LAUSR

A 62-year-old Caucasian male with a history of orthotopic heart transplantation approximately 15 years ago on immunosuppressive therapy was admitted with multifocal bronchopulmonary pneumonia. His postheart transplantation course 15 years ago was complicated by Nocardia pneumonia and has remained on suppressive minocycline therapy 100 mg twice daily as he was allergic to trimethoprimsulfamethoxazole, whichwas the preferred therapy. On this admission, he was noted to have prominent blue-gray discoloration over his face, bilateral arms, feet, and fingernails (Figure 1). It is exceedingly uncommon for patients to remain on minocycline for a prolonged time period due to the frequency of adverse effects including skin changes. After consultation with the Infection Diseases service, it was determined that the risk of recurrent Nocardia infection wasnow lowenough towarrant cessationofminocycline therapy inour patient.Minocycline hyperpigmentation occurs due to accumulation of the drug within the skin, where it oxidizes and turns black. It has been reported to occur in 2.4%–14.8% of patients on long-term treatment.1 Minocycline-induced skin hyperpigmentation is reported to occur in four types, with type 3 being the least common and characterized by diffuse muddy brown or blue-gray discoloration in sun-exposed areas, as seen in our patient.2,3 Type 3 minocycline-induced hyperpigmentation tends to persist indefinitely, while type 1 and 2may slowly resolve over time after minocycline withdrawal. Type 4 occurs over existing scars. The growing challenge of multidrug-resistant (MDR) bacteria has renewed interest in old antibiotics, with minocycline use being explored in various clinical situations.4–6 F IGURE 1 Blue-black discoloration over foreams, fingernails, face and feet