Sir,

Staphylococcal disease of the face is a bacterial skin infection secondary to staphylococcus aureus, which requires urgent and specialized management [1]. It is an acute septicemia or the venous and lymphatic system participate constantly; from a site generally located at the center of the face level (trapezium-shaped area, included between the corners of the mouth and the external angle of the eyes) or the venous network is rich in anastomosis [2]. In its malignant form, staphylococcal disease may be complicated by thrombosis of the cavernous sinuses and meningeal damage [3], justifying efficient anticoagulation in addition to an adapted antibiotic therapy. The diagnosis should be excluded in front of a dramatic situation of purplish erythema with facial edema. Indeed, a furuncle manipulated is the usual triggering event, yet any other central lesion facial may be the origin.

This report describes a rare case of staphylococcal disease of the face with an unusual original site.

A 68-year-old patient with a history of diabetes was admitted with erythema and edema of the face. An interrogation revealed a solid, round lesion of the nose progressing for five years, with a history of handling and squeezing five days before this current clinical presentation.

On general examination, the patient had a fever of 40°C, without any deterioration of his general condition. A skin examination revealed an area of purplish edematous erythema that was well demarcated, hot and painful, located in the center of the face without any peripheral swelling (Fig. 1a). On the left nasal wing, there was a painless pearly nodule that measured 15 mm, with an ulcerated smooth surface (Fig. 1b). Dermoscopic examination revealed focal ulceration, an arborizing blood vessel, and bluish-gray ovoid nests (Fig. 2). A craniofacial scan was prescribed and returned without thrombophlebitis of the cavernous sinus. A biological evaluation showed a hyperleukocytosis with predominantly PNN and a CRP of 275 mg/L. A favorable clinical and biological evolution of 72 hours was marked after the antibiotic treatment.

	Figure 1: (a) Purplish, edematous facial erythema. (b) Pearly nodule at the left nasal wing.
	Figure 2: Dermoscopy revealing bluish-gray, ovoid nests with arborizing vessels.

The histopathology of the nasal lesion revealed a nodular and infiltrating basal cell carcinoma, which was afterward excised.

The diagnosis retained was a staphylococcal disease of the face that was caused by a BCC manipulation.

In this case, although the untimely manipulation of the BCC was the initiating factor, the rapidity of the diagnosis and treatment avoided a dramatic end and the detection of a malignant lesion a posteriori.

A meticulous examination is, therefore, always necessary, and a well-informed eye may make the diagnosis in the case of an atypical origin of the disease, as in the case of our patient. The acute infectious situation was revelatory of a progressive and malignant tumor pathology such as BCC.

REFERENCES

1.  Kahn RM, Goldstein EJ. Common bacterial skin infections:Diagnostic clues and therapeutic options. Postgrad Med. 1993;936:175-82.

2.  Wertheim HF, Melles DC, Vos MC, van Leeuwen W, van Belkum A, Verbrugh HA, et al. The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis. 2005;512:751-62.

3.  Ayadi K, Mehdi M, Khannous M, Ben Hmida M, Ladeb MF, Mnif J, et al. [Septic thrombosis of the cavernous sinus complicating malignant staphylococcal infection of the face]. J Radiol. 1995;768:497-9.