Serrated Marine Nose
A 37-year-old woman who was receiving adalimumab for ankylosing spondylitis presented with a 6-week history of swelling and ulcerations with a hemorrhagic crust over her nose (Panels A and B). Serratia liquefaciens grew in biopsy samples obtained from the ulcers. A 3-week course of ciprofloxacin resulted in partial improvement (Panels C and D). Five weeks later, histologic examination revealed caseating granulomas, and Mycobacterium marinum, a nontuberculous mycobacterium associated with a condition known as fish-tank granuloma, was identified in cultures. Adalimumab treatment was stopped, and clarithromycin and ethambutol were initiated. Three months later, immunomodulatory treatment was reinitiated, and antimicrobial agents were continued for a total of 7 months. Six months after the completion of antimicrobial therapy, the nasal lesion had resolved (Panels E and F). The two organisms in this case can be found in water. It is unclear where the patient acquired these organisms, but 2 months before admission, she had used a glucocorticoid-containing nasal spray and had undergone inferior turbinate reduction by means of cauterization for the treatment of nasal breathing obstruction. In addition, she had regularly visited thermal baths.