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Superficial cutaneous abscess and multiple brain abscesses from Nocardia asteroides in an immunocompetent patient
Journal of the American Academy of Dermatology Volume 39, Number 5, Part 1
Brief communications 793
Superficial cutaneous abscess and multiple brain abscesses from Nocardia asteroides in an immunocompetent patient Christine S. Ng, MD,a and Walter C. Hellinger, MDb Jacksonville, Florida
Infection with Nocardia asteroides usually presents as a pulmonary infection in an immunocompromised host. Skin involvement occurs when the disease disseminates, with an incidence estimated at 10%, second only to central nervous system involvement.1 We describe a case of superficial cutaneous N asteroides infection in an immunocompetent man who presented with a seizure caused by multiple N asteroides brain abscesses. CASE REPORT A 74-year-old white man had a generalized seizure. He had a malignant melanoma of the neck in 1991, depth and level unknown. Examination revealed only a nodule on the left forearm (Fig 1). Computed tomography (CT) of the head revealed a left parieto-occipital multiloculated mass (Fig 2). The results of roentgenography of the chest and CT of the chest, abdomen, and pelvis were normal. He was treated with oral dexamethasone for 10 days; otherwise, he had not been receiving any other immunosuppressive treatment. He had no recent respiratory illnesses or any recent trauma. From the Department of Dermatologya and Department of Internal Medicine, Section of Infectious Diseasesb, Mayo Clinic Jacksonville. Reprint requests: Christine S. Ng, MD, Mayo Clinic Jacksonville, Department of Dermatology, 4500 San Pablo Rd, Jacksonville, FL 32224. J Am Acad Dermatol 1998;39:793-4. Copyright © 1998 by the American Academy of Dermatology, Inc. 0190-9622/98/$5.00 + 0 16/54/92461
Fig. 1. Hemorrhagic nodule on left forearm. On the third hospital day, a stereotactic needle biopsy of the brain mass yielded a nondiagnostic specimen. On the fifth hospital day, the patient experienced increasing weakness in his right lower extremity. Magnetic resonance imaging showed a significant increase in the brain mass; the patient underwent a craniotomy that revealed multiple abscesses in the left parieto-occipital area. A bacterial pathogen was suspected, and treatment with broad spectrum antibiotics was initiated. The asymptomatic nodule on the left forearm had been present for approximately 4 to 6 months. Examination revealed a 2-cm necrotic, hemorrhagic nodule without lymphadenopathy. Biopsy specimens
794 Brief communications
Fig. 2. CT scan: Left parieto-occipital mass with ring enhanced borders. showed marked inflammation; Gomori methenamine silver and Gram’s stains showed filamentous gram-positive organisms consistent with Nocardia spp. Brain tissue from the craniotomy and previous needle biopsy was reexamined and revealed similar findings. Cultures from the left forearm and brain grew N asteroides with identical antimicrobial susceptibilities. Therapy with trimethoprim-sulfamethoxazole (37 days intravenously, then orally) and minocycline was initiated. He was discharged after 6 weeks with continued symptomatic improvement and complete clearing of the cutaneous lesion. Minocycline was discontinued, and at his 1month follow-up the patient has continued to do well with trimethoprim-sulfamethoxazole alone. DISCUSSION
This appears to be the first case of disseminated N asteroides infection from a cutaneous nodule in an immunocompetent patient without apparent pulmonary disease. The Nocardia are gram-positive bacteria, with fine branching filaments that stain irregularly. Pulmonary or disseminated disease is caused by N asteroides. Risk factors for
Journal of the American Academy of Dermatology November 1998
