A case of cutaneous nocardiosis successfully treated with third-generation cephalosporin

IF 2.3 4区 医学 Q2 DERMATOLOGY
Tzu-Yu Liu, Feng-Ling Lin
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The patient did not receive systemic immunosuppressant or glucocorticoids, nor was he diagnosed with malignancy or an autoimmune disease. Topical antibiotic was given, and his wound gradually healed. However, pustular eruptions at the trauma site developed 1 week later. Cellulitis was impressed first, so topical fusidic acid cream and oral doxycycline were applied after obtaining the wound culture. The primary wound culture yielded coagulase-negative Staphylococcus epidermidis, which indicated colonization or contamination of the specimen. His symptoms also did not improve after 1-week oral antibiotic treatment. He then came to the dermatology clinic. Physical examination revealed erythematous firm nodules and pustules with erythematous-based patches on the left cheek [Figure 1a]. The patient was afebrile then.Figure 1: Clinical presentation: (a) before treatment: erythematous nodules and pustules on left cheek; (b) after treatment: erythema and pustules on left cheek resolved.Differential diagnoses included bacterial cellulitis, atypical infection (e.g. sporotrichosis, nocardiosis, tuberculosis, nontuberculous mycobacterium, or leishmaniasis), or Majocchi granuloma. He then received skin biopsy with tissue culture. Pathology report revealed suppurative microabscesses with aggregation of histiocytes [Figure 2a]. Immunohistochemistry stain showed negative for Gram’s stain [Figure 2b], periodic acid–Schiff stain [Figure 2c], or acid-fast stain [Figure 2d]. The tissue culture yielded Nocardiabrasiliensis, so cutaneous nocardiosis was diagnosed. The chest X-ray only showed enlarged heart size without increased infiltration or nodule at the lung field. Considering the impaired renal function of the patient, sulfamethoxazole was not given. We prescribed alternative treatment with oral cefixime 100 mg twice a day. After 4-week treatment, the skin lesion of the patient almost resolved [Figure 1b].Figure 2: Histopathological investigation: (a) Histopathology stain of the skin biopsy revealed suppurative microabscesses with aggregation of histiocytes (H and E, ×200); immunohistochemical stain of skin biopsy revealed negative for (b) Gram’s stain (×200), (c) periodic acid–Schiff stain (×200), and (d) acid-fast stain (×200).Cutaneous nocardiosis is skin and soft-tissue infection from a kind of filamentous bacteria which is aerobic Gram-positive. The portal of entry includes direct inoculation due to trauma and bloodstream in immunocompromised host. Cutaneous manifestation may present as nodular-pustular lesions with or without sporotrichoid distribution, cellulitis, or ulcerative lesions.[2] The most common extracutaneous lesion is pulmonary nocardiosis, especially in immunosuppressed patients. The first-line treatment is sulfonamides, such as sulfamethoxazole with or without trimethoprim. Other alternatives include minocycline, amikacin, imipenem, tigecycline, and third-generation cephalosporins.[3] Combination therapy is suggested in severe or complicated cases. In patients with immunosuppressive states, prolonged antibiotic use for 1–4 months is highly suggested. The prognosis of primary cutaneous nocardiosis is good when appropriate antibiotic therapy is given. Back to our patient, the treatment options of sulfamethoxazole and amikacin were excluded due to impaired renal function. Minocycline was not feasible because of a previous lack of response to doxycycline. The patient refused in-hospital treatment, so imipenem and tigecycline could not be given. Therefore, oral form third-generation cephalosporin may be an appropriate option based on previous article reviews and the response of the patient’s clinical presentation. In conclusion, cutaneous nocardiosis may be derived from local trauma related to plants and soil, resulting in abscess, cellulitis, or lymphocutaneous nodules in a sporotrichoid pattern. Sulfamethoxazole is the first-line therapy, but third-generation cephalosporin may be an effective alternative for patients who cannot tolerate sulfa drugs. