Late-Onset Methicillin-Resistant Staphylococcus aureus Infection after Facial Poly-L-Lactic Acid Injection
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Poly-L-lactic acid (PLLA) is widely used in lipoatrophy and facial rejuvenation for its ability to stimulate collagen neogenesis. Although its safety and efficacy have been established, adverse effects have been reported [12]. Late-onset adverse effects, occurring 6 months or more after injection, include granulomas, nodules, and pseudoabscess [1].
A 43-year-old woman presented with painful erythematous nodules on the left temple (Fig. 1), where PLLA had been injected for augmentation 14 months previously. She had no predisposing factors, and empirical antibiotic treatment did not lead to improvement. After incision of the nodules, pus and tissue materials were drained (Fig. 2), Histopathologic findings showed an abscess without granulomatous features around foreign body materials (Fig. 3), and methicillin-resistant Staphylococcus aureus (MRSA) was cultured. We therefore made the diagnosis of late-onset MRSA infection after PLLA injection.
In this case, the subcutaneous nodules showed no sign of a granulomatous reaction, and MRSA was grown in a bacterial culture. Bacterial contamination of the filler materials may have been the cause of these nodules, which is related to the biofilm theory. Biofilms, defined as communities of microorganisms, are attached to the inert surfaces of catheters, and Staphylococcus aureus is frequently found in a dormant state within biofilms. It can be reactivated by external triggering factors (e.g., trauma), causing low-grade infection and abscess [3]. Our patient had not undergone any additional procedures, but repetitive traumas in daily life may have served as the triggering factor. Intravenous vancomycin was administered accordingly, and the nodules recovered completely without scarring. Therefore, physicians who perform aesthetic procedures should be aware that late-onset painful nodules are likely to be caused by a bacterial infection such as MRSA, and identification of the bacteria may be preferable to hastily pursuing other treatment possibilities.
Notes
No potential conflict of interest relevant to this article was reported.