systemic involvement include preexisting lung disease and immunosuppression. Patients with pulmonary and disseminated disease have a mortality rate of 40%, and up to 70% of patients with central nervous system dissemination die.1,2 In contrast, superficial cutaneous nocardiosis is usually caused by N brasiliensis.1-3 Frequently, there is a history of injury or inoculation to an extremity in an outdoor setting.4,5 Infection from an insect bite6 or a cat scratch7 has been reported. No deaths have been attributed to superficial infections, and metastatic spread to other organs is unusual. Hence, N asteroides is primarily an opportunistic pathogen, whereas N brasiliensis causes skin infections in normal hosts.2 Sulfonamides are the drugs of choice for treating nocardiosis. Other agents that may be of benefit include minocycline, aminoglycosides, thirdgeneration cephalosporins, imipenem, and the fluoroquinolones. The optimal length of antimicrobial therapy is not known. Suggestions have ranged from 6 weeks for minor infections to a year for disseminated disease or if clinical response is slow.1,2,8 Surgical debridement and drainage of abscesses is also critical.4,8 Patients should be closely observed for at least a year and cultures repeated if recurrence is suspected. Monitoring of sulfonamide levels has also been advocated.1,2 REFERENCES 1. Kalb RE, Kaplan MH, Grossman ME. Cutaneous nocardiosis. J Am Acad Dermatol 1985;13:125-33. 2. Georghiou PR, Blacklock ZM. Infection with nocardia species in Queensland: a review of 102 clinical isolates. Med J Aust 1992;156:692-7. 3. Tsuboi R, Takamori K, Ogawa H, et al. Lymphocutaneous nocardiosis caused by Nocardia asteroides. Arch Dermatol 1986;122:1183-5. 4. Satterwhite TK, Wallace RJ Jr. Primary cutaneous nocardiosis. JAMA 1979;242:333-6. 5. Harth Y, Friedman-Birnbaum R, Lefler E, et al. Two patients with simultaneous, unusually located primary cutaneous nocardiosis. J Am Acad Dermatol 1992;26: 132-3. 6. O’Connor PT, Dire DJ. Cutaneous nocardiosis associated with insect bites. Cutis 1992;50:301-2. 7. Sachs MK. Lymphocutaneous Nocardia brasiliensis infection acquired from a cat scratch: case report and review. Clin Infect Dis 1992;15:710-1. 8. Seidel JF, Younce DC, Hupp JR, et al. Cervicofacial nocardiosis: report of case. J Oral Maxillofac Surg 1994;52:188-91.
Brief communications 793
Superficial cutaneous abscess and multiple brain abscesses from Nocardia asteroides in an immunocompetent patient Christine S. Ng, MD,a and Walter C. Hellinger, MDb Jacksonville, Florida
Infection with Nocardia asteroides usually presents as a pulmonary infection in an immunocompromised host. Skin involvement occurs when the disease disseminates, with an incidence estimated at 10%, second only to central nervous system involvement.1 We describe a case of superficial cutaneous N asteroides infection in an immunocompetent man who presented with a seizure caused by multiple N asteroides brain abscesses. CASE REPORT A 74-year-old white man had a generalized seizure. He had a malignant melanoma of the neck in 1991, depth and level unknown. Examination revealed only a nodule on the left forearm (Fig 1). Computed tomography (CT) of the head revealed a left parieto-occipital multiloculated mass (Fig 2). The results of roentgenography of the chest and CT of the chest, abdomen, and pelvis were normal. He was treated with oral dexamethasone for 10 days; otherwise, he had not been receiving any other immunosuppressive treatment. He had no recent respiratory illnesses or any recent trauma. From the Department of Dermatologya and Department of Internal Medicine, Section of Infectious Diseasesb, Mayo Clinic Jacksonville. Reprint requests: Christine S. Ng, MD, Mayo Clinic Jacksonville, Department of Dermatology, 4500 San Pablo Rd, Jacksonville, FL 32224. J Am Acad Dermatol 1998;39:793-4. Copyright © 1998 by the American Academy of Dermatology, Inc. 0190-9622/98/$5.00 + 0 16/54/92461
