Skin Nocardiosis

A 40-year-old Hispanic male with no significant past medical history was traveling back to his country when he was brought to the emergency department from the airport due to an altered mental status. The family members who came with the patient denied any history of trauma, nausea, vomiting, abdominal pain, diarrhea, sore throat, or shortness of breath.

Physical examination. On examination, the patient was lethargic and disoriented. Cardiopulmonary and abdominal exam was normal, and there was no lymphadenopathy. Skin examination showed multiple, subcutaneous, firm, brown-violaceous nodules in the external side of the left forearm—the biggest one measured 2 cm in diameter with yellowish drainage. There were multiple, ulcerated lesions in the inner side of both upper extremities near the elbow with subcutaneous nodules around them.

Laboratory tests. An MRI of the brain showed multiple ring-enhanced lesions; a CT found lesions that suggested central nervous system (CNS) toxoplasmosis. A rapid HIV test was positive.

The differential diagnoses for the skin lesions included disseminated toxoplasmosis, kaposi sarcoma, and skin lymphoma. A biopsy of the nodular and ulcerated lesion showed nocardia and the patient was started on intravenous trimethoprim/sulfamethoxazole. During hospitalization, the patient was given oral medication while treated for other conditions.

He was discharged about 30 days after admission and readmitted 1 week later because of oral thrush; at that time there were no skin lesions. He was treated for oral candidiasis and he was advised to continue treatment with trimethoprin/sulfamethoxazole. He was loss for follow-up because he traveled to his own country.

Discussion. Cutaneous nocardiosis is an uncommon disease and HIV infection has become 1 of the most common underlying condition.¹ It may manifest as a superficial primary skin lesion, lymphocutaneous infection, or mycetoma.² The superficial skin infection is characterized by pus-filled blister, cellulitis, and abscesses that sometimes heal with ulcer formation.

Lymph nodes are not usually enlarged.³ Lymphocutaneous infection is rare. It is characterized by ulcerative lesion, with cutaneous inflammation and subcutaneous nodules along the lymphatic chain.^4-6

Mycetome or Madura foot, is a chronic, destructive, and progressively deforming granulomatous inflammation in the deep dermis and subcutaneous tissue with formation of grains containing aggregates of the causative organisms that may be discharged onto the skin surface through multiple sinuses.⁷ These lesions are clinically indistinguishable from lesions produced by common pyogenic bacteria, parasitic, fungal, or nontuberculous mycobacterial infections. A high degree of suspicion is needed to diagnose nocardia infection and it should be included in the differential diagnoses of chronic cutaneous infections when the patient is immunocompromised.

References:

1. Minero MV, Marín M, Cercenado E, et al. Nocardiosis at the turn of the century. Medicine (Baltimore). 2009;88(4):250-261.
2. Fukushiro R, Kumagai T. Cutaneous nocardiosis. Hifubyoh-shinryoh. 1981;3:349-352.
3. Hiroshi Y, Etsuko S, Atsuhisa S, et al. Testicular nocardiosis accompanied by cutaneous lesions in an immunocompetent man. Intern Med. 2013;52(1):129-133.
4. George SJ, Rivera AM, Hsu S. Disseminated cutaneous nocardiosis mimicking cellulitis and erythema nodosum. Dermatol Online J. 2006;12(7):13.
5. Bryant E, Davis CL, Kucenic MJ, Mark LA. Lymphocutaneous nocardiosis: a case report and review of the literature. Cutis. 2010;85(2):73-76.
6. Hidetsugu F, Atsuko S, Nao U, et al. Lymphocutaneous type of nocardiosis caused by Nocardia brasiliensis: A case report and review of primary cutaneous nocardiosis caused by N. brasiliensis reported in Japan. J Dermatol. 2008;35:346-353.
7.  Venkatswami S, Sankarasubramanian A, Subramanyam S. The Madura foot: looking deep. Int J Low Extrem Wounds. 2012;11(1):31-42.