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.     

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.     

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.     

Lymphocutaneous nocardiosis caused by Nocardia asteroides. Case report and literature review

A 22-year-old man developed erythematous nodules and an ulcer mimicking sporotrichosis on his right hand and forearm, which was subsequently diagnosed as lymphocutaneous nocardiosis caused by Nocardia asteroides. To our knowledge, 21 cases of lymphocutaneous nocardiosis have been reported, with the majority of those cases, except for a few that remain uncertain, being due to Nocardia brasiliensis. The case reported herein, the first known definitive case caused by N asteroides (to our knowledge), showed a more chronic course and less inflammatory manifestation compared with that caused by N brasiliensis. This is probably because N brasiliensis has a stronger virulence than N asteroides.     

原发性皮肤奴卡菌病一例

患者,男,72岁。右侧手背、前臂结节伴肿痛3天。组织病理学:(右侧前臂)表皮缺失,真皮可见大片坏死组织,大量中性粒细胞、淋巴细胞及少许多核巨细胞浸润。右侧前臂分泌物细菌培养示:星形奴卡菌生长。诊断为原发性(淋巴型)皮肤奴卡菌病。给予哌拉西林钠舒巴坦钠,夫西地酸乳膏,红光照射治疗后逐渐好转。     

Cutaneous nocardiosis: report of two cases and review of the literature

Background Cutaneous nocardiosis is an uncommon infectious disease that presents as a primary cutaneous infection or as a disseminated disease. It is often misdiagnosed because of its rarity and nonspecific clinical picture. Methods We report a case of each type. The first case is an immunocompetent patient who was infected by Nocardia while gardening and developed a superficial skin infection – one of the three clinical manifestations of primary cutaneous nocardiosis. The second case is an immunocompromised patient with pulmonary nocardiosis that extended to the skin as part of a disseminated disease. Results The immunocompetent patient with primary cutaneous nocardiosis had the classical features of a superficial skin infection. He had a nodular–pustular lesion on the right arm, which appeared 7 days after gardening with bare hands. Nocardia was identified in a skin culture taken from a pustule, unfortunately not to the species level. Treatment with minocycline for 3 months resulted in full remission of the lesion. The immunocompromised patient with disseminated nocardiosis had high fever, productive cough, hemoptysis, and erythematous nodules and pustules on the extremities. N. brasiliensis was isolated from bronchial samples and skin. Treatment with a high dose of trimethoprim and sulfamethoxazole for five months resulted in full recovery from cutaneous and pulmonary complaints. No relapse of the infection was found on follow‐up in either patient. Conclusion These cases demonstrate the need for a high degree of suspicion, focused clinical search, and appropriate laboratory procedures in the diagnosis and management of cutaneous nocardiosis.     

Primary cutaneous nocardiosis caused by Nocardia takedensis with pulmonary dissemination in an immunosuppressed patient

We present a remarkable case of primary cutaneous nocardiosis with pulmonary dissemination due to Nocardia takedensis in a 76‐year‐old man suffering from marginal zone lymphoma and hypogammaglobulinaemia. We also discuss an alternative treatment to trimethoprim‐sulfamethoxazole, which could be contraindicated due to haematological and cutaneous toxicities. This case report is of interest due to the emergence of cutaneous nocardiosis in dermatology.     

Primary cutaneous nocardiosis caused by Nocardia brasiliensis following a wasp sting

We report a case of an 87‐year‐old woman who presented with painful erythema of her right forearm 10 days after she had been stung by a wasp on her right hand. The lesion had rapidly deteriorated during the week before presentation, and treatment with antibiotics and glucocorticoids did not improve the condition. After careful evaluation, we performed cultures from the lesion aspiration, and morphological and genetic analysis of bacteria cultures confirmed a bacterial infection with Nocardia brasiliensis. The patient recovered after 3 weeks. Primary cutaneous nocardiosis due to Nocardia spp. is relatively uncommon in clinics, but it was the distance of the lesions from the affected area of the wasp sting that has made this an even rarer case and of interest to report.     

Primary cutaneous nocardiosis in an immune-competent patient.

We present a patient who was hospitalized due to a purulent skin lesion with a surrounding erythematous area in the region of the right paranasal crease accompanied by a swelling of the right eyelid. Initially the diagnosis of a carbuncle caused by an infection with Staphylococcus aureus was supposed. A surgical debridement was performed and an antibiotic therapy was started. Only special microbial investigations requested by the clinician led to the diagnosis of a cutaneous infection with Nocardia brasiliensis. The presented case is remarkable because the nocardia infection was in an immune-competent patient and the patient showed a primary cutaneous nocardiosis without dissemination.     

Cutaneous nocardiosis associated with insect bites.

We report the first case of cutaneous nocardiosis associated with insect bites. The patient received these insect bites while camping a few days before he presented to the emergency room. The patient was a healthy twenty-six-year-old man, who was asplenic as a result of a motor vehicle accident. He presented to the emergency room with fever, multiple insect bites to his left lower extremity with pustules, lymphangitis, and left inguinal adenopathy. He was hospitalized but his condition failed to improve despite treatment with intravenous nafcillin for three days. Wound and blood cultures subsequently grew Nocardia brasiliensis. Treatment with intravenous amikacin (5 mg/kg every eight hours) was instituted along with oral trimethoprim-sulfamethoxazole double strength twice a day. The patient recovered with minimal scarring of the extremity. The amikacin was stopped after seven days and the patient was discharged to receive oral trimethoprim-sulfamethoxazole. This disease should be kept in mind when cutaneous infections do not respond to standard antibiotics, especially in the southwestern United States.     

