Cutaneous Nocardiosis
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Presentation
A 51-year-old man presented to the multidisciplinary wound clinic with right lower-extremity cellulitis and multiple open wounds of 6 months duration (Figure 1). His past medical history was significant for hypertension and insulin-dependent diabetes mellitus. Injured while gardening, his leg initially developed small punctures with surrounding contusions. As local erythema and edema evolved, the wounds became pustules and developed bullae. These chronic, worsening wounds opened and began draining, causing him to seek medical attention.
Diagnosis
Wound culture results and wound biopsy revealed Nocardia brasiliensis infection with chronic granulomatous tissue consistent with a chronic wound.
Discussion
Nocardiosis is an infection caused by the bacteria of the order Actinomycetales. They are gram-positive filamentous bacteria. Nocardiosis can be caused by 10 different species of the family, but N. asteroides,1–5 N. brasiliensis,6,7 and N. caviae are the most common species causing human infection.8,9 Nocardia asteroides accounts for 90% of all nocardial infections.1–5,10,11 Nocardiosis is typically an opportunistic pulmonary infection that affects immunocompromised individuals. It can become systemic and often forms abscesses in the brain and skin.1,2,4,5,7 Once disseminated to the brain, N. asteroides has a mortality rate as high as 87%.11 Nocardia brasiliensis accounts for 7–10% of all nocardial infections but is the predominate Nocardia infection seen in cutaneous infections.6,7,10,11 Nocardia caviae accounts for only 3% of cases.11 Overall, the rate of nocardial infection is on the rise with approximately 500–1,000 estimated cases each year.11,12
In 1888, Nocard first described an acid-fast actinomycete that caused a fatal disease in cattle known as bovine farcy.13,14,15 Three years later, Eppinger reported a man with pleuropulmonary disease, cerebral abscesses, and meningitis caused by the aerobic, gram-positive, acid-fast actinomycete, which he called a “pseudo-tuberculosis.”14,15,16 Over many years, the organism became known as Nocardia. In 1909, Lindenburg first isolated a separate subspecies, N. brasiliensis, from the leg of a Brazilian man.11
Nocardia brasiliensis is the most common cause of primary cutaneous nocardiosis.6,7,10,11 It is typically associated with traumatic inoculation of contaminated soil. Usually seen in gardeners, it is often associated with thorn puncture wounds, particularly from roses. This sometimes leads to the misdiagnosis of rose gardener’s disease, which is caused by the fungus Sporotrichum schenckii.10,14,17,18 Unlike N. asteroides, N. brasiliensis is more commonly a disease of the immunocompetent.6,7,11 This may be due to the fact that N. brasiliensis is the most virulent of the species, according to studies performed by Gonzalez Ochoa.7,11,19,20 Although the disease can initially present as an ulcer, abscess, granuloma, or cellulitis, it usually presents as pyodermatous lesions, which then form abscesses leaving tender subcutaneous nodules that may open spontaneously to drain.7,10,11 The abscesses are filled with a thick yellow material called sulfur granule.11,21 They often spread in a linear fashion under the skin to form separate sinuses.7,10,22 Less commonly, the disease can involve the lymphatic system and spread directly to the lymph nodes.6,15,17,18 Eventually, the disease can disseminate and spread to virtually any organ, most commonly the brain. Overall dissemination is far less common with N. brasiliensis when compared to N.
References
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