Dermatologic Manifestations of Nocardiosis Clinical Presentation

  • Author: Brent A Shook, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 11, 2012
 

History

  • Trauma: Elucidating a history of trauma, especially a puncture wound while gardening or a cat's scratch, can help make the correct diagnosis. Vehicular accidents are predisposing factors, particularly if significant exposure to soil occurred.[8] Trauma may have occurred several days to several months prior to clinical illness.
  • Occupational exposure: Rural laborers exposed to traumatic injuries while walking barefoot are at highest risk of mycetoma formation. Others at increased risk are farmers and gardeners.
  • Immunodeficiency
    • Immunosuppression is commonly a contributing factor in N asteroides infections but typically is not necessary for infections caused by N brasiliensis. N asteroides is primarily an opportunistic pathogen, while N brasiliensis causes skin infections in healthy hosts.
    • Additionally, with the advent of new immune-response modifying medications (eg, infliximab) for relatively common diseases such as rheumatoid arthritis, Crohn disease, and psoriasis, opportunistic nocardiosis may increase in prevalence.[9] A case report revealed Nocardia species as the causative organisms in a patient receiving infliximab and prednisone. Inquire about compliance with prophylactic antibiotics with certain underlying conditions, including HIV infection and certain cancers, including leukemia.
    • Given the sensitivity of Nocardia species to trimethoprim-sulfamethoxazole (TMP-SMZ), compliance with prophylaxis greatly decreases the likelihood of nocardiosis in these patients.[10]
  • Resistance to previous antibiotic therapy: Because many nocardial infections mimic infections caused by skin florae, standard antibiotic regimens for staphylococcal and streptococcal species often fail and the infection worsens while the patient is on empiric therapy.
  • History of fever: Fever is more common in patients with acute cellulitis and abscess.
  • Mild weight loss: Weight loss is more common in patients with the chronic mycetoma variant.
  • History of local recurrence: Cellulitis and abscesses caused by nocardial species require prolonged antibiotic therapy or they commonly recur.
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Physical

  • Superficial skin infection (eg, cellulitis, abscesses, ulcers) - Cannot be distinguished clinically from more common bacterial etiologies
    • Typically, no lymphadenopathy is noted.
    • Fever is common.
    • Superficial skin infection is often accompanied by a pyoderma, which is a purulent crusting lesion that heals with ulcer formation. In 1979, Satterwhite and Wallace[11] reported that 3 of 7 patients had associated pyoderma.
    • Patients may have other less common superficial infections, including paronychia, posttraumatic keratitis and endophthalmitis, and wound infections secondary to compound fractures or sternotomy.
  • Lymphocutaneous infection
    • This manifests as an initial ulcerative papule or nodule at the inoculation site with secondary subcutaneous nodules along lymphatic vessels (chaining nodular lymphangitis).[12]
    • It most commonly involves the upper extremities.
    • The lymphocutaneous infection is more acute and inflammatory, with more painful, tender, erythematous lesions, than in infections caused by Sporothrix schenckii.
    • Purulent drainage is noted.
    • Macroscopic sulfur granules can be expressed from lesions, although this is a rare occurrence.
    • Regional lymphadenopathy is common.
  • Mycetoma
    • This typically involves the dorsal foot, and it can be localized to the leg, arm, or hand.
    • It is a progressively destructive infection of the skin and can extend to subcutaneous tissues, fascia, bone, and muscle.
    • It appears as an area of localized tumorlike swelling with multiple sinus tracts; however, amazingly, it usually is not painful.
    • Macroscopic sulfur granules commonly can be expressed from sinus tracts.
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Causes

  • N brasiliensis is responsible for less than 10% of nocardiosis infections but causes most primary cutaneous lesions, especially in superficial skin and lymphocutaneous infections.
  • N asteroides is the primary culprit in systemic and pulmonary infections but less often causes cutaneous nocardiosis. Two exceptions include disseminated cutaneous disease, which typically is caused by N asteroides, and mycetoma (in some countries). Recently, N asteroides has been implicated in ocular infections after laser in situ keratomileusis (LASIK) surgery.[13]
  • Nocardia otitidiscaviarum (Nocardia caviae) is an infrequent cause of infection in humans and is believed to be less pathogenic than the more common species of Nocardia. N otitidiscaviarum can cause all 3 subtypes of primary cutaneous nocardiosis. Prior to 1995, of the 28 patients with cutaneous N otitidiscaviarum infections reported in the literature, 16 had superficial skin infections including abscess, ulcers, and wound infections. Mycetomas were classified in 8, and 1 had lymphocutaneous syndrome. Three patients were not classified. N otitidiscaviarum is often resistant to sulfonamides.[14]
  • Nocardia farcinica is significant historically because Edmond Nocard first described this species as the cause of bovine farcy in 1888. Clinically, this species is significant to humans because it has a high degree of antibiotic resistance, especially to third-generation cephalosporins and tobramycin. Fortunately, it usually is susceptible to TMP-SMZ and rarely infects humans. Only recently has it been accepted as an important human pathogen. Prior to 1993, N farcinica infection had been reported in 14 patients. The lungs were involved in 7 patients, the brain in 4, and the skin in only 3 patients. Wallace et al have suggested that a significant percentage of drug-resistant N asteroides species actually are N farcinica. Controversy surrounds the identity of N farcinica, either as a truly distinct species or as a variant of N asteroides.
  • Nocardia nova, like N farcinica, is a member of the N asteroides complex and is differentiated by its unique antibiotic susceptibility pattern.
  • Nocardia transvalensis causes mycetoma in Africa and life-threatening invasive infections in severely immunocompromised persons.
  • Nocardia paucivorans is a cause of disseminated nocardiosis in both immunocompromised and immunocompetent persons. One review revealed that N paucivorans has a relatively high incidence (>30%) of dissemination.[15]
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Contributor Information and Disclosures
Author

Brent A Shook, MD  Director, The Woodlands Skin Surgery Center, The Woodlands, Texas

Brent A Shook, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, American Society for MOHS Surgery, Christian Medical & Dental Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Ronald P Rapini, MD  Josey Professor and Chair, Department of Dermatology, Professor of Pathology, University of Texas Medical School at Houston and MD Anderson Cancer Center

Ronald P Rapini, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Society for Investigative Dermatology, and Texas Medical Association

Disclosure: Elsevier publishers Royalty Independent contractor

Specialty Editor Board

Daniel Mark Siegel, MD, MS  Director, Procedural Dermatology Fellowship Program, Clinical Professor of Dermatology, Department of Dermatology, State University of New York Downstate

Daniel Mark Siegel, MD, MS is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American College of Physician Executives, American Society for Dermatologic Surgery, American Society for MOHS Surgery, and International Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Lester F Libow, MD  Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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Red nodules on a patient with disseminated nocardiosis.
Ulcer on the arm of a patient with primary cutaneous nocardiosis.
Gomori methenamine silver stain demonstrating black filamentous Nocardia species.
 
 
 
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