B R I E F R E P O R T
Nocardia cyriacigeorgica Infections
Attributable to Unlicensed
Emerging Public Health Problem?
Andria Apostolou,1,3Shanna J. Bolcen,2Vaidehi Dave,4Nisha Jani,5
Brent A. Lasker,2Christina G. Tan,3Barbara Montana,3June M. Brown,2
and Carol A. Genese3
1Epidemic Intelligence Service, and2Bacterial Special Pathogens Branch, Centers
for Disease Control and Prevention, Atlanta, Georgia;3Communicable Disease
Service, New Jersey Department of Health and Senior Services, Trenton,4Essex
County Health Department, Cedar Grove,5Newark Department of Child and Family
Well Being, New Jersey
We describe an outbreak of Nocardia cyriacigeorgica soft-
tissue infections attributable to unlicensed cosmetic injec-
tions and the first report using multilocus sequence typing
sequence data for determining Nocardia strain relatedness
in an outbreak. All 8 cases identified had a common source
exposure and required hospitalization, surgical debride-
ment, and prolonged antimicrobial therapy.
Multiple recent publications and news reports, both in the
United States and internationally, have highlighted investi-
gations of illnesses associated with cosmetic procedures per-
formed by unlicensed individuals [1–5].
In February 2010, the New Jersey Department of Health
and Senior Services (NJ DHSS) was notified by a physician of
3 female patients reporting to 1 emergency department (ED)
with cellulitis in the buttocks after receiving injections of an
unidentified substance for cosmetic enhancement. An epide-
miologic investigation was launched to determine the out-
break’s cause and magnitude.
All 3 women were determined to have infections caused by
Nocardia species. Nocardia are Gram-positive, rod-shaped
in soil and water. Infections caused by Nocardia species are
acquired through inhalation or percutaneous inoculation from
environmental sources. Eighty percent of nocardiosis cases
present as invasive pulmonary infection, disseminated infec-
tion, or brain abscess; 20% present as cutaneous disease, inclu-
ding chronically draining ulcerative lesions, slowly expanding
nodules, pustules, abscesses, cellulitis, or pyoderma .
A case was defined as a culture-positive Nocardia species
infection in a New Jersey resident evaluated during August
2009–April 2010 who had received cosmetic injections. This
time frame encompassed 6 months prior to the identification
of the first case and 2 months following identification of the
lastcase. Toidentifyadditional cases, wedistributedmessagesto
public health and healthcare professionals through New Jersey’s
and the Centers for Disease Control and Prevention’s (CDC’s)
health alert networks requesting that persons meeting our case
definition be reported to the NJ DHSS.
We interviewed patients with reported cases using a stan-
dardized questionnaire to assess demographics, travel history,
past medical history, cosmetic procedure history, and details
regarding injections received within the period of interest. We
reviewed case medical charts using a standardized data collec-
tion tool to obtain information regarding presenting symp-
toms, hospitalizations, and treatment within the period of
interest and through 31 December 2010.
In total, we identified 8 case-patients (3 initially reported
cases and 5 additional cases) who received buttocks injections
during November 2009–February 2010; symptom onset
occurred during 19 February–23 March 2010. Two patients re-
ported receiving multiple injections; for these cases, the incu-
bation period was calculated using the last injection date to
symptom onset date. Incubation periods ranged from 8 days
to 3 months. All 8 patients presented to the ED with soreness,
pain, and abscess formation at the injection site (Figure 1). All
cases were in black women; the median age was 27 years
(range, 22–42). None of the patients had notable prior medical
histories nor were immunocompromised. All patients were
hospitalized (median, 19 total hospitalization days; range,
8–55) and had multiple healthcare-related visits (median,5 visits;
range, 2–13); patients sought care for a median 4.8 (range,
0.5–9.5) months following initial healthcare visit. All patients
required injection-site surgical debridement; 5 required mul-
tiple procedures (range, 2–7 procedures/patient). All patients re-
ceived empiric antimicrobial therapy prior to microbiologic
identification. Patients received antibiotics for a median of 48
(range, 24–128) days; the median number of antibiotics pre-
scribed to each patient was 8 (range, 5–11). Because of delays
Received 24 October 2011; accepted 5 March 2012; electronically published 5 April 2012.
Correspondence: Andria Apostolou, PhD, MPH, Epidemic Intelligence Service Officer, Com-
municable Disease Service, New Jersey Department of Health and Senior Services, PO Box
369, Trenton, NJ 08625 (email@example.com).
Clinical Infectious Diseases 2012;55(2):251–3
Published by Oxford University Press on behalf of the Infectious Diseases Society of America
BRIEF REPORT • CID 2012:55 (15 July) • 251
by guest on December 30, 2015
in correctly identifying the causative agent and in obtaining
antimicrobial susceptibility profiles, only 1 patient had received
the recommended antibiotic regiment (trimethoprim/sulfa-
methoxazole) in her initial therapy.
All patients reported having received injections of unknown
substances described as “hydrogel,” “botulinum toxin,” “sili-
cone,” “gel filler,” or “biogel.” Six patients indicated that they
had received injections from an unlicensed person, either at
home, in a hotel, or at a gathering where these injections were
administered to multiple persons; these patients had been re-
ferred to this provider through friends or Internet sites. No
information was available from the remaining 2 patients, who
refused to provide information to public health authorities.
