A Landscaper's Nodular Skin Lesions and Painful, Swollen Joints

Correct Answer: B. Nocardiosis

The patient’s diagnosis was chronic cutaneous and osteoarticular nocardiosis caused by Nocardia brasiliensis (N. brasiliensis). Intra-operative specimen gram stain showed aerobic catalase positive, gram positive, branching filamentous rods, with cultures turning positive for N. brasiliensis, confirming the diagnosis.

Sporotrichosis, also known as "rose gardener's disease," is a subacute or chronic infection caused by the saprophytic dimorphic fungus Sporothrix schenckii.

The characteristic infection involves suppurating subcutaneous nodules that progress proximally along lymphatic channels (lymphocutaneous sporotrichosis). ³ Primary pulmonary infection (pulmonary sporotrichosis) is rare, as is direct inoculation into tendons, bursae, or joints.³ Osteoarticular sporotrichosis is caused by direct inoculation or hematogenous seeding.³ This patient’s intra-operative specimens were negative for fungal stains and cultures.

The hallmark of cutaneous leishmaniasis is painless skin lesions ranging from erythematous papule, plaques, ulcers or nodules, which can spontaneously heal in 2 to 10 months.² This patient had a negative leishmaniasis serology and, further, leishmaniasis is not endemic in Mexico.

Coccidioidomycosis rarely has cutaneous and skeletal manifestations including osteomyelitis and septic arthritis.¹ This patient had negative coccidioidomycosis serologies.

Treatment and management. The patient was started initially on intravenous (IV) linezolid (600 mg IV every 12 hours) and trimethoprim-sulfamethoxazole (160 mg of trimethoprim component IV every 12 hours) N. brasiliensis showed in vitro susceptibility to linezolid and trimethoprim-sulfamethoxazole. After clear clinical improvement, including significant reduction in swelling and resolution of wounds, was noted, the patient was  transitioned to oral trimethoprim-sulfamethoxazole (160/800 mg twice a day). 

Outcome and follow-up. He completed a 6-month course of oral trimethoprim-sulfamethoxazole (160/800 mg twice a day) with complete resolution of his skin lesions (Figures 6 and 7) and joint complaints. At 6 months post-treatment follow-up, the patient stayed symptoms-free, and ESR and CRP fell within normal ranges.

Figure 6. Resolution of hand lesions and swelling, 6 months post-therapy

Figure 7. Resolution of hand lesions and swelling, 6 months post-therapy.

Discussion. Infectious causes of chronic nodular skin lesions may include a variety of organisms including Nocardia species (spp).⁴ Nocardia spp are ubiquitous environmental filamentous Gram-positive aerobic actinomycetes that may result in infection.⁵ Nocardial infections are uncommon. While occurring mostly in individuals with chronic pulmonary diseases or defects in cell-mediated immunity (as seen in patients receiving immunosuppressive therapy or HIV infection), these organisms may also produce infection in immunocompetent patients.⁶

The organism is usually acquired by inhalation but may also be acquired by direct inoculation.⁷ Infection may spread hematogenously and clinical manifestations may range from chronic skin and soft tissue infections to life-threatening disease.  Osteoarticular involvement with Nocardia spp is uncommon and most likely results from either direct inoculation or direct extension from a cutaneous lesion.⁹ In addition to skin and lungs, Nocardia spp have a predilection for spreading to the brain, so an MRI of the brain should be obtained whenever the organism is encountered.⁶ 

Antibiotic treatment of infections due to Nocardia spp can be challenging due to varying susceptibilities among isolates. Trimethoprim-sulfamethoxazole is often considered the drug of choice while other agents which may have good activity include linezolid, imipenem-cilastatin, meropenem, fluoroquinolones, tetracyclines, or macrolides.^10-11  Susceptibility testing of isolates and multiple drug regimens are recommended initially, especially in severe infections.⁸ A prolonged treatment course is often necessary for successful treatment.

Nocardia spp are actinomycetes and not true fungi and their cell walls are not felt to contain BDG. Nevertheless, BDG levels have been detected in association with Nocardia spp and are felt to result from cross-reaction with a polysaccharide present in the cell wall.¹² The clinical significance and utility of BDG in cases of nocardiosis is unknown. The finding of an elevated BDG should be interpreted with caution by the clinician as non-fungal diseases remain possible.

