Sporotrichoid Skin Infection Caused by Nocardia brasiliensis in a Kidney Transplant Patient

Abstract

Prompt and accurate diagnosis of Nocardia skin infections is important in immunocompromised hosts, especially transplant patients. The sporotrichoid form, which is otherwise known as the lymphocutaneous form of Nocardia skin involvement, can mimic other conditions, including those caused by fungi, mycobacteria, spirochetes, parasites and other bacteria. Delayed or inaccurate diagnosis and treatment of Nocardia skin infections in transplant patients could lead to dissemination of disease and other poor outcomes. Nocardia brasiliensis is a rare cause of lymphocutaneous nocardiosis in solid organ transplant patients with only two other cases reported to our knowledge. This case describes a middle-aged man, who presented 16 years post kidney transplant. He developed a sporotrichoid lesion on his upper extremity one week after gardening. Ultrasound showed a 35-cm abscess tract on his forearm, which was subsequently drained. Nocardia brasiliensis was isolated from pus culture and he was treated successfully with amoxicillin/clavulanate for 6 months. A review of the relevant literature is included.

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

“…N. brasiliensis is the most common species that causes skin infection especially in lymphocutaneous nocardiosis type (Ayoade, Mada, Joel Chandranesan, & Alam, 2018;Secchin et al, 2017;Wilson, 2012). Lymphocutaneous nocardiosis, also called lymphocutaneous type, may resemble sporotrichosis clinically and easy to misdiagnose (Ayoade et al, 2018;Bryant, Davis, Kucenic, & Mark, 2010;Secchin et al, 2017). The infection routes of cutaneous nocardia include direct inoculation and dissemination to skin from other systemic sources (Fukuda, Saotome, Usami, & Mukai, 2008).…”

“…Both Gram staining and Anti-acid staining showed positive branching bacterium (Figure 1d is not common to primary cutaneous nocardia infection in immunecompetent host. N. brasiliensis is the most common species that causes skin infection especially in lymphocutaneous nocardiosis type (Ayoade, Mada, Joel Chandranesan, & Alam, 2018;Secchin et al, 2017;Wilson, 2012). Lymphocutaneous nocardiosis, also called lymphocutaneous type, may resemble sporotrichosis clinically and easy to misdiagnose (Ayoade et al, 2018;Bryant, Davis, Kucenic, & Mark, 2010;Secchin et al, 2017).…”

Nocardia spp.: A Rare Cause of Pneumonia Globally

“…Nocardiosis is a well-recognized, albeit rare, complication of SOT. [6][7][8]25,54,91,92,[122][123][124][125][126] A retrospective review of 5,136 SOT recipients (SOTRs) at the University of Pittsburgh from January 1995 to December 2005 identified only 35 cases of nocardiosis (incidence: 0.6%). 54 In that study, nocardiosis was most common in lung transplant recipients (LTRs) and HTRs (3.5 and 2.5%, respectively), followed by intestine (1.3%), kidney (0.2%), and liver (0.1%) transplant recipients.…”

“…In Barcelona, Spain, mortality rates among 31 adults with nocardiosis were 41% with lung involvement only, 64% with dissemination and 100% with CNS involvement. 18 Skin/Soft Tissue Infections SSTI can occur from inoculation in outdoor settings 21,[25][26][27][28]57 ; gardening, 71 insect bites, 72 and exposure to contaminated water 75 have been associated, as has intralesional injection. 73 Skin involvement is more common with N. brasiliensis.…”

“…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.…”