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Year : 2011  |  Volume : 54  |  Issue : 1  |  Page : 185-186
Primary cutaneous disease due to Nocardia asteroides in an immunocompetent host


Department of Microbiology, Government Medical College, Nagpur, India

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Date of Web Publication7-Mar-2011
 

How to cite this article:
Agrawal S M, Raut S S. Primary cutaneous disease due to Nocardia asteroides in an immunocompetent host. Indian J Pathol Microbiol 2011;54:185-6

How to cite this URL:
Agrawal S M, Raut S S. Primary cutaneous disease due to Nocardia asteroides in an immunocompetent host. Indian J Pathol Microbiol [serial online] 2011 [cited 2019 Nov 17];54:185-6. Available from: http://www.ijpmonline.org/text.asp?2011/54/1/185/77399


Nocardia species are aerobic and saprophytic actinomycetes. Pathogenic species of Nocardia have been found in dust, sand, soil and swimming pools. It causes a variety of human infections including cutaneous, pulmonary and systemic nocardiosis. [1] Nocardiosis is usually an opportunistic infection and most commonly presents as pulmonary disease, and majority of patients with clinically recognized disease have underlying debilitating factors. [2]

Nocardia asteroides occasionally causes disease in healthy persons. It is the commonest clinically isolated actinomycete and is usually associated with pulmonary infection. But there are very few reports of microbiological confirmation from our area. The patient presented here did not give any history suggestive of any debilitating condition.

A 40-year-old nondiabetic, normotensive male, school peon by occupation, was referred to clinical microbiology department. He had hard, painful and swollen left leg of 15 years duration. Skin over the leg was black and showed multiple discharging sinuses with raised and inflamed openings [Figure 1]. The patient also had history of white purulent discharge from sinuses. There was no history suggestive of immune-compromised state. He received antibiotics in irregular doses, whenever required, from private practitioners. The patient never received steroid as treatment. No abnormality was detected on systemic examination. He was diagnosed as having mycetoma and investigated to find the etiology.
Figure 1: Nocardia mycetoma over left lower limb

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Laboratory studies revealed hemoglobin of 8.00 g/dl, total leukocyte count of 8000/mm 3 , and raised erythrocyte sedimentation rate of 75 mm in first hour. X-ray leg showed osteolytic lesions and X-ray chest revealed no abnormality. Test for HIV I and II antibody was nonreactive. Discharge from sinuses showed whitish granules. Gram's stain of the discharge revealed gram-positive, thin filamentous structures with right angle branching, resembling Nocardia species [Figure 2]. The bacterium was weakly acid fast. Sample was inoculated on Lowensten Jensen, Blood Agar and Macconkey agar. Plates were incubated aerobically at 37°C. After 3 days of incubation, white, rough, wrinkled colonies were seen. Gram's staining and acid fast (with 1% H 2 SO 4 ) staining of colonies, biochemical tests (positive urease, growth at 44°C, inability to hydrolyze casein, tyrosine and xanthine and sensitive to ciprofloxacin) confirmed the isolate as N. asteroides. Antibiotic sensitivity test by disk diffusion method showed the isolate to be sensitive to gentamycin, cotrimoxazole, amikacin, ciprofloxacin, ofloxacin, and resistant to ampicillin, tetracycline and nalidixic acid. Repeat sample yielded similar findings. Histopathology of skin biopsy confirmed the diagnosis of actinomycotic mycetoma.
Figure 2: Gram positive filamentous bacilli (Gram's, ×1000)

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Actinomycotic mycetoma is a chronic suppurative disease of subcutaneous tissue and bone with multiple sinuses discharging pus-containing granules. Among the several species of Nocardia causing cutaneous infections, Nocardia brasiliensis is the commonest species isolated. [3],[4] Our patient gave neither a history of trauma nor a history suggestive of immunocompromised state. N. asteroides, a rarely associated species with mycetoma, was isolated in this case. Shivprakash et al. [5] also reported N. asteroides complex from six patients of nocardiosis but all of them were immunosuppressed. High degree of suspicion among the clinicians and the clinical microbiologist would help in early diagnosis and initiation of early and definitive therapy.

 
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1.Mc Neil MM, Brown JM. The medically important aerobic actinomycetes; Epidemiology and microbiology. Clin Microbiol Rev 1994;7:357-417.  Back to cited text no. 1
    
2.Laidlaw M. Actinomyces: Nocardia: Streptomyces. In: Collee JG, Duguid JP, Fraser AG, Marmion BP, editors. Practical Medical Microbiology. 13 th ed. London: Churchill Livingstone; 1989. p. 425-30.   Back to cited text no. 2
    
3.Lakshmi V, Sundaram C, Meena AK, Murthy JM. Primary cutaneous nocardiosis with epidural abscess caused by Nocardia brasiiliensis: A case report. Neurol India 2002;50:90-2.  Back to cited text no. 3
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4.Chakrabarthi A, Singh K. Mycetoma in Chandigarh and surrounding areas. Indian J Med Microbiol 1998;16:64-5.   Back to cited text no. 4
    
5.Shivaprakash MR, Rao P, Mandal J, Biswal M, Gupta S, Ray P, et al. Nocardiosis in a tertiary care hospital in North India and review of patients reported from India. Mycopathologia 2007;163:267-74.  Back to cited text no. 5
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Correspondence Address:
S M Agrawal
Department of Microbiology, GMCH, Nagpur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.77399

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    Figures

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