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Year : 2008  |  Volume : 51  |  Issue : 3  |  Page : 432-434
Sporotrichoid pattern of cutaneous nocardiasis due to Nocardia asteroids


Department of Microbiology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai - 400 002, India

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   Abstract 

Cutaneous nocardiosis is a rare disease, only a few cases of which have been reported from the world as well as in India. This infection, when in the lymphocutaneous form, may clinically resemble sporotrichosis, hence causing a diagnostic dilemma. Here, we report a case of primary cutaneous, sporotrichoid pattern of cutaneous nocardiosis caused by Nocardia asteroides in immunocompetent host. The patient was a 32-year-old farmer, with no predisposing factors, who presented with cutaneous nocardiosis. The diagnosis was confirmed by culture of the biopsy, after which the patient was treated successfully with antibacterial agents.

Keywords: Cutaneous nocardiosis, lymphocutaneous form, sporotrichoid

How to cite this article:
Baradkar V P, Mathur M, Kulkarni S D, Kumar S. Sporotrichoid pattern of cutaneous nocardiasis due to Nocardia asteroids. Indian J Pathol Microbiol 2008;51:432-4

How to cite this URL:
Baradkar V P, Mathur M, Kulkarni S D, Kumar S. Sporotrichoid pattern of cutaneous nocardiasis due to Nocardia asteroids. Indian J Pathol Microbiol [serial online] 2008 [cited 2020 Jul 12];51:432-4. Available from: http://www.ijpmonline.org/text.asp?2008/51/3/432/42553



   Introduction Top


Nocardiosis has been reported from different parts of the world. The incidence of Nocardiosis is however difficult to assess, in part because it is not a reportable disease. With the rapidly growing population and the patients with various forms of immunological abnormalities, it is not unreasonable to predict that the number of patients developing Nocardiosis is increasing. [1] As there are increased number of cases, it has gained a significant recognition in the microbial world. [2] Cases of cutaneous Nocardiosis have been reported from India. [3],[4],[5] Here, we report a rare, sporotrichoid pattern of cutaneous nocardiosis diagnosed by microscopy and culture.


   Case History Top


A 26-year-old man, an agriculturist by profession, presented with a history of skin lesions over the right leg since 1 year. There were multiple ulcerating lesions spreading in a linear fashion on the leg [Figure 1] along with the involvement of inguinal lymph nodes. To start with, there was a small nodule on the lower side of the leg, which had ulcerated and had ragged undermined borders. Later, the patient developed other painless lesions in an ascending fashion. There was no other lesion elsewhere in the body. The hemogram and chest X-ray were within normal limits. The patient was non-diabetic and HIV seronegative. A provisional diagnosis of sporotrichosis was made. The history revealed that there was no associated fever or respiratory distress. The patient's further investigations showed that the liver and renal function tests were within normal limits.

The material from scrapings was sent for laboratory investigations. The histopathological examination revealed lining of keratinized stratified squamous epithelium, focally ulcerated, covered with exudates, beneath which fibrocollagenous tissue was seen, along with infected granualation tissue composed predominantly of lymphocytes, plasma cells, histiocytes and polymorphs.

The Gram stain of the biopsy was performed, which revealed Gram-positive filamentous bacilli with branching; therefore, in order to rule out Nocardia , a modified ZN staining (decolourising agent being 1% H 2 SO 4 ) was performed, which revealed acid-fast filamentous bacilli with branching [Figure 2]. Repeat biopsy was taken and cultured on Blood agar, MacConkey agar, Sabouraud's Dextrose agar (SDA), Lowenstein Jensen (LJ) medium. After 1 week of incubation of the cultures, orange-colored colonies appeared on SDA and LJ medium [Figure 3]. Gram's staining and modified acid-fast staining using 1% sulfuric acid was done from the colony which showed filamentous Gram positive, acid-fast bacilli, morphologically resembling Nocardia species . By performing the biochemical tests, [6] the isolate was confirmed as Nocardia asteroides. The patient showed dramatic improvement with Cotrimoxazole, Dapsone, Amikacin in cycles of 5 weeks followed by an additional course of Ciprofloxacin. After 6 months of treatment, the lesions healed with significant scarring.


   Discussion Top


Nocardiosis has been reported widely and studies have proved that it is no longer an uncommon disease in India. [1],[2],[3],[4],[5] Usually, it is seen in predominantly immunocompromised host and other predisposing conditions like renal transplant; but in the present case, there were no predisposing factors. The patient reported here was a farmer by occupation and probably might not have noticed any minor injury, which could have been the probable mode of infection in this patient.

The genus Nocardia belongs to the order Actinomycetales , a group of aerobic Gram-positive filamentous bacteria. They are weak, acid fast, resisting decolorization with 1% H 2 SO 4 as a decolorizing agent. [1],[2],[3],[4],[5],[6] Nocardia asteroids is the species commonly isolated from human infections. Other species like Nocardia otidis-caviarum,  Nocardia farcinica Scientific Name Search  and Nocardia nova are less commonly isolated. [4]

Cutaneous Nocardiosis presents either as a part of disseminated infection or as a primary infection resulting from inoculation. Primary cutaneous nocardiosis, though rare, a few cases have been reported even from India. [3],[4],[5] Three clinical variants have been identified: a superficial acute skin and soft tissue infection; a lymphocutaneous infection and deeper infection; and mycetoma. Mycetoma is commoner than the two other clinical variants.