Three of the 6 patients identified the same individual as the
provider; no specific information was available from the re-
maining 3 patients.
Eight clinical specimens were sent to commercial labora-
tories for culture and susceptibility testing; 7 specimens were
initially identified as Nocardia asteroides complex and 1 as
Rhodococcus equi. Available clinical isolates from 7 patients (6
N. asteroides and 1 R. equi) were forwarded to the CDC’s
Special Bacteriology Reference Laboratory for identification by
16s ribosomal RNA (rRNA) gene sequencing and antimicro-
bial susceptibility testing as previously described [7, 8]. Mol-
ecular subtyping by multilocus sequence typing (MLST) was
conducted as previously described by Langer et al, except gene
fragments for gyrB, glcB, hsp65, and pfk were used .
Sequencing of the 1440 base pair 16S rRNA gene fragment
and antimicrobial susceptibility profiles showed that all isolates
obtained from the 7 patients were identical to the N. cyriaci-
georgica (DSM 44484T) and reference (W9956) strains. All 7
exhibited susceptibility to amikacin, ceftriaxone, imipenem,
linezolid, tigecycline, and trimethoprim/sulfamethoxazole.
The MLST results showed that all 7 isolates were identical to
each other but differed from the type and reference strains,
which suggests a single clone for the patient isolates. These
laboratory results were particularly valuable in supporting the
epidemiologic investigation, and they indicated a common
source outbreak and assisted in institution of the appropriate
antimicrobial therapy for the patients.
Our findings and those from similar investigations highlight
the need for public health and medical communities to educate
consumers about risks associated with procedures performed
by unlicensed providers. Patients involved in such investi-
gations have reported easily identifying providers via Internet
sites and being enticed by the low cost compared with cosmetic
surgery by licensed physicians . Consumers should be aware
of the costs to themselves and to society resulting from these
Substantial resources were used for the care and treatment
of the 8 patients. All patients had multiple encounters with
the healthcare system and were hospitalized more than once.
In addition to antimicrobial therapy costs, all patients required
surgical debridement. Treatment of the patients in this out-
break was complicated by the presence of foreign material.
Along with direct healthcare costs, indirect costs should be
considered, including patients’ lost wages, permanent disfig-
urement, and expenditure of public health and law enforce-
This investigation provided several challenges and learning
opportunities. Patient involvement with an unlicensed provi-
der made the public health investigation particularly challen-
ging because affected patients were hesitant to cooperate with
interviews and initially provided inaccurate, conflicting ac-
counts that they later corrected; patients stated that they
feared legal repercussions and therefore attempted to protect
the identify of the unlicensed provider. Only 6 of the 8
patients eventually cooperated with the epidemiologic investi-
gation. Because the identity and whereabouts of the unlicensed
provider were unknown, we were unable to interview that
person, observe infection control practices, or obtain product
and environmental samples, which substantially hindered our
ability to perform analytic studies to identify the particular
practices or products associated with these Nocardia infec-
tions. In this investigation, public health officials interfaced
with law enforcement officials and the New Jersey State Board
of Medical Examiners, the agency responsible for licensing
and regulating healthcare professionals. Law enforcement offi-
cials subsequently identified and indicted the person believed
to have performed the procedures on all identified patients;
however, public health authorities were still unable to investi-
gate this person and practices or sample the injected material.
Female patient with buttock cellulitis attributable to cos-
252 • CID 2012:55 (15 July) • BRIEF REPORT
by guest on December 30, 2015
Although healthcare providers evaluating persons with in- Download full-text
fections after cosmetic/other medical procedures should con-
sider typical organisms (eg, Streptococcus, Staphylococcus),
atypical organisms (eg, Nocardia, Mycobacterium) should also
be included in the differential diagnosis. Atypical organisms
might present as more indolent infections and might not
respond to empiric treatments. Species-specific antimicrobial
susceptibility patterns are necessary to direct appropriate treat-
ment. Accurate identification of Nocardia species is difficult
and might be time and labor intensive .
Although nocardiosis is not a reportable condition in New
Jersey, healthcare providers must report outbreaks caused by
any organism. An astute physician involved in the care of 3
patients at 1 acute-care facility brought this outbreak to the
attention of public health authorities. Healthcare providers
identifying clusters of infections associated with these pro-
cedures should notify public health authorities to ensure sur-
veillance activities and infection control measures are initiated.
However, even a single case of infection with an atypical
organism after a cosmetic or other medical procedure, particu-
larly in an otherwise healthy patient, should be a cause for
concern; in such situations, physicians should have a high index
of suspicion for improper healthcare/infection control prac-
tices during the prior procedure(s), use of contaminated pro-
ducts, or possible practice by an unlicensed provider, and they
should report the case immediately to public health and regu-
and public health professionals to maintain open lines of com-
munication at all times to protect their shared consumer
partment of Health, and the hospitals’ staff for their assistance with the
investigation. We also thank Kristine Bisgard, DVM, MPH, and C. Kay
We thank Ellen Shelly, MPH, Union County De-
Smith, MEd, Centers for Disease Control and Prevention, for their edi-
torial comments and suggestions.
The findings and conclusions in this report are those of
the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
Potential conflicts of interest.
All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the
content of the manuscript have been disclosed.
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