ). Immediately after the procedure, the patient's skin was cleansed with sterile saline, and emollient was applied. Postprocedure home wound care consisted of vinegar solution (vinegar diluted with bottled water) applications once a day and avoidance of showering, scrubbing, and cosmetics for 72 h.

Figure 1.

A) Neck and chest of a 53-year-old woman (case-patient 1) 14 days after fractionated CO2 laser resurfacing. B) Neck of the patient after 5 months of multidrug therapy and pulsed dye laser treatment.

Ten days post–laser treatment, erythematous papules and pustules developed over the face, neck, and chest of the patient. Outpatient treatment was initiated with oral fluconazole, doxycycline, and valacyclovir for presumed fungal, staphylococcal, or disseminated herpes simplex virus infection. Because of extensive pruritus, the patient was given locoid lipocin (0.1% hydrocortisone butyrate) and a tapered dose of prednisone for possible allergic contact dermatitis. She reported adherence to instructions to avoid showering and washing her face with tap water for 72 h after the procedure. However, she was exposed to dust from sanding she did at home during the week after the procedure. She did not show improvement over the next 2 days and, after a low-grade fever developed, was hospitalized and received intravenous acyclovir therapy for presumed disseminated herpes simplex virus infection.

When the patient was hospitalized, lesions were nearly confluent over her neck and chest and scattered over her face but limited to areas treated with the CO2 laser. PCR results for herpes simplex virus, varicella zoster virus, and fungal cultures were negative. Gram staining showed polymorphonuclear leukocytes and gram-variable rods. Two skin biopsy specimens demonstrated multiple, tiny foci of suppurative granulomatous dermatitis with elastophagocytosis (Figure 2, panel A) and numerous long acid-fast rods that were gram positive (Figure 2, panel B).

Figure 2.

Skin biopsy specimens of a 53-year-old woman (case-patient 1) after fractionated CO2 laser resurfacing. A) Hematoxylin and eosin–stained and B) Ziehl-Neelsen acid-fast–stained sections show a tiny superficial microabscess surrounded by sparse granulomatous inflammation. Several groups of acid-fast organisms can be seen at the lower left of panel B. Original magnifications ×400 in (A) and ×600 in (B).

The patient was given empiric treatment for nontuberculous mycobacterial infection with intravenous tigecycline combined with oral moxifloxacin and azithromycin. Two weeks later, tissue culture of her lesions grew M. abscessus. Drug susceptibility testing showed resistance to moxifloxacin, amoxicillin/clavulanate, tobramycin, trimethoprim/sulfamethoxazole, ciprofloxacin, doripenem, linezolid, and doxycycline, and susceptibility to azithromycin, amikacin, kanamycin, imipenem, cefoxitin, and tigecycline.

One month after initiation of the multidrug regimen, repeat culture of a persistent pustule on her face again grew M. abscessus. Treatment with tigecycline and moxifloxacin was stopped after 2 months and treatment with azithromycin was stopped after 5 months because the patient showed clinical improvement. Scarring and dyspigmentation were observed. Thus, for cosmesis, she subsequently underwent a series of procedures with a pulsed dye laser (Figure 1, panel B).