ABSTRACT
Nocardia pyomyositis in immunocompetent patients is a rare occurrence. The diagnosis may be missed or delayed with the risk of progressive infection and suboptimal or inappropriate treatment. We present the case of a 48-year-old immunocompetent firefighter diagnosed with pyomyositis caused by Nocardia brasiliensis acquired by direct skin inoculation from gardening activity. The patient developed a painful swelling on his right forearm that rapidly progressed proximally and deeper into the underlying muscle layer. Ultrasound imaging of his right forearm showed a 7-mm subcutaneous fluid collection with surrounding edema. Microbiologic analysis of the draining pus was confirmed to be N brasiliensis by Matrix-Assisted Laser Desorption/Ionization Time-of-Flight (MALDI-TOF) Mass Spectrometry. After incision and drainage deep to the muscle layer to evacuate the abscess and a few ineffective antibiotic options, the patient was treated with intravenous ceftriaxone and oral linezolid for 6 weeks. He was then de-escalated to oral moxifloxacin for an additional 4 months to complete a total antibiotic treatment duration of 6 months. The wound healed satisfactorily and was completely closed by the fourth month of antibiotic therapy. Six months after discontinuation of antibiotics, the patient continued to do well with complete resolution of the infection. In this article, we discussed the risk factors for Nocardia in immunocompetent settings, the occupational risks for Nocardia in our index patient, and the challenges encountered with diagnosis and treatment. Nocardia should be included in the differential diagnosis of cutaneous infections, particularly if there is no improvement of "cellulitis" with traditional antimicrobial regimens and the infection extends into the deeper muscle tissues.
Subject(s)
Anti-Bacterial Agents , Gardening , Immunocompetence , Nocardia Infections , Nocardia , Pyomyositis , Humans , Male , Middle Aged , Nocardia Infections/diagnosis , Nocardia Infections/drug therapy , Nocardia/isolation & purification , Anti-Bacterial Agents/therapeutic use , Pyomyositis/drug therapy , Pyomyositis/diagnosis , Pyomyositis/microbiology , Ceftriaxone/therapeutic use , Spectrometry, Mass, Matrix-Assisted Laser Desorption-Ionization , Drainage , Moxifloxacin/therapeutic use , Moxifloxacin/administration & dosage , Linezolid/therapeutic useABSTRACT
Leukocytoclastic vasculitis is a rare, small-vessel vasculitis that can be caused by sulfamethoxazole-trimethoprim. Most presentations involve skin rash but serious systemic involvement is possible. The precise mechanism is unclear but genetic and immune-based tissue damage has been postulated. The rash often resolves with discontinuation of sulfamethoxazole-trimethoprim with or without steroids.
ABSTRACT
Periapical actinomycosis is a relatively rare form of cervicofacial actinomycosis, which typically involves the periapical region with subsequent potential spread to the jaw bones. We hereby present two cases of periapical actinomycosis. Both patients presented with jaw pain and "holes" in their gum and lacked the characteristic clinical features commonly seen in cervicofacial actinomycosis such as jaw mass, draining ulcers, sinuses and fistulae. The first patient was an immunocompetent host with chronic stable medical conditions but with a rather bad dentition requiring multiple recent teeth extractions. The second patient was edentulous, had refractory multiple myeloma, was on low-dose chronic steroids and pomalidomide therapy and therefore relatively immunocompromised. Both cases of actinomycosis were diagnosed by jaw bone histopathology, which showed characteristic sulfur granules and embedded Actinomyces-like organisms. The two patients had excellent clinical response to six months of penicillin therapy without any need for surgical intervention. The cases remind clinicians of including actinomycosis in the differential diagnosis of periapical lesions and illustrates the possibility of achieving cure with non-surgical treatment.
