A Primary Cutaneous Nocardiosis of the Hand

Successful treatment with amoxicillin-clavulanic acid: cutaneous nocardiosis caused by Nocardia brasiliensis

AIM

To emphasize the role of non-sulfonamides in the treatment of Nocardia infection and reduce the adverse reactions caused by sulfonamides.

METHODS

We retrospectively analyzed a case of cutaneous nocardiosis in an immunocompetent individual. The colonies obtained by staining the pus in the lesion with antacid and culturing the agar plates were identified by flight mass spectrometry. The pathogenic identification showed Nocardia brasiliensis infection and the patient was treated with amoxicillin-clavulanic acid.

RESULTS

After treatment with amoxicillin and clavulanic acid, the ulcer gradually peeled and crusted, leaving dark pigmentation. The patient has finally recovered.

CONCLUSION

Sulfonamides are the first-line antibacterial agents for years in treatment of nocardiosis but are of great toxicity and side effects. This patient was successfully treated with amoxicillin-clavulanic acid and it provided a reference protocol for patients with sulfonamide-resistant Nocardia or sulfonamides intolerance.

Uncommon lymphocutaneous cellulitis after insect bite: a case report of primary cutaneous nocardiosis and literature review

Nocardia is a genus of aerobic actinomycetes that are usually responsible for opportunistic infection in immunocompromised patients. Less frequently nocardiosis can interest immunocompetent population, causing especially primary cutaneous infections. Cutaneous involvement by Nocardia spp. may occur mostly as one of four clinical manifestations: superficial cellulitis or abscess, mycetoma, lymphocutaneous (also defined "sporotrichoid") infection and secondary cutaneous involvement from systemic disease. Infections usually present after minor local injury, especially in traumatic outdoor activities (e.g. gardeners, farmers, road accidents), with subsequent environmental contamination of the wound. In sporadic cases cutaneous infection follows an insect bite. Microbiological diagnosis is often difficult to obtain and N. brasiliensis is the species isolated in most cases (80%). We present the case of a 45-year-old female with fever and a painful and necrotizing lesion on her right leg with secondary ascending lesions occurred on the homolateral knee and consensual groin lymphadenopathy after insect sting (maybe a spider bite). Cultures on skin biopsy identified Nocardia brasiliensis. Infection was completely healed after 5 months of targeted antibiotic therapy. In addition, we performed a literature review of all cutaneous nocardiosis cases in immunocompetent individuals, finding that only in 22 cases the infection presented after insect bite; in most of these cases lymphocutaneous manifestation was seen and N. brasiliensis was the Nocardia species isolated. Our case, along with others in literature, reveals that the real burden of soft-tissues nocardiosis seems low but probably many cases might go undiagnosed because of difficulties in microbiology diagnosis. Primary cutaneous nocardiosis should be included in the diagnostic pathway in cases of cellulitis following insect bite or sting, especially when localized to extremities.

Isolation and Characterization of Nocardiae Associated with Foaming Coastal Marine Waters

Nocardiosis is an infectious disease caused by Nocardia species that occurs worldwide, albeit more prevalently in tropical/subtropical regions. It can appear as either acute, subacute or as a chronic infection mostly with those with a compromised/weakened immune system. Inhalation of spores and or mycelium fragments is the main transmission route for developing pulmonary nocardiosis. In contrast, cutaneous nocardiosis usually occurs via direct contact. In the subtropical region of the Sunshine Coast in Australia foaming events with thick and persistent and orange-brown color foam have been observed during summer seasons in the near shore marine environments. This study reports the existence of nocardiae in these near shore marine environments by the use of a novel isolation method which used the gas requirements of nocardiae as a selective battery. A total of 32 nocardiae were isolated with the use of this novel method and subsequently conducted molecular identification methods confirmed that the isolates belonged to the genus Nocardia. Twenty-one isolates out of the 32 were closely related to N. nova strains MGA115 and one was related to CBU 09/875, in addition when compared with human pathogenic nocardiae twenty of the isolates were found to be related to N. nova strain JCM 6044. Isolates displayed varied resistance against some of the antibiotics tested when interpretation threshold recommended the Comite de L'Antibiogramme de la Societe Francaise de Microbiologie were used. The highest level of resistance against cefotaxime (n = 27) and ceftriaxone (n = 24). Some of the isolates (n = 6) that displayed resistance to selected antibiotics also possessed potential human pathogenic characteristics such as adherence and translocation through human long epithelial cells as well as displaying phage resistance (n = 26). They might thus present a potential public health risk if frequently encountered through exposure to aerosols generated by the foam as well as direct contact through a wound. Preventative measures to control the growth of nocardiae in such environments such as the control of pollutants, might prevent potential infections that might be caused by these bacteria in humans as well as in marine animals.

