Abstract
BackgroundIn 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.Case presentationWe 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.ConclusionN. 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.
Highlights
In recent years, Nocardia farcinica has been reported to be an increasingly frequent cause of localized and disseminated infections in the immunocompromised patient
A higher index of suspicion is needed, as diagnosis can be missed due to the absence of characteristic symptoms and the several difficulties usually encountered in identifying the pathogen
Nocardiosis is a localized or disseminated uncommon infection caused by an aerobic Actinomycetes of the genus Nocardia [1]
Summary
N.farcinica is a Gram–positive, branching, filamentous bacillus causing many localized and disseminated infectious in humans, including pulmonary and wound infections, brain abscesses, and bacteraemia. Peleg et al described the risk factors of N. farcinica infection in organ transplant recipients. In this case series, patients with Nocardia infection had significantly higher prednisone dosages (p 0.007), lower lymphocyte counts (p 0.003), and higher neutrophil counts (p 0.006) at the time of infection, compared with control subjects [13]. The patient had undergone therapy with prednisone in the preceding 12 months because of leprosy reaction. The patients had sub-clinical or transient primary pulmonary infection followed by dissemination to the brain, skin, bones, and kidney [15]. Since no cases of N. farcinica treated with daptomycin have been described in literature (there are only sensitivity studies in vitro) [21], we started empirical antibiotic combination therapy with imipenem plus trimethoprim-sulfamethoxazole. Authors’ contributions AC and PDN took care of the patient and wrote the case report; MGP did the laboratory work; MLG and PG took care of the patient; EG, CT, RT took part in the drafting; SN, EN and AA contributed to literature search and reviewed the final manuscript; all authors read and approved the final version of the manuscript
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