Lymphocutaneous type of nocardiosis caused by Nocardia brasiliensis: a case report and review of primary cutaneous nocardiosis caused by N. brasiliensis reported in Japan

Nocardiosis is a mixed suppurative and granulomatous inflammatory disease caused by infection with Nocardia organisms, a group of aerobic actinomycetes. We recently encountered a 25-year-old woman with posttraumatic nocardiosis of the lower extremities. The clinical symptoms noted during her first visit included erythematous swelling of the right knee accompanied by white maceration of the center of the knee and erosions, shallow ulcers and satellite pustules. In addition, multiple erythematous areas (up to the size of the tip of the thumb) were linearly distributed on the right thigh. These lesions were painful, and right inguinal lymphadenopathy was also noted. No lesion was found in internal organs such as the lungs. Histopathologically, signs of nonspecific granulomatous inflammation were observed, as well as several filamentous branching bacilli positive on Grocott stain. The organisms isolated from culture of pus were acid-fast, Gram-positive long rods. The isolated strain was finally identified as Nocardia brasiliensis. The patient was therefore diagnosed with lymphocutaneous type of primary cutaneous nocardiosis caused by N. brasiliensis. Drip infusion of flomoxef sodium was initially performed to treat her condition. Because of exacerbation of erythematous swelling of the right knee and an increase in number of pustules, treatment was switched to oral minocycline hydrochloride therapy. The disease healed 9 weeks after the start of oral minocycline hydrochloride therapy. Our patient was free of systemic immunosuppression and was neither under 10 nor over 65 years of age. She may therefore be considered a rare case of lymphocutaneous type of nocardiosis. We present this case and discuss reported cases of primary cutaneous nocardiosis due to N. brasiliensis in Japan.     

Unusually located lymphocutaneous nocardiosis caused by Nocardia brasiliensis

Summary We report a patient with primary lymphocutaneous Nocardia brasiliensis infection affecting the face and left arm. The mode of infection was via skin abrasions which occurred 2 weeks prior to the development of the skin lesions. Treatment with intravenous minocycline for 4 weeks resulted in a cure. We also review 12 previously reported Japanese cases of lymphocutaneous nocardiosis.     

A case report and review of lymphocutaneous nocardiosis caused by Nocardia brasiliensis reported in China

Primary cutaneous nocardiosis caused by Nocardia brasiliensis is an uncommon disease. The present authors report a Chinese woman presented with lymphocutaneous nocardiosis caused by N. brasiliensis. The lesion begin with her right hand after an unknown insect sting and evolved rapidly and formed painful erythema and two subcutaneous nodules and abscesses on her right forearm in 5 days. N. brasiliensis was isolated from pustule and identified by gene sequencing. The patient received 2 weeks of combination therapy contained infusion of amoxilin potassioum clavinet and oral TMP/SMX and followed by a single therapy of oral TMP/SMX for 1 month and got a marked improvement. The present authors reviewed a case of lymphocutaneous nocardiosis caused by N. brasiliensis reported in China.     

Cutaneous nocardiosis caused by Nocardia brasiliensis after an insect bite.

We report the case of a primary lymphocutaneous nocardiosis occurring on the right calf of a healthy 56-year-old man after an insect bite. Analysis of the purulent exudate obtained from the nodule revealed Nocardia brasiliensis. The initial therapy with trimethoprim-sulfamethoxazole had to be stopped due to a drug eruption. However, with minocycline treatment the patient recovered within 5 weeks. Superficial (sporotrichoid) infections and a history of outdoor injury should be considered suspicious for cutaneous nocardiosis.     

Disseminated Nocardia brasiliensis infection following cryptococcal disease

Nocardiosis is an increasing clinical problem, especially in immunocompromised patients. The offending species is almost always Nocardia asteroides. Cryptococcosis is also an increasing problem in the immunosuppressed. We describe a patient with probable disseminated cryptococcosis followed by disseminated Nocardia brasiliensis infection. Only eight patients with disseminated N brasiliensis infection have been described, to our knowledge, in the United States.     

Primary facial cutaneous nocardiosis in a HIV patient and review of cutaneous nocardiosis in India

Nocardiosis is an acute, subacute or chronic bacterial infection caused by several species of geophilic aerobic bacteria of the genus Nocardia. Cutaneous nocardiosis is an uncommon infectious disease that presents as primary cutaneous infection or as a sequale of disseminated pulmonary nocardiosis. Its rarity and as nocardiosis is not an AIDS defined disease it is often underreported. The global incidence of cutaneous nocardiosis is not exactly known. The frequency of nocardiosis in HIV patients has increased from 0.3 to1.85%. In Immunocompetent persons Primary Cutaneous Nocardiosis is more commonly seen among gardeners and agriculturists. We report a case of extensive primary facial cutaneous nocardiosis due to Nocardia asteroides, in an adult immunocompromised lady who had no pulmonary focus. The lesions were seen as sinus tracts on the zygomatic arch, preauricular and Infraauricular regions. Bacteriological examination of the pus confirmed the presence of N. asteroides. The rarity of the presentation and Cutaneous nocardiosis in India is reviewed.     

