Soil-acquired cutaneous nocardiosis on the forearm of a healthy male contracted in a swamp in rural eastern Virginia

Abstract

A 45-year-old man complained of pain and swelling on his right wrist after receiving a scratch while playing paintball in a swampy area of eastern Virginia. Two weeks later, he noticed a pimple-like lesion developing, which quickly grew in size and then ulcerated. Because of the severity of his condition, the patient was taken to the emergency room where surgical drainage of the abscess was carried out and the pus was sent for culture and sensitivity testing. Enlarged and tender lymph nodes were palpable going up the arm and surrounding the right axillary area. Three days following culture of pus from his lesion, colonies of Nocardia brasiliensis were isolated. He was successfully treated with an extended regimen of trimethoprim-sulfamethoxazole. Because of its low incidence, nocardiosis is usually not considered in the initial diagnosis. The rapidity with which his infection developed from a pimple-like lesion into an extensive ulcerated area, the involvement of his lymphatic system, the extended time needed to successfully treat his infection, and the potential for infection to rapidly disseminate, reinforces the necessity for laboratory identification and immediate treatment of severe pyogenic cutaneous lesions.

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

“…Third-generation cephalosporins are active against Nocardia spp. 6 In our latter two cases, oral cefixime is also proved to be effective to N. brasiliensis . Because the disease has a tendency to recur, all the patients need to be closely followed up.…”

“…A combination of antibiotics and appropriate surgical drainage is the preferred treatment. 6 Sulfonamides have been the first-line drug therapy for nocardiosis. However, the resistance of the bacteria and the patients’ intolerance to the drugs necessitate the use of alternative antibiotics.…”

First Case of Nocardia pseudobrasiliensis Causing Primary Cutaneous Nocardiosis in an Immunocompetent Patient

“…8 Coccidioides immitis along with Histoplasma capsulatum , Cryptococcus neoformans , Pseudoallescheria boydii , Blastomyces dermatitidis , and viruses like cowpox or herpes simplex are few of the less common causes of lymphangitis. 9…”

“…8 Coccidioides immitis along with Histoplasma capsulatum, Cryptococcus neoformans, Pseudoallescheria boydii, Blastomyces dermatitidis, and viruses like cowpox or herpes simplex are few of the less common causes of lymphangitis. 9 Diagnosing nocardiosis is challenging as clinical presentation is similar to other diseases mentioned above. Commercial availability as well as reliability of serological test is not good.…”

Image Gallery: Acute primary cutaneous nocardiosis due to Nocardia brasiliensis

“…The entity can occur sporadically worldwide. As an unreportable disease in many areas, its actual prevalence is unknown . This infection remains a diagnostic challenge due to its nonspecific clinical appearance.…”