An unusual successful treatment with non-sulfonamides: primary cutaneous nocardiosis caused by <em>Nocardia brasiliensis</em>

Abstract

IntroductionPrimary cutaneous nocardiosis is a rare suppurative or granulomatous inflammation disease caused by Nocardia infection. Because of nonspecific clinical findings, it is always misdiagnosed as common pyogenic infection. Sulfonamides have been the standard treatment for nocardiosis, but the outcome is always poor due to the high rates of misdiagnosis and refractoriness of the disease.Cases presentationsThe presented cases are patients of acute suppurative cutaneous infection without involvement of other organs. We report four cases, of which two cases were localized cutaneous nocardiosis and the other two were lymphocutaneous type of nocardiosis. All cases were diagnosed with pus culture which turned out to be Nocardia brasiliensis. We report an improvement of primary cutaneous nocardiosis symptoms in the four patients treated with non-sulfonamides. All patients were cured and recovered without recurrence during follow-up.ConclusionOur results suggest that non-sulfonamides are effective treatment for the patients with primary cutaneous nocardiosis who are resistant or intolerant to sulfonamides.

Clinical analysis of 11 cases of nocardiosis

“…Nocardia can spread to almost all parts of the body through the blood from the lungs (especially the upper lobes of the lungs) or infected areas of the skin. As inhalation is the main route of transmission for Nocardia , the respiratory tract is the most affected organ, followed by the CNS, skin and soft tissue, kidneys, and peritoneum [ 19 , 20 , 21 ]. The symptoms of CNS infection include headache, meningeal irritations, seizures, and focal neurological dysfunction.…”

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

“…But sulfonamide resistance has been reported in some cases in recent years (Brown‐Elliott et al, ; Chen et al, ; Maraki et al, ; Uhde et al, ). Nevertheless, more studies suggested that the combined drug therapy is recommended especially in severe infection or resistant to TMP‐SMX (Baio et al, ; Brown‐Elliott et al, ; Chen, Qin, Sun, Luo, & Cheng, ; Coussement et al, ; Lebeaux et al, ; Uhde et al, ) . Combination drug treatment for infection of N. brasiliensis , especially TMP/SMX combined with minocycline or cephalosporins or imipenem treatment, may have advantages compare to single drug treatment, affording to better clinical improvement and shorter treatment periods and better prevention of recurrence (John & Wilson, ; Paredes et al, ; Uhde et al, ).…”

“…Combination drug treatment for infection of N. brasiliensis, especially TMP/SMX combined with minocycline or cephalosporins or imipenem treatment, may have advantages compare to single drug treatment, affording to better clinical improvement and shorter treatment periods and better prevention of recurrence (John & Wilson, 2012;Paredes et al, 1999;Uhde et al, 2010). Other combinations therapy includes imipenem combined with amikacin or cefotaxime, as well as combined with moxifloxacin (Chen et al, 2018;John & Wilson, 2012). So far, the optimal combination treatment regiments still have not been recommended for lacking of prospective controlled trials and individualized treatment should be considered (John & Wilson, 2012;Munoz et al, 2007).…”

Nocardia spp.: A Rare Cause of Pneumonia Globally

“…73 Skin involvement is more common with N. brasiliensis. [21][22][23][24]165 Manifestations may include pustules (►Fig. 3), abscesses, necrosis, 166 and nodular pustular pyoderma with sporotrichoid spreading 22,29,37,57,72,167,168 ; infection may extend into contiguous tissues (e.g., muscle, 169 fascia, 170 bone, 29,168 and lymphatics).…”

“…16,18 Pulmonary nocardiosis may mimic communityacquired pneumonia, and this may be more common among individuals with agricultural or outdoor occupations in developing countries. 10,12,16 Nocardiosis primarily involves the lungs, 5,[19][20][21] but skin and soft tissue infections (SSTIs), [21][22][23][24][25][26][27][28][29] central nervous system (CNS) infection (brain abscesses, meningitis), 7,[30][31][32][33][34] and dissemination 4,11,12,21,35 may occur. Given the rarity of the disease, the diagnosis and initiation of appropriate antimicrobial therapy are often delayed.…”