Non-Tuberculous Mycobacterial Infections Following Cosmetic Laser Procedures: A Case Report and Review of the Literature

January 2015 | Volume 14 | Issue 1 | Case Report | 80 | Copyright © 2015

Jacqueline Goulart Berliner MD,a Bishr Aldabagh MD,a Thaddeus Mully MD,b
Siegrid S. Yu MD,a Brian S. Schwartz MD,c Timothy G. Berger MDa

a,b,d,fDepartment of Dermatology, University of California San Francisco, CA
cDepartment of Pathology, University of California San Francisco, CA
eDepartment of Infectious Disease, University of California San Francisco, CA

Abstract

Skin infections are not uncommon after cosmetic laser procedures. Infection rates following ablative laser resurfacing procedures are reported to be as high as 7.6%, compared to 1.9% for fractional ablation. 1,2 An infrequent yet important infectious complication of ablative laser treatment is that caused by non-tuberculous mycobacteria (NTM).

J Drugs Dermatol. 2015;14(1):80-83.

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CASE REPORT

A 66-year-old female underwent full-face fractional laser treatment with a 2790nm device. Five days later she developed multiple erythematous papules, some with central pustules, in the treatment areas (Figure 1). These were distributed in a uniform pattern reduplicating the microthermal treatment zones of fractional resurfacing. She had no lymphadenopathy and denied fevers or chills. She was unsuccessfully treated with short courses of oral minocycline, acyclovir, trimethoprim-sulfamethoxazole, and fluconazole plus topical clindamycin, dapsone, and benzoyl peroxide. Biopsy revealed suppurative and granulomatous dermatitis with focally dense infiltrates of histiocytes and neutrophils (Figure 2), stains for fungi and bacteria were negative. Bacterial culture revealed rapidly growing mycobacterium with subsequent speciation via DNA sequencing showing Mycobacterium chelonae.

She was initially treated with azithromycin and trimethoprim-sulfamethoxazole was added later as guided by antimicrobial susceptibilities. A Fite stain performed on the biopsy specimen was positive for acid-fast bacilli (Figure 3). Time from onset of the eruption to diagnosis and appropriate therapy was approximately one month. At the completion of four months of combination antibiotic treatment she demonstrated clinical improvement (Figure 4), but continued to have inflammatory papules on exam. Repeat biopsy revealed a suppurative and granulomatous dermatitis and a tissue culture confirmed persistent Mycobacterium chelonae. She was referred to dermatologic surgery for punch excision of two lesions with the goal of reducing local disease burden. In addition, she was instructed to use adjuvant heat therapy by applying a heating pack to her face for 10 minutes twice daily.

DISCUSSION

Discussion and Review of Cases from the Literature

To date, six cases of NTM infections following cosmetic laser procedures have been described (Table 1). 3-6 The patients were all women ranging from 30-66 years of age. Indications for laser treatment included laser hair removal for one patient, fullface CO2 resurfacing for one, and full-face fractional resurfacing for four. Time from laser procedure to onset of symptoms ranged from 5-33 days. The clinical presentations were similar in all patients, described variably as “acneiform eruptions” in two patients, “nodules” in two patients, and “papules and pustules” in two patients; all infections presented within the treated areas. The NTM species isolated were M. chelonae in four patients, M. abscessus in one patient, and M. fortuitum in one patient. These are all rapidly growing mycobacteria, the most frequent group of NTM complicating cosmetic surgical procedures and pedicures. 7

"Rapidly growing NTM are ubiquitous in the environment and are found in soil, air, and water."

The diagnosis of NTM infection after cosmetic laser procedures is often delayed, typically presenting weeks to months following the procedure. In this case series, the time from clinical presentation to identification of NTM species for three of the six patients and ranged from 7.3 to 21 weeks. Additional delay in diagnosis is often attributed to lack of clinical suspicion. As demonstrated in this series, patients often undergo multiple, ineffective empiric therapies before the diagnosis is suspected and confirmed. Mak-

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