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.     

Cutaneous nocardiosis developing around gravel inserted during a traffic injury

A 65-year-old Japanese woman with nocardial mycetoma which developed five years after a compound bone fracture of the left foot due to a traffic accident was reported. During this accident, two small pieces of gravel had entered her foot. Nocardia asteroides, which had been attached to the gravel, was probably inserted 5 years previously during the trauma. The lesion did not respond to oral minocycline and trimethoprim-sulfamethoxazole and was finally removed surgically; she has been free from recurrences for one year, of follow-up.     

Primary cutaneous nocardiosis in immunocompetent children

Primary cutaneous nocardiosis is an infrequent opportunistic infection that mainly affects immunodepressed hosts. We describe two immunocompetent patients who exhibited two clinical forms of cutaneous nocardiosis, a mycetoma from walking barefoot in contaminated water and in the case of the other patient a lymphocutaneous form on the basis of a stabbing-cutting injury. In both cases the tests performed ruled out any immunodeficiency, particularly chronic granulomatose disease, since nocardiosis is regarded as an infection that acts as a marker for that illness. Treatment with cotrimoxazole led to the total healing of the lesions in both patients.     

A novel case of nocardiosis with skin lesion due to Nocardia araoensis

Nocardiosis is caused by gram-positive aerobic actinomycetes that live in soil and are known to be responsible for opportunistic infections. The condition mostly affects the lung, brain or skin. Here, we present a 24-year-old Japanese woman who had had systemic lupus erythematosus since the age of 20 years, and lupus nephritis since the age of 23 years. She developed cutaneous lymph duct-type nocardiosis due to Nocardia araoensis while on immunosuppressant therapy. The patient had cutaneous findings from the right inguinal region to the right lower thigh and did not have lesions on the rest of the body. Minocycline and co-trimoxazole were co-administrated, and her condition improved. To our knowledge, this is the first case in which N. araoensis was detected by analysis on rRNA base sequence in skin lesions.     

Subcutaneous Abscesses Caused by Nocardia brasiliensis Complicated by Malignant Lymphoma

A 47-year-old Japanese man suffering from T-cell leukemia was examined for multiple subcutaneous abscesses followed to abrasion wound on his right knee. The causative organism was clustered, fine-branched filaments in pus aspirated from the lesions, identified as Nocardia brasiliensis. Most of the lesions regressed from the combined therapy of sulfamethoxazole and trimethoprim, leaving an ulcer on the patient's left leg. The nocardiosis cases in Japan until 1984, including this one, were briefly surveyed.     

Primary cutaneous nocardiosis due to Nocardia nova in a healthy woman

We describe a 68-year-old healthy woman with an unusual skin manifestation of mycetoma. A dark reddish erythematous plaque was present on the dorsum of the left hand for over 10 years. A skin biopsy revealed sulphur granules in the abscess, and Nocardia nova was identified from the specimen. Treatment with dapsone resulted in significant improvement. We review the clinical features of cutaneous N. nova infections.     

Initial cutaneous manifestations associated with histopathological leukocytoclastic vasculitis in two patients with antiphospholipid antibody syndrome

Antiphospholipid antibody syndrome (APS) is a multisystem disorder associated with a variety of circulating autoantibodies that target different phospholipid protein complexes. APS is sometimes lethal as a result of severe sequelae, which may be primary or secondary to the underlying disease. We report two women who presented histopathologically with leukocytoclastic vasculitis as the first cutaneous manifestation and were subsequently diagnosed with APS associated with systemic lupus erythematosus (SLE). Patient 1 presented with widespread cutaneous necrosis (WCN) with rapidly spreading pain down the lower extremities. Skin biopsy specimens from her leg purpura and WCN revealed perivascular infiltrates with neutrophils consistent with leukocytoclastic vasculitis and thromboses of small-sized dermal vessels. Patient 2 exhibited livedo reticularis, painful cutaneous nodules with necrosis, ulcer, and erythematous macules on her lower extremities, shoulder, and face. Skin biopsies of her right knee showed intravascular thrombosis of small dermal vessels and infiltration of perivascular tissues with necrotizing granulomatous vasculitis in the dermis. We found that these various cutaneous manifestations with leukocytoclastic vasculitis were present at an early stage of APS. Although progression to leukocytoclastic vasculitis in patients with APS is uncommon, our data suggest that the association between microvascular occlusions and cutaneous vessel vasculitis has a predictive value for the pathogenesis. It is important for dermatologists to recognize these cutaneous signs to permit early and accurate diagnosis and treatment.     

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.     

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.     

Subcutaneous Abscesses Caused by Nocardia brasiliensis Complicated by Malignant LymphomaL A Survey of Cutaneous Nocardiosis Reported in Japan

Abstract: A 47-year-old Japanese man suffering from T-cell leukemia was examined for multiple subcutaneous abscesses followed to abrasion wound on his right knee. The causative organism was clustered, fine-branched filaments in pus aspirated from the lesions, identified as Nocardia brasiliensis. Most of the lesions regressed from the combined therapy of sulfamethoxazole and trimethoprim, leaving an ulcer on the patient's left leg. The nocardiosis cases in Japan until 1984, including this one, were briefly surveyed.