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Data availability statement Data sharing not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.","PeriodicalId":11107,"journal":{"name":"Dermatologica Sinica","volume":"51 7","pages":"0"},"PeriodicalIF":2.3000,"publicationDate":"2023-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Dermatologica Sinica","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.4103/ds.ds-d-23-00109","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"DERMATOLOGY","Score":null,"Total":0}
引用次数: 0

Abstract

Dear Editor, Cutaneous nocardiosis is a type of skin and soft-tissue infection caused by Nocardia species, a kind of bacteria isolated from the environment. Sulfamethoxazole is the priority choice of oral medication,[1] but impaired renal function is a concern. Herein, we present a case successfully treated with oral cefixime as an alternative. An 87-year-old man with diabetes mellitus, congestive heart failure, and stage 4 chronic kidney disease (estimated glomerular filtration rate: 28.5 mL/min/1.73 m²) suffered from painful lesions on the face after falling to the ground. Abrasion wound and ecchymosis developed initially, so he was brought to local clinic for management. The patient did not receive systemic immunosuppressant or glucocorticoids, nor was he diagnosed with malignancy or an autoimmune disease. Topical antibiotic was given, and his wound gradually healed. However, pustular eruptions at the trauma site developed 1 week later. Cellulitis was impressed first, so topical fusidic acid cream and oral doxycycline were applied after obtaining the wound culture. The primary wound culture yielded coagulase-negative Staphylococcus epidermidis, which indicated colonization or contamination of the specimen. His symptoms also did not improve after 1-week oral antibiotic treatment. He then came to the dermatology clinic. Physical examination revealed erythematous firm nodules and pustules with erythematous-based patches on the left cheek [Figure 1a]. The patient was afebrile then.Figure 1: Clinical presentation: (a) before treatment: erythematous nodules and pustules on left cheek; (b) after treatment: erythema and pustules on left cheek resolved.Differential diagnoses included bacterial cellulitis, atypical infection (e.g. sporotrichosis, nocardiosis, tuberculosis, nontuberculous mycobacterium, or leishmaniasis), or Majocchi granuloma. He then received skin biopsy with tissue culture. Pathology report revealed suppurative microabscesses with aggregation of histiocytes [Figure 2a]. Immunohistochemistry stain showed negative for Gram’s stain [Figure 2b], periodic acid–Schiff stain [Figure 2c], or acid-fast stain [Figure 2d]. The tissue culture yielded Nocardiabrasiliensis, so cutaneous nocardiosis was diagnosed. The chest X-ray only showed enlarged heart size without increased infiltration or nodule at the lung field. Considering the impaired renal function of the patient, sulfamethoxazole was not given. We prescribed alternative treatment with oral cefixime 100 mg twice a day. After 4-week treatment, the skin lesion of the patient almost resolved [Figure 1b].Figure 2: Histopathological investigation: (a) Histopathology stain of the skin biopsy revealed suppurative microabscesses with aggregation of histiocytes (H and E, ×200); immunohistochemical stain of skin biopsy revealed negative for (b) Gram’s stain (×200), (c) periodic acid–Schiff stain (×200), and (d) acid-fast stain (×200).Cutaneous nocardiosis is skin and soft-tissue infection from a kind of filamentous bacteria which is aerobic Gram-positive. The portal of entry includes direct inoculation due to trauma and bloodstream in immunocompromised host. Cutaneous manifestation may present as nodular-pustular lesions with or without sporotrichoid distribution, cellulitis, or ulcerative lesions.