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Case Reports
. 2013 Jun 30;7(2):52-5.
doi: 10.3315/jdcr.2013.1142. Print 2013 Jun 30.

Disseminated Nocardia infection presenting as hemorrhagic pustules and ecthyma in a woman with systemic lupus erythematosus and antiphospholipid antibody syndrome

Daniel Mosel  1 , Leslie Harris, Emily Fisher, Edit Olasz, Barbara Wilson
Affiliations
Case Reports

Disseminated Nocardia infection presenting as hemorrhagic pustules and ecthyma in a woman with systemic lupus erythematosus and antiphospholipid antibody syndrome

Daniel Mosel et al. J Dermatol Case Rep. .

Abstract

Background: Nocardia is an opportunistic pathogen that can cause disseminated infection in immunocompromised hosts. The most common type of skin lesion reported with disseminated Nocardia is a subcutaneous nodule; however, there are reports with unusual cutaneous presentations. Long term corticosteroid treatment is one of the largest risk factors for developing disseminated Nocardia. Initial treatment is empiric as each strain has unique susceptibilities and it takes weeks to speciate and test sensitivities.

Main observations: A 66-year-old female on long term corticosteroids for systemic lupus erythematosus (SLE) and antiphospholipid syndrome presented with a polymorphous skin eruption and systemic symptoms concerning for infection. Especially concerning were areas of hemorrhagic pustules on the lower legs, and two ecthymatous lesions on the thigh. Tissue culture Gram stain revealed Gram positive branching filamentous rods concerning for Nocardia. The patient improved with empiric treatment.

Conclusions: This case of Nocardiosis had unusual cutaneous findings that could have misguided the clinician, but the tissue culture and Gram stain proved to be useful for rapid diagnosis and proper treatment.

Keywords: antiphospholipid syndrome; infection; systemic lupus erythematosus.

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Figures

Figure 1
Figure 1
Physical exam revealed numerous cutaneous findings including A) multiple hemorrhagic pustules on the left lower extremity, B) a 4 cm ecthymatous lesion on the right thigh, C) an erythematous subcutaneous nodule on the right upper arm, D) and a warm erythematous plaque on the left knee.
Figure 2
Figure 2
The histologic findings were in favor of an infectious process A) low power view with an infiltrate in the mid and deep dermis, focally extending into the subcutaneous fat, B) high power view with a mostly neutrophilic infiltrate, C) Tissue culture Gram stain with Gram positive branching filamentous rods.
See this image and copyright information in PMC

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