Fig. 1. Hemorrhagic nodule on left forearm. On the third hospital day, a stereotactic needle biopsy of the brain mass yielded a nondiagnostic specimen. On the fifth hospital day, the patient experienced increasing weakness in his right lower extremity. Magnetic resonance imaging showed a significant increase in the brain mass; the patient underwent a craniotomy that revealed multiple abscesses in the left parieto-occipital area. A bacterial pathogen was suspected, and treatment with broad spectrum antibiotics was initiated. The asymptomatic nodule on the left forearm had been present for approximately 4 to 6 months. Examination revealed a 2-cm necrotic, hemorrhagic nodule without lymphadenopathy. Biopsy specimens
794 Brief communications
Fig. 2. CT scan: Left parieto-occipital mass with ring enhanced borders. showed marked inflammation; Gomori methenamine silver and Gram’s stains showed filamentous gram-positive organisms consistent with Nocardia spp. Brain tissue from the craniotomy and previous needle biopsy was reexamined and revealed similar findings. Cultures from the left forearm and brain grew N asteroides with identical antimicrobial susceptibilities. Therapy with trimethoprim-sulfamethoxazole (37 days intravenously, then orally) and minocycline was initiated. He was discharged after 6 weeks with continued symptomatic improvement and complete clearing of the cutaneous lesion. Minocycline was discontinued, and at his 1month follow-up the patient has continued to do well with trimethoprim-sulfamethoxazole alone. DISCUSSION
This appears to be the first case of disseminated N asteroides infection from a cutaneous nodule in an immunocompetent patient without apparent pulmonary disease. The Nocardia are gram-positive bacteria, with fine branching filaments that stain irregularly. Pulmonary or disseminated disease is caused by N asteroides. Risk factors for
Journal of the American Academy of Dermatology November 1998
systemic involvement include preexisting lung disease and immunosuppression. Patients with pulmonary and disseminated disease have a mortality rate of 40%, and up to 70% of patients with central nervous system dissemination die.1,2 In contrast, superficial cutaneous nocardiosis is usually caused by N brasiliensis.1-3 Frequently, there is a history of injury or inoculation to an extremity in an outdoor setting.4,5 Infection from an insect bite6 or a cat scratch7 has been reported. No deaths have been attributed to superficial infections, and metastatic spread to other organs is unusual. Hence, N asteroides is primarily an opportunistic pathogen, whereas N brasiliensis causes skin infections in normal hosts.2 Sulfonamides are the drugs of choice for treating nocardiosis. Other agents that may be of benefit include minocycline, aminoglycosides, thirdgeneration cephalosporins, imipenem, and the fluoroquinolones. The optimal length of antimicrobial therapy is not known. Suggestions have ranged from 6 weeks for minor infections to a year for disseminated disease or if clinical response is slow.1,2,8 Surgical debridement and drainage of abscesses is also critical.4,8 Patients should be closely observed for at least a year and cultures repeated if recurrence is suspected. Monitoring of sulfonamide levels has also been advocated.1,2 REFERENCES 1. Kalb RE, Kaplan MH, Grossman ME. Cutaneous nocardiosis. J Am Acad Dermatol 1985;13:125-33. 2. Georghiou PR, Blacklock ZM. Infection with nocardia species in Queensland: a review of 102 clinical isolates. Med J Aust 1992;156:692-7. 3. Tsuboi R, Takamori K, Ogawa H, et al. Lymphocutaneous nocardiosis caused by Nocardia asteroides. Arch Dermatol 1986;122:1183-5. 4. Satterwhite TK, Wallace RJ Jr. Primary cutaneous nocardiosis. JAMA 1979;242:333-6. 5. Harth Y, Friedman-Birnbaum R, Lefler E, et al. Two patients with simultaneous, unusually located primary cutaneous nocardiosis. J Am Acad Dermatol 1992;26: 132-3. 6. O’Connor PT, Dire DJ. Cutaneous nocardiosis associated with insect bites. Cutis 1992;50:301-2. 7. Sachs MK. Lymphocutaneous Nocardia brasiliensis infection acquired from a cat scratch: case report and review. Clin Infect Dis 1992;15:710-1. 8. Seidel JF, Younce DC, Hupp JR, et al. Cervicofacial nocardiosis: report of case. J Oral Maxillofac Surg 1994;52:188-91.