Primary cutaneous nocardiosis: a diagnosis of consideration in a renal transplant recipient

Primary cutaneous nocardiosis caused by Nocardia nova with possible Apremilast contribution

Primary cutaneous nocardiosis accounts for 5-8 % of all nocardiosis cases and represents a diagnostic dilemma among immunocompetent and immunocompromised hosts. Herein, we present a case of a 30-year-old male with history of psoriasis with recent addition of Apremilast. Patient received intralesional triamcinolone injections for psoriatic plaques on the hands and abdomen prior to traveling to warm climate vacation. While on vacation, patient developed hand swelling and painful, red nodules on the dorsal hands and abdomen, sites where he received intralesional injections. Patient was empirically given doxycycline, but continued to develop new nodules. An abdominal lesion was biopsied for H&E and tissue culture. Tissue culture revealed beaded gram-positive rods identified as Nocardia nova by MALDI-TOF. Patient was switched to trimethoprim-sulfamethoxazole with significant improvement. This case represents an atypical primary cutaneous nocardiosis with Nocardia nova most likely in the setting of intralesional steroid injections and possible contribution of Apremilast.

Updates on Nocardia Skin and Soft Tissue Infections in Solid Organ Transplantation

PURPOSE OF REVIEW

Due to their immunocompromised status, solid organ transplant (SOT) recipients are at risk for Nocardia infections. These infections often necessitate early invasive diagnostics alongside prolonged, often combination antimicrobial therapy. This review summarizes the importance of this pathogen in skin and soft tissue infections (SSTIs) in SOT recipients inclusive of recently reported cases in the literature and an update on the epidemiology, diagnostics, and management.

RECENT FINDINGS

Six studies with 13 isolated SSTIs due to Nocardia have been published in the last 5 years in SOT recipients. The most common underlying type of transplant was kidney and time from transplantation to infection varied from 6 months to 16 years. Misdiagnosis was frequent. Available identified species included N. brasiliensis (2), N. farcinica (2), N. flavorosea (1), N. abscessus (1), N. anaemiae (1), N. asteroides (1), N. nova (1), and N. vinacea (1). Treatment choice and duration varied widely, and trimethoprim-sulfamethoxazole was utilized most often with no documented infection relapse. Nocardia SSTIs can occur both in isolation and as a component of a disseminated infection. Overall, isolated Nocardia SSTIs are uncommon in SOT recipients and are often initially misdiagnosed. They present multiple challenges to the clinician including evaluation for potential co-pathogens and/or non-infectious processes and ruling out the presence of disseminated infection. While trimethoprim-sulfamethoxazole remains the agent of choice for management of most isolated SSTIs, therapy must be tailored to the individual patient based on species-specific susceptibility patterns and formal susceptibility testing, site(s) of infection, and patient tolerability.