Mycobacterium Fortuitum Breast Abscess after Nipple Piercing

A 21-year-old HIV-negative woman underwent nipple piercing in April 2008. During the summer of 2008, she swam in what she described as “nasty algae water.” She developed a painless lump in her left breast 1 month later. She denied experiencing any fever, chills, night sweats, or weight loss. On examination, she had a 2 × 3–cm painless mass at the 3-o’clock position of her left breast, which was mobile with irregular margins, but without any redness, drainage, or increased temperature. The patient removed her piercing. She began taking cephalexin, but the mass did not show any signs of improvement. She noticed redness of the overlying skin and reported pain. A mammogram and breast ultrasound showed a hypoechoic lesion in the left breast near the nipple, mobile on compression ultrasound and consistent with a breast abscess. The patient underwent diagnostic aspiration, which did not reveal any malignancy. She began taking trimethoprim-sulfamethoxazole (TMP-SMX), but had no clinical improvement. A repeat aspiration yielded a large amount of pus; culture grew some Nocardia species and M fortuitum. Her antibiotic therapy was changed to levofloxacin and TMP-SMX, but her abscess continued to progress. She required debridement of the abscess, with closure by secondary intent. Cultures from samples taken during surgery grew only M fortuitum. Fungal and anaerobic cultures had negative results. While being treated, the patient became pregnant, and her antibiotic treatment was changed to TMP-SMX and azithromycin. She was treated for a total of 6 months. She required a second surgical debridement for relapse of the abscess while taking these antibiotics. She was well at her quarterly follow-up visits at the infectious disease clinic and at 1 year had no residual infection