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LETTER TO EDITOR  
Year : 2013  |  Volume : 56  |  Issue : 3  |  Page : 333-334
Nocardial Mycetoma: Re-infection with a different species at an unusual site - A rare case


1 Department of Microbiology, M. S. Ramaiah Medical College and Teaching Hospital, MSR Nagar, MSRIT post, Bangalore, Karnataka, India
2 Department of Surgery, M. S. Ramaiah Medical College and Teaching Hospital, MSR Nagar, MSRIT post, Bangalore, Karnataka, India

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Date of Web Publication24-Oct-2013
 

How to cite this article:
Banashankari G S, Rudresh H K, Sreeja S, Beena. Nocardial Mycetoma: Re-infection with a different species at an unusual site - A rare case . Indian J Pathol Microbiol 2013;56:333-4

How to cite this URL:
Banashankari G S, Rudresh H K, Sreeja S, Beena. Nocardial Mycetoma: Re-infection with a different species at an unusual site - A rare case . Indian J Pathol Microbiol [serial online] 2013 [cited 2020 Sep 20];56:333-4. Available from: http://www.ijpmonline.org/text.asp?2013/56/3/333/120424


Sir,

Nocardiosis is an infection caused by different species of Nocardia which are soil-borne aerobic bacteria. [1] Cutaneous nocardiosis may present as primary infection in immunocompetent individuals with history of trauma or may present as a part of disseminated infection secondary to pulmonary focus in immunocompromised individuals. Primary cutaneous nocardiosis clinically presents as acute infection (abscess or cellulitis), sporotrichoid infection or mycetoma. It is commonly caused by Nocardia brasiliensis and rarely by Nocardia asteroides. [1],[2]

We present a case of recurrent Nocardial mycetoma caused by two different species of Nocardia. A 36-year-old immunocompetent male farmer came with complaints of pain and swelling on his back of 1 week duration. There was a history of repeated trauma (trauma to the back with sand particle when patient was sleeping on the bare ground) on the back and past history of nocardial mycetoma caused by Nocardia brasiliensis which was successfully treated one and half years back by Modified Welsh regime (cotrimoxazole, amikacin and rifampicin).

On local examination there were few discharging and multiple healed sinuses on the back. A fluctuating, tender swelling about 3 × 4 centimeter in size was present on the right scapular region [Figure 1]. Soft tissue ultrasonography of the lesion showed loculated collection in the right scapular and suprascapular region. The patient's hemoglobin was 11.3g%, total leukocyte count was 11,280 cells/mm 3 . Pus was aspirated and sent for culture and sensitivity.
Figure 1: Discharging and multiple healed sinuses on the back and swelling on the right scapular region (circled)

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Gram stain of the aspirated pus showed moderate number of pus cells and occasional Gram positive branching filaments. Modified Ziehl Neelsen staining using 1% sulfuric acid revealed scanty acid fast branching filaments morphologically resembling Nocardia. After 7 days of aerobic incubation at 37°C chocolate agar plates showed dry chalky yellowish white and wrinkled colonies of Nocardia species. The isolate was sent for characterization to Kasturba Medical College, Manipal. The isolate was identified as Nocardia asteroides by standard biochemical tests and was sensitive to cotrimoxazole and tetracycline and resistant to penicillin, ampicillin, and erythromycin.

Further incision and drainage along with surgical debridement was performed and tissue sample was sent for culture and sensitivity which also yielded the growth of Nocardia asteroides. He was treated with a combination of cotrimoxazole and rifampicin. He responded well and was advised 2 months maintenance phase with the same drugs. The patient on follow up showed marked improvement.

In India, incidence of Nocardial mycetoma varies from 5.2 to 35% of mycetoma. [3] Re-infection by a different species of Nocardia is a rare occurrence. Isolation and characterization of Nocardia species by culture is a tedious process as the organism is slow growing and colonies being small may be overgrown by other rapidly growing organisms which results in an initial negative culture report for Nocardia. [4]

The two widely used treatment regime in treating nocardial mycetoma are Welsh Regime and Modified Welsh regime. In Modified Welsh regime oral rifampicin is added as a third drug along with cotrimoxazole and amikacin in the Welsh regime. [5] Minimal surgical interventions like incision and drainage of the abscesses may be needed in few cases like in our case for better prognosis. [4]

Primary cutaneous nocardiosis remains a diagnostic challenge because of its nonspecific clinical presentation and difficulties in isolation in the laboratory. In conclusion a high degree of clinical suspicion and prompt efforts from the microbiologist would help in early diagnosis and treatment of the infection which will bring down the morbidity and mortality drastically. [2],[4]


   Acknowledgement Top


For confirmation of the isolate Mr. Prakash Peralam Yegneswaran, Kasturba Medical College, Manipal, Karnataka, India.

 
   References Top

1.Shook BA. Dermatologic manifestations of Nocardiosis.c2012. Available from: http://emedicine.medscape.com/article/1052944-overview. [Last updated on 2012 Jan 11; cited on 2012 Aug 30].  Back to cited text no. 1
    
2.Peerapur VB, Parandekar KP, Naveen G, Shymala. Primary cutaneous nocardiosis of axillary region: A case report.Journal of Krishna Institute of Medical Sciences University 2012;1:142-6.  Back to cited text no. 2
    
3.Praveen Kumar S, Sumathy TK, Shyam Prasad AL, Gayathri Devi DR, Shivaswamy KN, Ranganathan C. An unusual presentation of primary cutaneous nocardiosis at a rare site: Successful treatment with a modified Welsh regimen. Dermatol Online J 2011;17:1.  Back to cited text no. 3
    
4.Inamadar CA, 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.Welsh MD. Mycetoma: Current concepts in treatment. Int J Dermatol 1991;30:387-90.  Back to cited text no. 5
    

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Correspondence Address:
G S Banashankari
Department of Microbiology, M.S. Ramaiah Medical College, MSR Nagar, MSRIT post, Bangalore - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.120424

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