Conclusion. Nocardia spp may cause chronic cutaneous infection and may spread to involve essentially any tissue including bones and joints. Due to antimicrobial resistance, therapy may be difficult requiring multiple drugs and/or lengthy courses of treatment.  Given appropriate clinical and epidemiological settings, infections due to Nocardia spp should be considered. Nocardia infections are generally seen in immunocompromised patients. This is a rare presentation of invasive nocardiosis in an immunocompetent young adult.

References

1. Galgiani JN. Coccidioidomycosis (Coccidioides species). In: Bennett JE. Principles and Practices of Infectious Diseases, Mandell, Douglas and Bennet. 6th ed. Elsevier; 2005. Vol 2: 3040-51.
2. Braunwald E, Fauci AS, Hauser SL, et al. Leishmaniasis. 15th ed. Harrison's Manual of Medicine. 2001: McGraw-Hill
3. de Lima Barros MB, de Almeida Paes R, Schubach AO. Sporothrix schenckii and Sporotrichosis. Clin Microbiol Rev. 2011;24(4):633-654. doi:10.1128/CMR.00007-11
4. Smego RA Jr, Castiglia M, Asperilla MO.  Lymphocutaneous syndrome.  a review of non-sporothrix causes. Medicine (Baltimore). 1999;78(1):38-63.  doi:10.1097/00005792-199901000-00004
5. Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ Jr.  Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy.  Clin Microbiol Rev. 2006;19(2):259-282.  doi:10.1128/CMR.19.2.259-282.2006
6. Beaman BL, Beaman L.  Nocardia species: host-parasite relationships. Clin Microbiol Rev. 1994;7(2):213-264. doi:10.1128.CMR.7.2.213
7. Lederman ER, Crum NF.  A case series and focused review of nocardiosis:  clinical and microbiologic aspects. Medicine (Baltimore). 2004;83(5):300-313. doi: 10.1097/01.md.0000141100.30871.39
8. Muralidhar Reddy Y, Parida S, Jaiswal SK, Murthy JM.  Nocardiosis – an uncommon infection in patients with myasthenia gravis:  report of three cases and review of literature. BMJ Case Rep. 2020;13(12):e237208.  doi:10.1136/bcr-2020-237208
9. Thakur A, Eapen J, Cherian SS. Septic arthritis by Nocardia farcinica: Case report and literature review. IDCases. 2022;31:e01668. doi: 10.1016/j.idcr.2022.e01668
10. Lebeaux D, Bergeron E, Berthet J, et al. Antibiotic susceptibility testing and species identification of Nocardia isolates: a retrospective analysis of data from a French expert laboratory, 2010-2015. Clin Microbiol Infect.  2019;25(4):489-495. doi:10.1016/j.cmi.2018.06.013
11. Restrepo A, Clark NM. Nocardia infection in solid organ transplantation:  Guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation. Clin Transplant. 2019;33(9):e13509.  doi:10.1111/ctr.13509
12. Yagyu K, Nakatsuji Y, Matsushita H. Elevated serum β-D-glucan levels in cavitary pulmonary nocardiosis. BMJ Case Rep. 2020;13(7):e234738.  doi:10.1136/bcr-2020-234738

AUTHORS:
Kashif Memon, MD¹ • Kerry O. Cleveland, MD² • Furqan Tarique Memon, MBBS³

AFFILIATIONS:
¹Chief of Infectious Diseases, CommonSpirit Health, Utah Division, Salt Lake City, UT
²Professor of Medicine, Department of Medicine, Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, TN
³Liaquat University of Health & Medical Sciences, Jamshoro, Sindh, Pakistan

CITATION:
Memon K, Cleveland KO, Memon FT. Nodular skin lesions and painful, swollen joints in a landscaper. Consultant. Published online November 21, 2024. doi:10.25270/con.2024.11.000004

Received February 20, 2024. Accepted June 26, 2024.

DISCLOSURES:
The authors report no relevant financial relationships.

ACKNOWLEDGEMENTS:
None.

CORRESPONDENCE:
Kashif Memon, MD, Chief of infectious Diseases, CommonSpirit Health, Utah Division,3570 West 9000 South, Suite 100, West Jordan, UT 84088  (kashifmemon@yahoo.com)

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