A 43-year-old woman from Reunion, France, presented with a nodular infi ltrated painless lesion of the right cheek and ear (fi gure, A). The lesion began 7 years ago as an infi ltrated plaque on the ear lobe. The fi rst biopsy samples showed giant cell granulomas, leading to the diagnosis of cutaneous sarcoidosis. Tuberculin skin test was negative. She was treated with oral steroids, which were initially eff ective, but relapse occurred on decreasing dosages. The patient was then treated with hydroxychloroquine, but this was stopped because of retinitis. Thalidomide, methotrexate, and ciclosporin were not eff ective. The lesion extended to the cheek and the whole external ear. She then had three perfusions of infl iximab without any improvement. After that, she was referred to our dermatology department. Clinical examination revealed an infracentimetric cervical right lymphadenopathy. Chest radiography was normal and tuberculin skin test was negative. A second histology specimen was taken, which showed a granulomatous lymphocytic infi ltrate (fi gure, B; black arrow, granulomas; green arrow, giant multinucleated cells). We ruled out granulomatous lymphoma by the absence of atypical lymphocytes and the absence of clonal T and B cells in the infi ltrate. A separate punch biopsy was sent for direct examination and culture for mycobacteria species. The culture was positive on the second week with Mycobacterium avium indentifi ed by PCR. The diagnosis was chronic granulomatous M avium infection. The unusual growth might have resulted from the use of drugs with immunosuppressive eff ect. The patient was given a 6-month treatment with clarithromycin 500 mg twice a day, ethambutol 20 mg/kg per day, and rifabutine 300 mg per day. The lesion gradually fl attened, leaving only some macular pigmented marks in its place (fi gure, C). M avium skin infections do occur in healthy individuals. They can take unusual forms and grow into a granulomatous pseudotumour in immuno suppressed patients or those taking anti-tumour necrosis factor therapies. The diagnosis is made on skin biopsy culture and molecular identifi cation.