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Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 5  |  Issue : 5  |  Page : 537-539
Disseminated cutaneous nocardiosis in case of nephritic syndrome


1 Department of Microbiology, Sir Hurkisondas Narrutumdas Hospital and Research Centre, Girgaon, Mumbai, India
2 Department of Pathology, Sir Hurkisondas Narrutumdas Hospital and Research Centre, Girgaon, Mumbai, India
3 Department of Nephrology, Sir Hurkisondas Narrutumdas Hospital and Research Centre, Girgaon, Mumbai, India
4 Department of Medicine, Sir Hurkisondas Narrutumdas Hospital and Research Centre, Girgaon, Mumbai, India

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Date of Web Publication27-Dec-2012
 

   Abstract 

Dissemination of the pulmonary nocardiosis most commonly occurs to the sites like brain, kidney, chest wall, and skin. Dissemination to the skin and the subcutaneous may occur but rarely been observed in clinical settings. Here, we present an unusual case of disseminated cutaneous nocardiosis from pulmonary nocardiosis in a patient of nephritic syndrome who was on steroids and immunosuppressants. This case highlights the importance of considering nocardiosis in differential diagnosis in case of immunocompromised patients presenting with pulmonary complaints and cutaneous lesions.

Keywords: Disseminated cutaneous nocardiosis, nephritic syndrome, Nocardia asteroides

How to cite this article:
Mali S, Tasneem B, Doshi A, Sharma R. Disseminated cutaneous nocardiosis in case of nephritic syndrome. Ann Trop Med Public Health 2012;5:537-9

How to cite this URL:
Mali S, Tasneem B, Doshi A, Sharma R. Disseminated cutaneous nocardiosis in case of nephritic syndrome. Ann Trop Med Public Health [serial online] 2012 [cited 2018 Aug 15];5:537-9. Available from: http://www.atmph.org/text.asp?2012/5/5/537/105158

   Introduction Top


Nocardiosis is usually an opportunistic infection and most commonly presents as pulmonary disease. Common predisposing conditions for nocardiosis are underlying chronic lung disease, AIDS, diabetes mellitus, malignancies, and transplantation. Cutaneous nocardiosis can be primary or disseminated. [1] There are few case reports of primary cutaneous nocardiosis and cause being trauma or inoculation, but case reports of disseminated and secondary cutaneous nocardiosis is rarely been reported. [2],[3],[4] Incidence of primary cutaneous nocardiosis ranges from 5% to 24% in various countries like UK, Spain. [5],[6] But, exact incidence of secondary cutaneous and disseminated nocardiosis is not known, though there are few case reports. [7],[8] This would be an unusual case of pulmonary nocardiosis disseminating to the multiple cutaneous sites.


   Case Report Top


A 46-year-old female from urban area, known case of nephritic syndrome, presented with the chief complaints of breathlessness and cough since 8 days and swelling over left thigh, chest, and other parts of body since 4 days. Swellings were varying in size, 1 x 1 to 3 x 3 cm size, indurated, tender. Patient was on steroids and immunosuppressant-mycophenolate since last 8 months for nephritic syndrome. There was no history of diabetes mellitus, travelling to rural area, trauma, thorn prick etc.

Hemogram suggested leukocytosis with total count of 24,800/cmm, 90% being neutrophils. Chest X-ray revealed cavitatory lesions in the both lungs along with patchy areas of nodular opacity.

Sputum gram stain revealed leucocytes, gram-positive cocci singles and pairs, few gram-negative bacilli and very occasional filamentous branching gram-positive bacilli. Acid fast staining (AFB) was negative. Modified acid fast staining was done by using 1% H2SO4, which also revealed occasional branching acid fast bacilli. Sputum culture was done on blood agar, MacConkey agar, LJ medium, and Sabouraud's dextrose agar.

