Primary cutaneous nocardiosis in an immunocompetent host following laser resurfacing
Authors: James M. Graham, Kyle B. Bartlett, Annie Gonzalez, Jane L. Messina, Philip D. Shenefelt
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: A 66-year-old immunocompetent woman presented with a 3-month history of a nonhealing left infraorbital ulcer. The lesion began as a pustule following erbium:YAG laser resurfacing performed to improve cosmesis after an upper and lower blepharoplasty. Over several weeks the lesion evolved into a shallow, nonhealing ulceration. Initially, the patient was treated with minocycline, cephalexin, and topical mupirocin without improvement. On presentation to our dermatology clinic, the patient was being treated with oral prednisone 60 mg daily, topical desoximetasone 0.25% ointment, and valacyclovir 1000 mg twice daily.On physical examination, a 1.4-cm oval shallow ulceration without purulence or exudate was noted on the left infraorbital rim (Fig 1). Skin biopsy revealed ulceration with a mixed inflammatory infiltrate. Gram stain demonstrated gram-positive, focally branching, bacilli (Fig 2). Periodic acid–Schiff and acid-fast bacilli stains were negative; however, mycobacterium tuberculosis polyclonal antibody stain (Biocare Medical PP140AA) showed dot-like positivity. No evidence of herpes viral change was noted.Fig 2Primary cutaneous nocardiosis Gram stain demonstrating gram-positive, focally branching bacilli.View Large Image Figure ViewerDownload Hi-res image Download (PPT)On follow-up, prednisone was gradually discontinued and minocycline was started for presumed atypical mycobacterial infection. Another biopsy was obtained for bacterial, fungal, and mycobacterial culture. The receiving microbiology lab was notified in advance of the possibility of atypical mycobacteria and Nocardia species. Bacterial cultures were initially reported as normal skin flora. The microbiology laboratory was asked to specifically look for Nocardia. Several days later, Nocardia asteroides complex was isolated. Fungal and mycobacterial cultures were negative at 6 weeks. Trimethoprim-sulfamethoxazole DS 3 times daily was initiated and the patient was referred to an infectious disease physician for a workup to identify potential sources of infection. The workup included magnetic resonance imaging of the brain, as well as computed tomography examination of the chest; no systemic source of infection was identified. Marked improvement was noted at 2 weeks (Fig 2), although a mild ectropion developed at 3 months.Nocardiosis is caused by the gram-positive, filamentous, partially acid-fast bacilli Nocardia, which includes more than 50 ubiquitous, slow growing aerobic species.1Young L.S. Rubin R.H. Mycobacterial and nocardial diseases.in: Rubin R.H. Young L.S. Clinical approach to Infection in the compromised host. 4th ed. Kluwer Academic/Plenum, New York2002: 257-260Crossref Google Scholar Approximately 500 to 1000 cases of nocardiosis occur in the United States per year.2Centers for Disease Control and Prevention. Available from: http://www.cdc.gov/nocardiosis/infection.Google Scholar Primary cutaneous nocardiosis, most often caused by Nocardia brasiliensis, typically affects immunocompetent individuals with a history of trauma and is grouped into three entities: lymphocutaneous infection, mycetoma, and superficial skin infection including ulceration, abscess, and cellulitis. N asteroides complex typically causes skin infection from hematogenous dissemination from a pulmonary focus and is frequently associated with systemic disease.3Outhred A.C. Watts M.R. Chen S.C. Sorrell T.C. Nocardia infections of the face and neck.Curr Infect Dis Rep. 2011; 13: 132-140Crossref PubMed Scopus (9) Google Scholar Treatment should include evaluation for systemic disease as well as a minimum of 6 weeks of antibiotic therapy with trimethoprim-sulfamethoxazole, the treatment of choice for nocardiosis; treatment may be needed for up to 1 year.Given the difficulty in isolating Nocardia spp, it is crucial to notify the laboratory if nocardiosis is suspected so that the appropriate time (3 to 21 days) and growth conditions are provided.1Young L.S. Rubin R.H. Mycobacterial and nocardial diseases.in: Rubin R.H. Young L.S. Clinical approach to Infection in the compromised host. 4th ed. Kluwer Academic/Plenum, New York2002: 257-260Crossref Google Scholar, 3Outhred A.C. Watts M.R. Chen S.C. Sorrell T.C. Nocardia infections of the face and neck.Curr Infect Dis Rep. 2011; 13: 132-140Crossref PubMed Scopus (9) Google Scholar, 4Greenfield RA. Nocardiosis. Medscape. Available from: http://emedicine.medscape.com/article/224123-overview.Google Scholar As demonstrated in this case, it is imperative for the clinician to follow up on abnormal or unexpected results, and to contact the laboratory