Case #10:

Clinical Presentation:
A healthy, 35 year old woman underwent autologous fat transplant in Ecuador to both lower extremities for cosmetic purposes. Several months later, the transplant sites had become edematous and painful; multiple sinus tracts developed exuding a thick fluid. Cultures of the exudate were negative. Over the succeeding months, large, ulcerated lesions developed (Case 10 Image 1).

Clinical Diagnoses:
Bacterial Infection (eg Staphylococcus, Streptococcus, Corynebacterium jekium, Nocardiosis) Fungal Wound Infection (eg Mycetoma)

A culture of the lesion, after 72 hours incubation, grew opaque colonies (Case 10 Image 2) with smooth edges. A Gram stain (Case 10 Image 3) of these colonies showed gram-variable, slightly curved, beaded bacilli. Ziehl-Neelsen stain of a skin biopsy (Case 10 Image 4) demonstrated beaded acid-fast rods in a field of polymorphonuclear leukocytes.

Discussion:
Microbiologic Diagnosis:
non-tuberculous Mycobacterium infection (Mycobacterium fortuitum)
This microorganism may be misidentified as a Corynebacterium species due to its rapid growth and Gram-staining characteristics. Antibiotic susceptibility showed the isolate to be resistant to all agents except amikacin, gentamicin, timethoprim/sulfamethoxazole, and tetracycline raising the suspicion of a rapidly growing Mycobacterium. This organism is present in soil and water and can contaminate wounds if there is a break in aseptic technique.