Actinomycetoma of the chest wall attributed to Nocardia nova after reconstructive surgery.
A 29-year-old man, presented with multiple ulcers, nodules, abscesses, fistulae, and atrophic scars, over the right chest wall. Six years prior, the patient had a car accident, which resulted in skin loss of the right arm, shoulder, thoracic wall. In addition, he suffered a supracondylar fracture; orthopedic surgery and skin grafts were required. Material discharging from sinus tracts was obtained for mycological and bacteriological studies. Direct microscopic examination revealed small white grains. Cultures on Sabouraud and Lowenstein-Jensen media isolated orange-white colonies suggestive of Nocardia. PCR assay identified Nocardia nova. Thoracic and right upper limb CT showed signs of chronic osteomyelitis. Treatment with imipenem/cilastatin for 8 weeks, followed by amoxicillin clavulanate for 6 months, resulted in healing of lesions and improvement in the patient's general health. Primary cutaneous nocardiosis remains a diagnostic challenge. Nocardia are soil-borne filamentous gram-positive bacteria. Identification of characteristic granules on examination of discharge smears from discharge or tissue biopsy is essential for diagnosing mycetoma. Because grain discharge is discontinuous, multiple clinical specimens should be submitted for microscopic examination and culture. Sulfonamides have been the mainstay of Nocardia actinomycetoma treatment. However, our patient's strain was resistant to Co-trimoxazole. Therefore, treatment with imipenem followed by amoxicillin clavulanate was favored, with good clinical and analytical response.
Serviço de Dermatologia, Hospital de Santa Maria, Lisboa, Portugal.
Joana
J
Antunes
David
D
Pacheco
Rita
R
Travassos
Hortênsia
H
Sequeira
Paulo
P
Filipe
Manuel Sacramento
MS
Marques
D000328:Adult; D019980:Amoxicillin-Potassium Clavulanate Combination / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D015377:Cilastatin / Q000627:therapeutic use; D006801:Humans; D015378:Imipenem / Q000627:therapeutic use; D008297:Male; D008271:Mycetoma / Q000175:diagnosis* / Q000188:drug therapy* / Q000382:microbiology; D009617:Nocardia Infections / Q000175:diagnosis* / Q000188:drug therapy*; D011480:Protease Inhibitors / Q000627:therapeutic use; D035441:Thoracic Wall / Q000601:surgery
D000900:Anti-Bacterial Agents; D011480:Protease Inhibitors; D015377:Cilastatin; D015378:Imipenem; D019980:Amoxicillin-Potassium Clavulanate Combination