key: cord-0739046-5h7vgtl4
authors: Ash, Mark M.; Hamad, Judy; Ziemer, Carolyn M.; Googe, Paul B.
title: Prompt identification of primary cutaneous nocardiosis utilizing immunohistochemical staining: a case report
date: 2020-07-11
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2020.06.040
sha: 77d4d48fb7d058bae4aab53b852208111d52fe6d
doc_id: 739046
cord_uid: 5h7vgtl4

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Nocardia are aerobic bacteria that exist ubiquitously in the environment (e.g. soil) and typically cause 3 disease in the immunocompromised (the occurrence rate may be as high as 2.65% in solid organ 4 transplant recipients with an associated overall mortality around 17%). 1 Nocardiosis typically presents as 5 pneumonia in organ transplant recipients but may also cause primary cutaneous infections after traumatic 6 inoculation and disseminate to multiple organs, including the brain, liver, kidney, bones, and 7 pericardium. 2,3 Microscopically, Nocardia have gram-positive, branched filaments that may fragment into distinguished by the fine filamentous morphology of Nocardia (RGM typically exhibit coccobacillary 13 morphology). 5,6 However, confirming the identity of Nocardia in culture based on the growth of aerial 14 hyphae typically requires at least 3-5 days and can be obfuscated by more rapidly growing bacteria. 3,5,7 3 Case:

A 72-year-old male with a complex medical history (Factor V Leiden deficiency, ischemic 19 cardiomyopathy, treated pulmonary cryptococcosis, thin basement membrane disease, and renal 20 transplantation after nephrectomy for clear cell renal cell carcinoma) sustained a laceration to the right 21 forearm after a fall onto gravel. A tetanus vaccine booster was administered, the wound was irrigated, and 22 bacitracin was applied daily. He was maintained on mycophenolate, tacrolimus, and prednisone for 23 immunosuppression without trimethoprim-sulfamethoxazole prophylaxis.

Three weeks after sustaining the laceration, he reported onset of a painful, pustular rash of the right 26 extensor arm that did not respond to outpatient clindamycin or ceftriaxone ( Figure 1 ). On admission, CT 27 imaging of the arm showed no organized fluid, gas, or acute osseous abnormality. He was started on 28 cefepime, metronidazole, vancomycin, and acyclovir empirically and skin biopsies for H&E and tissue 29 culture were obtained. Acyclovir was discontinued after HSV/VZV PCR swabs resulted as negative. One 

A 20-year experience with nocardiosis in solid 133 organ transplant (SOT) recipients in the Southwestern United States: A single-center 134 study

Clinical and clinical laboratory aspects of nocardial infection

Nocardial infection in immunosuppressed kidney 141 transplant recipients

Critical aspects for bacteriological diagnosis

Clinical and laboratory aspects of 146 the diagnosis and management of cutaneous and subcutaneous infections caused by 147 rapidly growing mycobacteria

Not everything acid fast is Mycobacterium 149 tuberculosis--a case report

Nontuberculous 151 mycobacterial infections: comparison of the fluorescent auramine-O and Ziehl-Neelsen

The Utility of 154

Immunohistochemistry in Mycobacterial Infection: A Proposal for Multimodality

Nocardiosis in 132 patients with 157 cancer: microbiological and clinical analyses

We would like to honor the memory of our wonderful patient and thank his gracious spouse for 127 encouraging us to report his case to hopefully benefit the medical community and other patients. We