Aspirated pus sample from cutaneous lesions over left thigh and chest revealed abundant pus cells and gram-positive branching, filaments. They were sinuous with right angle branching [Figure 1]. AFB staining was negative. Modified AFB stain revealed acid fast branching filaments [Figure 2] morphologically resembling Nocardia species. Culture was done on blood agar, MacConkey agar, LJ medium, and Sabouraud's dextrose agar.
Figure 1: Gram-positive branching filaments in aspirate from cutaneous lesion (100X)

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Figure 2: Partially acid fast branching filaments; Modified AFB stain in aspirate from cutaneous lesion (100x)

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Sputum sample grew Klebsiella pneumoniae. While the pus sample on Blood agar, LJ medium showed growth within 3-4 days. While Sabouraud's dextrose agar showed growth within 7 days. Colonies on Blood agar were dry, granular, white-colored initially; turned cream-colored and wrinkled on further incubation [Figure 3] Cream-colored wrinkled colonies observed also on LJ medium and Sabouraud's dextrose agar after 7 to 10 days. Gram staining, modified AFB stain by using 1% H2SO4 of colonies on all three culture media revealed gram-positive branching, filaments, and acid fast branching filaments respectively, morphologically resembling Nocardia species. AFB stain with 25% H2SO4 was negative. Isolate was provisionally identified as Nocardia species on the basis of gram stain, 1% AFB stain, and lysozyme resistance testing [Figure 4]. [9] Further confirmed as Nocardia asteroides on the basis of biochemical tests like hydrolysis of casein and tyrosine, growth in 7% Nacl and utilization of mannitol. [9],[10],[11]
Figure 3: Dry, granular, wrinkled colonies of  Nocardia asteroides Scientific Name Search  on blood agar in 4 days

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Figure 4: Lysozyme resistance test: First test tube glycerol broth without lysozyme, second test tube glycerol broth with lysozyme showing breadcrumb like turbidity in presence of lysozyme

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Patient started with oral antibiotics cotrimaxazole double strength and linezolid. Within 3-4 days of the treatment, patient improved considerably. On follow-up after two weeks, cough, breathless were subsided and chest X-ray was clear and cutaneous lesions were also healed completely.


   Discussion Top


Cutaneous nocardiosis presents either as a primary cutaneous nocardiosis or as a part of disseminated infection. Primary cutaneous being relatively common and usually is associated with trauma. In cutaneous nocardiosis, three clinical variants have been reported. Superficial acute skin and soft tissue infection, lymphocutaneous and deeper infection also called as sporotrichoid pattern and mycetoma. [2],[3] Here, in this case, the presentation was superficial acute skin and soft tissue infection. In Immunocompromised patients, pulmonary nocardiosis is more frequently reported, though there are few case reports of cutaneous nocardiosis and brain abscess in transplant patients. [1],[12],[13] Though metastatic lesions occur anywhere in the body, the brain is most common secondary site of nocardiosis, followed by skin, kidney, chest wall, eye, and lymphnodes. Dissemination to brain was found in 27% cases, to skin in 9%, to kidney in 8%, to chest wall in 8%, to eye and lymphnodes in 3% each. In these disseminated cases, underlying condition was steroid therapy in 23% cases, immunosuppression (leukemia, lymphoma, pancytopenia etc.) in 17% cases was found. [10]

The present patient was a case of nephritic syndrome, taking steroids and immunosuppressant since 8 months. This would have been the risk factor for nocardiosis. In this case, there were multiple site skin infections; there was no history of trauma, thorn prick or any occupational risk. So, it is likely to be disseminated infection; and also, there were clinical and radiological evidences of pulmonary nocardiosis, which improved after treatment with cotrimaxazole and linezolid. It suggests that the primary pulmonary nocardiosis being disseminated to the multiple skin sites. There were no clinical as well as radiological evidences of dissemination to the other sites like brain, kidney etc.