Primary cutaneous nocardiosis caused by Nocardia nova with possible Apremilast contribution

Primary cutaneous nocardiosis accounts for 5-8 % of all nocardiosis cases and represents a diagnostic dilemma among immunocompetent and immunocompromised hosts. Herein, we present a case of a 30-year-old male with history of psoriasis with recent addition of Apremilast. Patient received intralesional triamcinolone injections for psoriatic plaques on the hands and abdomen prior to traveling to warm climate vacation. While on vacation, patient developed hand swelling and painful, red nodules on the dorsal hands and abdomen, sites where he received intralesional injections. Patient was empirically given doxycycline, but continued to develop new nodules. An abdominal lesion was biopsied for H&E and tissue culture. Tissue culture revealed beaded gram-positive rods identified as Nocardia nova by MALDI-TOF. Patient was switched to trimethoprim-sulfamethoxazole with significant improvement. This case represents an atypical primary cutaneous nocardiosis with Nocardia nova most likely in the setting of intralesional steroid injections and possible contribution of Apremilast.

Primary Cutaneous Nocardiosis in an Adolescent with Crohn Disease

Nocardia is an aerobic, Gram-positive, partially acid-fast bacterium that often manifests as pulmonary infection since the primary route of entry is via the respiratory tract. As an opportunistic organism, Nocardia primarily affects immunocompromised individuals. Infection with Nocardia is uncommon. Primary cutaneous nocardiosis which is caused by percutaneous inoculation is even more rare. Here, we report a case of primary cutaneous nocardiosis in an adolescent with Crohn disease receiving treatment with adalimumab and azathioprine. Early identification and treatment are important to prevent disease progression and to avoid severe complications. Diagnosis is made principally by culture. Given that culture results may take up to two weeks to return, primary cutaneous nocardiosis should be maintained in the differential for any superficial cutaneous infection that arises in individuals undergoing treatment with immunosuppressive agents.

[Sporotrichoid nocardiosis by Nocardia brasiliensis]

Nocardia brasiliensis is a gram-positive, branched, aerobic, acid-resistant, rod-shaped bacillus that inhabits in soil, rotten organic matter and waters. Cutaneous nocardiosis in immunocompetent individuals can manifest in three different forms: actinomycetoma, superficial skin infection or lymphocutaneous infection. A case of an 85-year-old woman with an ulcerated lesion on the back of her left hand with erythematous papules in the lymphatic tract infected by N. brasiliensis is described. The microorganism was presumptively identified by conventional and inexpensive methods for a medium complexity laboratory at the species level. The morphological characteristics of colonies, the mold smell, a positive Kinyoun stain and the presence of aerial mycelium were the key tests to identify the genus. Species level identification was confirmed by mass spectrometry (MALDI-TOF MS). The trimethoprim-sulfamethoxazole treatment was effective as this agent was active in the susceptibility testing.