皮肤诺卡菌病诊断与治疗进展

皮肤诺卡菌病是诺卡菌属经皮肤伤口引起的感染,多种诺卡菌均可引起,包括巴西诺卡菌、星形诺卡菌等.皮肤诺卡菌病临床表现无特异性,但以皮下结节伴有瘘管形成最常见.及时、准确的诊断对皮肤诺卡菌病的治疗有重要意义.磺胺类药物仍是治疗皮肤诺卡菌病的一线药物,但耐药株和多重耐药株的发现为临床治疗带来了新的挑战.建立准确的体外药敏谱和选择敏感抗生素对临床用药有指导意义.     

Head actinomycetoma with a double aetiology, caused by Nocardia brasiliensis and N. asteroides

We describe a 64-year-old man with an actinomycetoma of the frontal region of the head caused simultaneously by two aetiological agents, Nocardia brasiliensis and N. asteroides. This case is presented due to the unusual body site affected and, above all, because two aetiological agents were isolated.     

A Case of Lymphocutaneous Nocardiosis with a Review of Lymphocutaneous Nocardiosis Reported in Japan

An 82-year-old Japanese male developed nodules and ulcers along the lymphatics after a fall in the garden of his house resulting in injuries to the dorsum of his left hand which lasted for 3 months. Nocardia brasiliensis was isolated from a nodule, supporting a diagnosis of the lymphocutaneous type of nocardiosis. He had previously developed generalized bone metastasis from prostatic cancer, and his resulting depressed immunity might have played a part in the nocardiosis genesis. Sixteen cases of the lymphocutaneous type of nocardiosis reported in Japan were reviewed.     

Primary cutaneous Nocardia brasiliensis infection isolated in an immunosuppressed patient: a case report

Cutaneous nocardiosis is a rare infection that may manifest as a superficial skin lesion, lymphocutaneous infection, mycetoma, or diffuse cutaneous infection from a disseminated systemic infection. We report a case of a 65-year-old immunocompromised man with persistent primary cutaneous Nocardia brasiliensis infection following a motor vehicle collision. A high degree of suspicion is needed to diagnose Nocardia infection because of its resemblance to other bacterial infections. Nocardiosis should be included in the differential diagnosis of chronic cutaneous infections, especially when the response to antibiotics is inadequate or when the patient is immunocompromised. Because Nocardia may take several weeks to grow in standard bacterial culture media, laboratories should be notified of the suspicion so that culture plates are held for longer time periods. Long-term therapy, usually with sulfonamides, often is necessary.     

Treatment of actinomycetoma due to Nocardia spp. with amoxicillin-clavulanate

BACKGROUND: Actinomycetoma is a chronic occupational condition that occurs frequently in tropical regions. In Mexico 85% of cases are caused by Nocardia brasiliensis. There are two treatments of choice for these cases: a regimen of dapsone plus trimethoprim-sulfamethoxazole (co-trimoxazole) and, recently, amikacin, either alone or combined. However, not all cases respond properly to these therapies. OBJECTIVES: To report a retrospective, 11-year study of cases of actinomycetomas caused by Nocardia spp., treated with amoxicillin-clavulanate (co-amoxiclav). METHODS: All cases were identified clinically and microbiologically and had previously failed standard therapies. Oral co-amoxiclav 875/125 mg was administered every 12 h. Clinical, microbiological and laboratory follow up was performed every 2 months during the treatment period. RESULTS: Twenty-one cases of actinomycetoma were included, 19 caused by N. brasiliensis and one each by N. asteroides and N. otitidiscaviarum. Clinical and microbiological cure occurred in 15 of 21 cases (71%); two cases improved (10%) and four failed (19%). Mean treatment period was 9.6 months, during which neither side-effects nor laboratory test alterations were reported. CONCLUSIONS: Treatment with co-amoxiclav represents an alternative or rescue treatment for cases that have previously failed standard therapies.     

Primary Lymphocutaneous Nocardiosis Due to Nocardia otitidiscaviarum: The First Case Report from Japan

We report a case of lymphocutaneous syndrome caused by Nocardia otitidiscaviarum (formerly known as N. caviae) in a 78-year-old woman who underwent long-term therapy with prednisolone for bronchial asthma. Histological examination showed granulomatous reaction with multiple polymorphonuclear leukocytes and revealed a Gram positive filament in the dermis. Grampositive, slightly acid-fast branched filaments were also found in the smear of the purulent material. The cell wall constituents of the isolate were meso-diaminopimelic acid, arabinose, and galactose; the mycolic acid pattern of the isolate was Nocardia type. The organism decomposed xanthine and hypoxanthine, but not tyrosine or casein, which distinguished it from N. asteroides and N. brasiliensis. The skin lesions responded to minocycline and later to a combination of doxycycline and ofloxacin. This primary lymphocutaneous nocardiosis due to N. otitidiscaviarum is the first in Japan.     