[2] The most common extracutaneous lesion is pulmonary nocardiosis, especially in immunosuppressed patients. The first-line treatment is sulfonamides, such as sulfamethoxazole with or without trimethoprim. Other alternatives include minocycline, amikacin, imipenem, tigecycline, and third-generation cephalosporins.[3] Combination therapy is suggested in severe or complicated cases. In patients with immunosuppressive states, prolonged antibiotic use for 1–4 months is highly suggested. The prognosis of primary cutaneous nocardiosis is good when appropriate antibiotic therapy is given. Back to our patient, the treatment options of sulfamethoxazole and amikacin were excluded due to impaired renal function. Minocycline was not feasible because of a previous lack of response to doxycycline. The patient refused in-hospital treatment, so imipenem and tigecycline could not be given. Therefore, oral form third-generation cephalosporin may be an appropriate option based on previous article reviews and the response of the patient’s clinical presentation. In conclusion, cutaneous nocardiosis may be derived from local trauma related to plants and soil, resulting in abscess, cellulitis, or lymphocutaneous nodules in a sporotrichoid pattern. Sulfamethoxazole is the first-line therapy, but third-generation cephalosporin may be an effective alternative for patients who cannot tolerate sulfa drugs. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Data availability statement Data sharing not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
第三代头孢菌素成功治疗皮肤诺卡菌病1例
皮肤诺卡菌病是一种由诺卡菌引起的皮肤和软组织感染,诺卡菌是一种从环境中分离出来的细菌。磺胺甲恶唑是口服药物的首选[1],但肾功能受损是一个问题。在这里,我们提出了一个案例成功地治疗口服头孢克肟作为一种选择。一名87岁男性,患有糖尿病、充血性心力衰竭和4期慢性肾脏疾病(估计肾小球滤过率:28.5 mL/min/1.73 m²),跌倒后面部出现疼痛病变。最初出现擦伤和瘀斑,因此被带到当地诊所治疗。患者未接受全身免疫抑制剂或糖皮质激素治疗,也未被诊断为恶性肿瘤或自身免疫性疾病。局部给予抗生素治疗,伤口逐渐愈合。然而,创伤部位1周后出现脓疱。首先是蜂窝织炎,因此在获得伤口培养后,局部应用夫西地酸乳膏和口服强力霉素。最初的伤口培养产生凝固酶阴性表皮葡萄球菌,这表明定植或污染标本。口服抗生素治疗1周后症状未见改善。然后他来到了皮肤科诊所。体格检查显示左脸颊有红斑性硬结节和脓疱,伴有红斑性斑块[图1a]。病人当时不发烧。图1:临床表现:(a)治疗前:左脸颊红斑性结节、脓疱;(b)治疗后:左脸颊红斑、脓疱消退。鉴别诊断包括细菌性蜂窝织炎、非典型感染(如孢子虫病、诺卡病、结核病、非结核分枝杆菌或利什曼病)或马氏肉芽肿。然后接受皮肤活检和组织培养。病理报告显示化脓性微脓肿伴组织细胞聚集[图2a]。免疫组化染色革兰氏染色阴性[图2b],周期性酸-希夫染色阴性[图2c],抗酸染色阴性[图2d]。组织培养产生诺卡菌,诊断为皮肤诺卡菌病。胸部x线片仅显示心脏增大,未见肺野浸润或结节增加。考虑到患者肾功能受损,未给予磺胺甲恶唑治疗。我们开了另一种治疗方法,口服头孢克肟100毫克,每天两次。治疗4周后,患者皮肤病变基本消退[图1b]。图2:组织病理学检查:(a)皮肤活检组织病理学染色显示化脓性微脓肿,组织细胞聚集(H和E, ×200);皮肤活检免疫组化染色(b)革兰氏染色(×200), (c)周期性酸-希夫染色(×200)和(d)抗酸染色(×200)为阴性。皮肤诺卡菌病是由一种需氧革兰氏阳性丝状细菌引起的皮肤和软组织感染。进入途径包括由于创伤和免疫功能低下宿主的血液直接接种。皮肤表现可表现为结节性脓疱病变,伴或不伴孢子毛样分布,蜂窝织炎或溃疡性病变。[2]最常见的皮外病变是肺诺卡菌病,尤其是免疫抑制患者。一线治疗是磺胺类药物,如磺胺甲恶唑加或不加甲氧苄啶。其他替代品包括米诺环素、阿米卡星、亚胺培南、替加环素和第三代头孢菌素。[3]严重或复杂病例建议联合治疗。对于免疫抑制状态的患者,强烈建议延长抗生素使用1-4个月。当给予适当的抗生素治疗时,原发性皮肤诺卡菌病的预后良好。回到我们的病人,由于肾功能受损,我们排除了磺胺甲恶唑和阿米卡星的治疗选择。米诺环素不可行,因为先前对强力霉素缺乏反应。患者拒绝住院治疗,无法给予亚胺培南、替加环素治疗。因此,口服形式的第三代头孢菌素可能是一个适当的选择,基于先前的文章综述和患者的临床表现的反应。总之,皮肤诺卡菌病可能源于与植物和土壤有关的局部创伤,导致脓肿、蜂窝织炎或孢子毛样淋巴性皮肤结节。磺胺甲恶唑是一线治疗,但第三代头孢菌素可能是不能耐受磺胺类药物的患者的有效选择。患者同意声明作者证明他们已经获得了所有适当的患者同意表格。在这张表格中,患者已经同意他的图像和其他临床信息将在杂志上报道。 患者明白,他的姓名和首字母不会被公布,并将尽力隐藏他的身份,但不能保证匿名。数据可用性声明数据共享不适用于本文,因为在当前研究中没有生成或分析数据集。财政支持及赞助无。利益冲突没有利益冲突。
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来源期刊
Dermatologica Sinica
Dermatologica Sinica DERMATOLOGY-
CiteScore
2.80
自引率
20.00%
发文量
28
审稿时长
>12 weeks
期刊介绍: Dermatologica Sinica aims to publish high quality scientific research in the field of dermatology, with the goal of promoting and disseminating dermatological-related medical science knowledge to improve global health. Articles on clinical, laboratory, educational, and social research in dermatology and other related fields that are of interest to the medical profession are eligible for consideration. Review articles, original articles, brief reports, case reports and correspondence are accepted.
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