and other involved physicians. Dermatologists must be aware of this potentially difficult to diagnose organism as a potential cause of nonhealing ulceration and other cutaneous infections. To the Editor: A 66-year-old immunocompetent woman presented with a 3-month history of a nonhealing left infraorbital ulcer. The lesion began as a pustule following erbium:YAG laser resurfacing performed to improve cosmesis after an upper and lower blepharoplasty. Over several weeks the lesion evolved into a shallow, nonhealing ulceration. Initially, the patient was treated with minocycline, cephalexin, and topical mupirocin without improvement. On presentation to our dermatology clinic, the patient was being treated with oral prednisone 60 mg daily, topical desoximetasone 0.25% ointment, and valacyclovir 1000 mg twice daily. On physical examination, a 1.4-cm oval shallow ulceration without purulence or exudate was noted on the left infraorbital rim (Fig 1). Skin biopsy revealed ulceration with a mixed inflammatory infiltrate. Gram stain demonstrated gram-positive, focally branching, bacilli (Fig 2). Periodic acid–Schiff and acid-fast bacilli stains were negative; however, mycobacterium tuberculosis polyclonal antibody stain (Biocare Medical PP140AA) showed dot-like positivity. No evidence of herpes viral change was noted. On follow-up, prednisone was gradually discontinued and minocycline was started for presumed atypical mycobacterial infection. Another biopsy was obtained for bacterial, fungal, and mycobacterial culture. The receiving microbiology lab was notified in advance of the possibility of atypical mycobacteria and Nocardia species. Bacterial cultures were initially reported as normal skin flora. The microbiology laboratory was asked to specifically look for Nocardia. Several days later, Nocardia asteroides complex was isolated. Fungal and mycobacterial cultures were negative at 6 weeks. Trimethoprim-sulfamethoxazole DS 3 times daily was initiated and the patient was referred to an infectious disease physician for a workup to identify potential sources of infection. The workup included magnetic resonance imaging of the brain, as well as computed tomography examination of the chest; no systemic source of infection was identified. Marked improvement was noted at 2 weeks (Fig 2), although a mild ectropion developed at 3 months. Nocardiosis is caused by the gram-positive, filamentous, partially acid-fast bacilli Nocardia, which includes more than 50 ubiquitous, slow growing aerobic species.1Young L.S. Rubin R.H. Mycobacterial and nocardial diseases.in: Rubin R.H. Young L.S. Clinical approach to Infection in the compromised host. 4th ed. Kluwer Academic/Plenum, New York2002: 257-260Crossref Google Scholar Approximately 500 to 1000 cases of nocardiosis occur in the United States per year.2Centers for Disease Control and Prevention. Available from: http://www.cdc.gov/nocardiosis/infection.Google Scholar Primary cutaneous nocardiosis, most often caused by Nocardia brasiliensis, typically affects immunocompetent individuals with a history of trauma and is grouped into three entities: lymphocutaneous infection, mycetoma, and superficial skin infection including ulceration, abscess, and cellulitis. N asteroides complex typically causes skin infection from hematogenous dissemination from a pulmonary focus and is frequently associated with systemic disease.3Outhred A.C. Watts M.R. Chen S.C. Sorrell T.C. Nocardia infections of the face and neck.Curr Infect Dis Rep. 2011; 13: 132-140Crossref PubMed Scopus (9) Google Scholar Treatment should include evaluation for systemic disease as well as a minimum of 6 weeks of antibiotic therapy with trimethoprim-sulfamethoxazole, the treatment of choice for nocardiosis; treatment may be needed for up to 1 year. Given the difficulty in isolating Nocardia spp, it is crucial to notify the laboratory if nocardiosis is suspected so that the appropriate time (3 to 21 days) and growth conditions are provided.1Young L.S. Rubin R.H. Mycobacterial and nocardial diseases.in: Rubin R.H. Young L.S. Clinical approach to Infection in the compromised host. 4th ed. Kluwer Academic/Plenum, New York2002: 257-260Crossref Google Scholar, 3Outhred A.C. Watts M.R. Chen S.C. Sorrell T.C. Nocardia infections of the face and neck.Curr Infect Dis Rep. 2011; 13: 132-140Crossref PubMed Scopus (9) Google Scholar, 4Greenfield RA. Nocardiosis. Medscape. Available from: http://emedicine.medscape.com/article/224123-overview.Google Scholar As demonstrated in this case, it is imperative for the clinician to follow up on abnormal or unexpected results, and to contact the laboratory and other involved physicians. Dermatologists must be aware of this potentially difficult to diagnose organism as a potential cause of nonhealing ulceration and other cutaneous infections.