Disseminated Cutaneous Nocardia Brasiliensis Infection

Abstract: Nocardia brasiliensis is an uncommon pathogen in the United States despite its presence in soil samples. It is most frequently seen in patients who are immunosuppressed, but can occur in the immunocompetent host also. Usually in a healthy host the infection is localized to one area of the body. Disseminated infection was diagnosed in a healthy child who recovered fully after initiation of oral sulfonamide therapy. We suspect that the source was soil to which the patient was exposed during a family camping trip.
Nocardia asteroides is the most frequent cause of nocardial infections in North America (1). These infections are unusual in healthy individuals, occurring more often in immunologically compromised hosts (1). They are usually acquired by a pulmonary route and may disseminate widely, most commonly to the central nervous system and skin. Nocardia brasiliensis , when it does occur in the United States, usually causes a chronic cutaneous and subcutaneous infection manifesting itself as mycetoma, abscess, or ulcer (2). We saw acute suppurative lymphocutaneous Nocardia brasiliensis infection in an otherwise healthy 2-year-old boy.     

Disseminated cutaneous nocardiosis mimicking cellulitis and erythema nodosum

Infection with Nocardia asteroides is a rare, life-threatening infection, which is most commonly encountered in immunocompromised patients. Cutaneous involvement is usually seen with disseminated infection but may also occur as primary cutaneous nocardiosis. We present a case of an immunocompromised patient who presented with cellulitis of the right hand and disseminated subcutaneous nodules of the lower extremities resembling erythema nodosum. Cultures from both a skin biopsy of a subcutaneous nodule on the leg as well as a surgical specimen from the debridement of her hand grew Nocardia asteroides. The patient was treated successfully with trimethoprim-sulfamethoxazole. This case likely represents primary cutaneous nocardiosis with secondary dissemination, which has been rarely reported. It also emphasizes that nocardial infection should be considered in the differential diagnosis of lesions suggestive of cellulitis or erythema nodosum in the severely immunocompromised patient.     

SMALL GRAIN MYCETOMAS IN THE TROPICS

Biopsy specimens from 159 patients with mycetoma filed in the departments of pathology of four medical colleges in Tamil Nadu, India, were examined histologically; small grain mycetoma due to Nocardia species was found in 27 cases. In addition, 17 clinically diagnosed cases of mycetoma without the characteristic discharging “granules” were investigated for the presence of Nocardia spp. by paraffin baiting and Nocardia spp. were isolated from nine of them. Of these, five were Nocardia asteroides, one was N. brasiliensis and three were identified as Nocardia spp. The classification and geographic distribution of Nocardia spp. are discussed.     

Cutaneous nocardiosis. Case reports and review

Two cases of cutaneous nocardial infection are reported. The Nocardia species are gram-positive, partially acid-fast bacteria. Cutaneous involvement may develop as one of four types: (1) mycetoma, (2) lymphocutaneous (sporotrichoid) infection, (3) superficial skin infection, or (4) systemic disease with cutaneous involvement. A review of each of these types of infection is included, as well as potential clues that may suggest the diagnosis of nocardiosis.     

Mycetoma due to Nocardia caviae

Mycetoma is the most frequent deep mycosis in Mexico and is caused by Nocardia brasiliensis in 86% of the cases. Two cases of mycetoma due to Nocardia caviae, the first in Mexico, are reported. The strains were identified by their biochemical properties according to the criteria of Gordon and Mihm (1962). Few cases of mycetoma caused by this actinomycete have been reported in the world. One of our cases was unusual: occurring on the trunk as a tumor and diagnosed by finding the "grains" on histologic examination.     

星形诺卡菌性足菌肿

报告1例星形诺卡菌性足菌肿。患者男,29岁。左踝部外伤后出现肿块、结节,并形成窦道,有脓液溢出,逐渐加重9年。皮损组织病理检查示脓肿中央液化坏死,可见颗粒,颗粒周围有菌鞘。深部组织脓液培养见放线菌生长,但菌种鉴定为星形诺卡菌,诊断为足菌肿。给予青霉素G联合复方磺胺甲口恶唑治疗,病情好转。     

Pemphigus vulgaris and disseminated nocardiosis.

Infectious diseases, in particular septicaemia from Staphylococcus aureus, Proteus vulgaris and Pseudomonas aeruginosa, are the most severe and frequent complications for the immunosuppressive therapy of pemphigus. Infection by Nocardia asteroides in subjects with pemphigus vulgaris is rare. We report the sixth case found of such an association; the subject died of disseminated nocardiosis while receiving steroids and immunosuppressive drugs, 4 years after being diagnosed with chronic pemphigus vulgaris.     

Primary cutaneous nocardiosis

A case of primary cutaneous nocardiosis due to Nocardia asteroides occurring in a steroid-dependent asthmatic with no history of trauma is presented. He had a 5 month history of painful nodules on his right shin and calf. He was initially treated with a 6 week course of oral cephalexin 500 mg four times daily, followed by a 2 week course of minocycline 100 mg twice daily with worsening of the infection. A 12 week course of oral clarithromycin 500 mg twice daily led to complete resolution. A discussion of the problems associated with antimicrobial susceptibility testing and nocardia resistance is presented.