Uncommon burn complication: skin nocardiosis

Skin nocardiosis is an uncommon form of cutaneous infection caused by Nocardia. More than 100 different species have been isolated and they mainly inhabit soil and water. Cutaneous affection can be divided into primary and secondary forms. Cell culture is the most used diagnosis method and trimethoprim-sulfamethoxazole the antibiotic treatment.We present a patient diagnosed with skin nocardiosis whose way of inoculation has not been described in the literature. However in future this kind of infection will probably increase due to the increasing interest in phytotherapy. Physicians should be aware of clinical manifestation, diagnosis and treatment.

A case report of Nocardia cyriacigeorgica presenting as cellulitis with multiple discharging sinuses

Nocardia spp. are filamentous Gram positive bacteria that are ubiquitous soil saprophytes. The majority of nocardial infections occur in severely immunocompromised patients who are particularly susceptible to pulmonary disease and dissemination. Extrapulmonary nocardiosis is relatively common and can occur through hematogenous dissemination or a contiguous spread of necrotizing pneumonitis. Primary cutaneous and soft tissue nocardiosis can result from traumatic injury to the skin that involves contamination with soil. After skin inoculation, a superficial abscess or localized cellulitis can develop. Co-trimoxazole is the drug of choice for all types of nocardiosis. We are reporting a case of Nocardia cyriacigeorgica presenting as cellulitis followed tooth extraction.

Primary Cutaneous Nocardiosis: A Rare Presentation of Nocardiosis

Nocardia is an uncommon gram-positive, weakly acid-fast bacterium that causes systemic or localized suppurative disease in humans and animals. Nocardiosis is typically regarded as an opportunistic infection, but approximately one-third of the patients are immunocompetent. The most common presentation is pulmonary disease (39%) followed by systemic involvement, defined as involvement of more than two sites; cutaneous presentation constitutes only 8% of the cases. Nocardia is widely distributed geographically; however, in the US, it is mostly found in warm and dry areas of South West and South East. We present a perfect case of cutaneous nocardiosis of a 70-year-old male, who presented with a traumatic splinter injury, leading to pustules formation on the right index finger, along with erythema and induration of the right arm. The patient was empirically diagnosed and treated for cellulitis, with amoxicillin and clavulanic acid, resulting in deterioration of the wound. The patient underwent incision and drainage and wound culture grew nocardia. The index of suspicion should be kept in mind while treating infectious blisters which have failed outpatient cellulitis treatment, immunocompromised hosts, and in nocardia prevalent regions.

Sporotrichoid Skin Infection Caused by Nocardia brasiliensis in a Kidney Transplant Patient

Prompt and accurate diagnosis of Nocardia skin infections is important in immunocompromised hosts, especially transplant patients. The sporotrichoid form, which is otherwise known as the lymphocutaneous form of Nocardia skin involvement, can mimic other conditions, including those caused by fungi, mycobacteria, spirochetes, parasites and other bacteria. Delayed or inaccurate diagnosis and treatment of Nocardia skin infections in transplant patients could lead to dissemination of disease and other poor outcomes. Nocardia brasiliensis is a rare cause of lymphocutaneous nocardiosis in solid organ transplant patients with only two other cases reported to our knowledge. This case describes a middle-aged man, who presented 16 years post kidney transplant. He developed a sporotrichoid lesion on his upper extremity one week after gardening. Ultrasound showed a 35-cm abscess tract on his forearm, which was subsequently drained. Nocardia brasiliensis was isolated from pus culture and he was treated successfully with amoxicillin/clavulanate for 6 months. A review of the relevant literature is included.

Comment on a Primary Cutaneous Nocardiosis of the Hand

Nocardia spp. are gram-positive, partially acid-fast bacteria which are lives in environmental sources and cause of various infection that called nocardiosis in animals and humans. Identification of this group of bacteria was important due to accurate diagnosis, patient management and prevention of antibiotic resistant among of bacteria. Molecular methods including PCR-RFLP and sequencing using housekeeping genes such as 16S rRNA, hsp65, rpoB and gyrB are recommended to accurate and reliable identification of nocardiosis.