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.

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Immune thrombocytopenic purpura (ITP) can be acquired or secondary to other drugs, infections, or autoimmune disorders. Legionella is a known intracellular organism that causes Legionnaire's disease and affects the lungs. Presented is the first case showing a direct association between Legionella and ITP. Our patient was a 61-year-old female with a past medical history of asthma whose clinical presentation was consistent with pneumonia secondary to Legionella . Her hospital course was complicated by critical bleeding with severe thrombocytopenia. She responded to antibiotics, steroids, and intravenous immunoglobulins (IVIG). Our case suggests an association between ITP and Legionella and emphasizes its timely diagnosis for appropriate treatment.