The exact incidence of primary cutaneous nocardiosis is not clear. The number of cases of primary cutaneous nocardiosis is very few. A 12% incidence was reported in a 24-year survey of Nocardial infection in Spain. [7] According to Palmer et al, [8] the incidence of primary cutaneous nocardiosis reported in the English literature between 1961 and 1971 was 5%. An incidence of 10% has been quoted by Uttaramchandani et al , [9] in patients with HIV. Though data regarding the overall incidence of primary cutaneous Nocardiosis is not available from India, a few cases have been documented. [3],[4],[5]

Cutaneous infections with Sporothrix schenckii and N. brasiliensis are one of the probable infections to be complicated by nodular lymphangitis. These syndromes usually, but not invariably, occur in immunocompetent hosts and remain confined to lymphocutaneous structures. [10] When primary cutaneous nocardiosis presents as a rare sporotrichoid pattern, culture is necessary to confirm the diagnosis and to treat the patient. The lymphocutaneous pattern of the disease is the rarest type and commonly occurs in otherwise healthy individuals. [7] Clinically, it simulates sporotrichosis, but differs from this fungal infection by its acute onset, erythema of the overlying skin, tenderness and a highly inflammatory course. [7] Rarely, granules may be observed in the discharge from noduloulcerative lesions. However, an estimation of the incubation period can provide additional help in predicting the infecting agent. Nocardia infections may have a relatively brief incubation period (frequently less than 2 weeks). [10] The time between inoculation and development of the disease often substantially exceeds 2 weeks for infections caused by Sporothrix species. [10] The initial cutaneous lesions seen in sporotrichosis are typically ulcerated papules compared to Nocardial lesions, which often exude frank pus; the lymphangitic nodules themselves can sometimes ulcerate and suppurate, especially in Nocardia infections. [10] Although regional adenopathy commonly develops in patients infected by N. brasiliensis , it is less frequent in sporotrichosis. Lack of response to therapy can be used as a discriminating diagnostic tool.

Many patients who have nodular lymphangitis are treated as though they have sporotrichosis and they do not receive a definitive diagnosis. In this setting, failure of the patient to respond should prompt consideration of other causes, prioritized according to the clinical context. However, apparent responses can be misleading because spontaneous recovery is not uncommon in many of these infections. [10] Appropriate smears and cultures of biopsy specimens can establish the diagnosis in most patients.

The lymphocutaneous is the rarest type and commonly occurs in otherwise healthy individuals. In our report also, the patient was immunocompetent. Both species, Nocardia asteroids and  Nocardia brasiliensis Scientific Name Search is have been reported to cause lymphocutaneous form of Nocardiosis. [1],[2],[8] In the present case, Nocardia asteroids was isolated from the specimen.

Patients with primary cutaneous nocardiosis respond well to medical treatment. Cotrimoxazole is the mainstay of treatment. Other effective drugs are dapsone, amikacin, ciprofloxacin, cephalosporins, clindamycin and imipenem. [7] In our patient, a good response was observed with combination therapy.

Primary cutaneous nocardiosis remains a diagnostic challenge. The majority of acute nocardial abscess and lymphocutaneous infections go unsuspected and undiagnosed because of nonspecific clinical pictures and difficulty in isolation of the organism. Rapid and reliable molecular methods, though available, [4] are beyond the reach of many investigators in our country.

A high index of clinical suspicion is needed for the diagnosis of the condition, along with the stringent efforts of microbiologists to isolate the organism.

 
   References Top

1.Peerapur BV, Inamdar AC. Mycetoma of scalp due to Nocardia brasiliensis . Indian J Med Microbiol 1997;15:85-6.  Back to cited text no. 1    
2.Beaman BL, Beaman L. Nocardia species: Host parasite relationship. Clin Microbiol Rev 1994;7:213-64.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Das S. Cutaneous nocardiosis in East-Delhi: A case report. Indian J Med Sci 2001;55:337-9.  Back to cited text no. 3    
4.Inamdar AC, Palit A. Primary cutaneous nocardiosis: A case study and review. Indian J Dermatol Venerol Leprol 2003;69:386-91.  Back to cited text no. 4    
5.Rama R, Girji K. Spontaneous remission of primary cutaneous nocardiosis. Indian J Dematol Venerol Leprol 1993;59:37-8.  Back to cited text no. 5    
6.Babara A, Brown E, Brow JM, Conville P, Wallace RJ. Clinical and laboratory features of Nocardia spp . based on current Molecular Taxonomy. Clin Microbiol Rev 2006;19:259-82.  Back to cited text no. 6    
7.Pintatdo N, Gomez-Mampaso E, Fortum J, Meseguer MA, Coba J, Nevas E, et al . Clinical spectrum of the disease and species distribution in Madrid, Spain 1978-2001. Infection 2001;30:338-40.  Back to cited text no. 7    
8.Palmer DL, Harvey RL, Wheeler JK. Diagnostic and therapeutic considerations in Nocardia asteroids infection. Medicine 1974;53:391-401.  Back to cited text no. 8  [PUBMED]  
9.Uttamchandani RB, Daikos GL, Reyes RR, Fischl MA, Dickinson GM, Yamaguchi E, et al . Nocardiosis in 30 patients with advanced HIV infection: Clinical features and outcome. Clin Infect Dis 1994;18:348-53.  Back to cited text no. 9  [PUBMED]  
10.Kostman JR, DiNubile MJ. Nodular lymphangitis: A distinctive but often unrecognized syndrome. Ann Intern Med 1993;118:883-8.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]

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Correspondence Address:
V P Baradkar
Department of Microbiology, LTMMC and LTMGH, Sion, Mumbai - 400 022
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.42553

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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