A 52 y.o. woman presents with a lesion on the arm

She was treated with Bactrim and bactroban at an urgent care but continued to worsen. She was seen in the ED and switched to doxycycline and noted worsening with nodes in the axilla. She has two cats and two birds.

What would you do?

Our patient had an infection which grew out Nocardia pantoea.  Nocardia are aerobic gram positive bacilli that can invade the lung, skin or CNS. While they are technically bacteria, they have a filamentous growth pattern like fungi and require a long course of treatment.

Nocardia can go to the brain and form abcesses

The skin lesions of nocardia can be confused with actinomycosis and sporotrichosis all of which have filamentous branching patterns.  To review:

ACTINOMYCOSIS–

Is a bacterial infection caused by a gram-positive  anaerobic  bacteria.  It is characterized by contiguous spread and multiple abscesses that may discharge sulfur granules. The granules are made up of aggregates of microorganisms mixed with inflammatory debris.  It often occurs on the face where it is called “lumpy jaw”.  In women pelvic actinomycosis is possible. Actinomycosis is an endogenous disease since it is present on mucosal surfaces.

lumpy jaw

SPOROTRICHOSIS-

Is known as rose gardener’s disease because it frequently presents in patients who work outside and are exposed to soil fungi.  It is caused by a fungus called Sporothrix and  is usually a cutaneous syndrome ;rarely a pulmonary infection. The most typical presentation is nodular lymphangitis. The treatment is itraconazole for three months or supersaturated potassium iodide.

Our patient was initially treated with Bactrim and switched to doxycycline.  The wound continued to worsen  and when the infection grew Nocardia she was switched to Bactrim and augmentin for three months.  

FUN FACTS

Animals are sometimes responsible for transmitting Nocardia to humans.  A large outbreak of Nocardia was reported that was traced to cats.

Cattle also get actinomycosis and “lumpy jaw.”.

A cow with actinomycosis

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Varkey B. Sulfur granules JAMA 1982;248(22):3025.

Saoji V, Saoji S, Gadegone R, Menghani P. Primary cutaneous nocardiosis.  2012 Indian J Dermatol. Sep-Oct ;57(5):404-406.