Disseminated cutaneous nocardiosis is less common than primary cutaneous nocardiosis. [2] In case of primary cutaneous nocardiosis history of trauma, thorn prick or occupational history like farmer may help in diagnosis, but in the case of disseminated cutaneous nocardiosis, high index of suspicion is required, especially in immunocompromised patients. Though drugs like amoxycillin, clindamycin, ciprofloxacin, erythromycin, imipenem have been reported as sensitive, the present case responded very well to cotrimaxazole and linezolid. [2],[3]

This case highlights the importance of considering nocardiosis in differential diagnosis in case of nephritic syndrome patients presenting with pulmonary complaints and cutaneous lesions; prompt and appropriate treatment can not only completely cure the lesions but also prevents further complications.

 
   References Top

1.Bearman BL, Bearman L. Nocardia species: Host parasite relationship. Clin Microbiol Rev 1994;7:213-64.   Back to cited text no. 1
    
2.Inamadar AC, Palit A. Prmary cutaneous nocardiosis: A case study and review. Indian J of Dermatol Venerol Leprol 2003;69:386-91.  Back to cited text no. 2
    
3.Baradkar VP, Mathur M, Kulkarni SD, Kumar S. Sporotrichoid pattern of cutaneous nocardiosis due to nocardia asteroids. Indian J Pathol Microbiol 2008;51:432-4.   Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Das S. Cutaneous nocardiosis in East-Delhi. Indian J Med Sci 2001;55:337-9.   Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Pintatdo-N, Gomez Mampaso E, Forum J, Meseguer MA, Coba J, Nevas E, et al. Clinical spectrum of diseases and species distribution in Madrid Spain 1978-2001. Infection 2001;30:338-40.  Back to cited text no. 5
    
6.Palmer DL, Harvey RL, Wheeler JK. Diagnostic and therapeutic considerations in nocardia asteroides infection. Medicine 1974;53:391-401.  Back to cited text no. 6
[PUBMED]    
7.Amatya R, Koirala R, Khanal B, Dhakal SS. Nocardia brasiliensis primary pulmonary nocardiosis with subcutaneous involvement in an immunocompetent patient. Indian J Med Microbiol 2011;29:68-70.   Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.Callen JP, Kingman J. Disseminated cutaneous nocardia brasiliensis infection. Padiatr Dermatol 1984;2:49-51.   Back to cited text no. 8
[PUBMED]    
9.Winn W, Allen S, Janda W, Koneman E, Procop G, Schreckenberger P, et al. Aerobic actinomycetes in Koneman's Color Atlas and Textbook of Diagnostic Microbiology. 6 th ed. Baltimore Philadelphia: Lippincott Williams and Wilkins; 2006. p. 859-76.   Back to cited text no. 9
    
10.Rippon JW. Medical mycology-The pathogenic fungi and the pathogenic actinomyctes. 2 nd ed. Philadelphia, London, Toronto, Mexico: Rio de Janeiro, Sydney, Tokyo: W. B. Saunders company; 1982. p. 51-65.   Back to cited text no. 10
    
11.Kiska DL, Hicks K, Pettit DJ. Identification of Medically Relevant Nocardia Species with an Abbreviated Battery of Tests. J Clin Microbiol 2002;40:1346-51.   Back to cited text no. 11
[PUBMED]    
12.Fontana I, Gasloli G, Rossi AM, Bornacina C, Dodi F, Bertocchi M, et al. Nocardiosis in a Kidney-Pancreas Transplant. J Transpl 2010;2010:573234.  Back to cited text no. 12
    
13.Charfeddine K, Kharrat M, Yaich S, Abdelmalek R, Hakim H, Bahloul H, et al. Systemic Nocardiosis with Multiple Brain Abscesses in a Renal Transplant Recipient: Successfully Treated with Antibiotics Alone. Saudi J Kidney Dis Transpl 2002;13:498-500.  Back to cited text no. 13
[PUBMED]  Medknow Journal  

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Correspondence Address:
Swapna Mali
Department of Microbiology, Sir Hurkisondas Narrutumdas Hospital and Research Centre, Girgaon, Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.105158

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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