Case of muscle abscess due to disseminated nocardiosis in a patient with autoimmune hemolytic anemia, and review of the published work

Abstract

Although disseminated nocardiosis has been increasing with the expansion of immunosuppressive therapy and improvement in diagnostic methods, muscle abscess is a rare complication. There have been only nine case reports of muscle abscess due to Nocardia infection in the English-language published work. We present a case of muscle abscess with disseminated nocardiosis, and review the published work. The patient had been taking prednisolone at 20 mg a day for autoimmune hemolytic anemia for 14 years. She presented with erythema on her thigh resembling cellulitis. Computed tomography showed muscle abscess. The isolated organism was identified as Nocardia farcinica employing polymerase chain reaction and antibiotic sensitivity testing. The diagnosis of muscle abscess due to nocardiosis can be easily missed because there are no characteristic symptoms.

Disseminated Nocardiosis Masquerading as Soft-Tissue Malignancy

“…In immunosuppressed people, however, nocardiosis can disseminate to any organ, most commonly resulting in brain abscesses 3,7 . Intramuscular nocardial abscesses are a rare manifestation with no well-described characteristic symptoms 5 . An extensive literature review yielded only 20 cases, with 9 abscesses in the thigh 4,5,21-24 , 6 in the iliopsoas muscle 5,7,9,21,25,26 , 2 in the calf muscles 27 , 1 in the gluteal muscles 5 , 1 in the lower abdominal wall musculature 21 , and 1 in the deltoid muscle 21 .…”

“…Intramuscular nocardial abscesses are a rare manifestation with no well-described characteristic symptoms 5 . An extensive literature review yielded only 20 cases, with 9 abscesses in the thigh 4,5,21-24 , 6 in the iliopsoas muscle 5,7,9,21,25,26 , 2 in the calf muscles 27 , 1 in the gluteal muscles 5 , 1 in the lower abdominal wall musculature 21 , and 1 in the deltoid muscle 21 . Clearly, Nocardia has a predilection for lower extremity and hip flexor musculature.…”

“…Clearly, Nocardia has a predilection for lower extremity and hip flexor musculature. Ten cases were primary to the muscle 4,5,21-23,26,27 , and 10 were disseminated from elsewhere 5,7,9,21,24,25,27 , mostly pulmonary origins. Seventeen patients survived their infections 4,5,7,9,21-27 , whereas 2 died 5,27 and 1 outcome was not provided 5 .…”

“…Ten cases were primary to the muscle 4,5,21-23,26,27 , and 10 were disseminated from elsewhere 5,7,9,21,24,25,27 , mostly pulmonary origins. Seventeen patients survived their infections 4,5,7,9,21-27 , whereas 2 died 5,27 and 1 outcome was not provided 5 . Speciation revealed N. farcinica , N. asteroides , N. paucivorans , N. brasiliensis , N. pseudobrasiliensis , and N. abscessus .…”

Nocardia farcinica complicating Cogan's syndrome

“…The lung is most commonly affected, but Nocardia can disseminate haematogenously to the central nervous system (CNS) and also to bone, retina, heart, joints, kidneys and soft tissues. Cutaneous infection is the least common site of infection and presents mainly with abscesses [ 2 , 3 ]. Cell-mediated immunity is critical in containing Nocardia infection and this makes immunocompromised patients with cell-mediated abnormalities, more susceptible to Nocardia infections [ 4 , 5 ].…”