title: Left thigh phlegmon caused by Nocardia farcinica identified by 16S rRNA sequencing in a patient with leprosy: a case report.
abstract: BACKGROUND
  In recent years, Nocardia farcinica has been reported to be an increasingly frequent cause of localized and disseminated infections in the immunocompromised patient. However, recent literature is limited. We report a case of left thigh phlegmon caused by N. farcinica that occurred in a patient with leprosy undergoing treatment with prednisone for leprosy reaction.
  
  
  METHODS
  We describe the case of left thigh phlegmon caused by Nocardia farcinica in a 54-year-old Italian man affected by multi-bacillary leprosy. The patient had worked in South America for 11 years. Seven months after his return to Italy, he was diagnosed with leprosy and started multi-drug antibiotic therapy plus thalidomide and steroids. Then, during therapy with rifampicin monthly, minocycline 100 mg daily, moxifloxacin 400 mg daily, and prednisone (the latter to treat type 2 leprosy reaction), the patient complained of high fever associated with erythema, swelling, and pain in the left thigh. Therefore, he was admitted to our hospital with the clinical suspicion of cellulitis. Ultrasound examination and Magnetic Resonance Imaging showed left thigh phlegmon. He was treated with drainage and antibiotic therapy (meropenem and vancomycin replaced by daptomycin). The responsible organism, Nocardia farcinica, was identified by 16S rRNA sequencing in the purulent fluid taken out by aspiration. The patient continued treatment with intravenous trimethoprim/sulfamethoxazole and imipenem followed by oral trimethoprim/sulfamethoxazole and moxifloxacin. A whole-body computed tomography did not reveal dissemination to other organs like the lung or brain.The patient was discharged after complete remission. Oral therapy with trimethoprim/sulfamethoxazole, moxifloxacin, rifampicin monthly, clofazimine and thalidomide was prescribed to be taken at home. One month after discharge from the hospital the patient is in good clinical condition with complete resolution of the phlegmon.
  
  
  CONCLUSIONS
  N. farcinica is a rare infectious agent that mainly affects immunocompromised patients. Presentation of phlegmon only without disseminated infection is unusual, even in these kinds of patients. In any case, a higher index of suspicion is needed, as diagnosis can easily be missed due to the absence of characteristic symptoms and the several difficulties usually encountered in identifying the pathogen.
authors.affiliation: Lazzaro Spallanzani National Institute for Infectious Diseases-IRCCS, Via Portuense 292, Rome, 00149, Italy. dr.pasqualedenardo@gmail.com
authors.forename: Pasquale
authors.initials: P
authors.lastname: De Nardo
authors.forename: Maria Letizia
authors.initials: ML
authors.lastname: Giancola
authors.forename: Salvatore
authors.initials: S
authors.lastname: Noto
authors.forename: Elisa
authors.initials: E
authors.lastname: Gentilotti
authors.forename: Piero
authors.initials: P
authors.lastname: Ghirga
authors.forename: Chiara
authors.initials: C
authors.lastname: Tommasi
authors.forename: Rita
authors.initials: R
authors.lastname: Bellagamba
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: Paglia
authors.forename: Emanuele
authors.initials: E
authors.lastname: Nicastri
authors.forename: Andrea
authors.initials: A
authors.lastname: Antinori
authors.forename: Angela
authors.initials: A
authors.lastname: Corpolongo
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002481:Cellulitis / Q000188:drug therapy / Q000382:microbiology* / Q000473:pathology* / Q000601:surgery; D004269:DNA, Bacterial / Q000737:chemistry / Q000235:genetics; D004275:DNA, Ribosomal / Q000737:chemistry / Q000235:genetics; D004322:Drainage; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use; D007558:Italy; D007918:Leprosy / Q000150:complications* / Q000188:drug therapy; D008297:Male; D008875:Middle Aged; D009615:Nocardia / Q000302:isolation & purification*; D009617:Nocardia Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000473:pathology* / Q000601:surgery; D011241:Prednisone / Q000009:adverse effects / Q000627:therapeutic use; D012336:RNA, Ribosomal, 16S / Q000235:genetics; D017422:Sequence Analysis, DNA; D013848:Thigh / Q000473:pathology*; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D004269:DNA, Bacterial; D004275:DNA, Ribosomal; D007166:Immunosuppressive Agents; D012336:RNA, Ribosomal, 16S; D011241:Prednisone
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