Abstract

A 44-year-old man from Jamaica with type 2 diabetes and hypertension presented to the hospital with a 2-year history of swelling and ulcerated verrucous nodules of his left forearm. Eight years prior, the patient had a bicycle accident during which he sustained a cut on the palmar surface of his left hand along with swelling, which self-resolved. Two years prior to presentation, he developed swelling and ulceration of his forearm and hand, which initially improved with a few weeks of antibiotics. However, eight months prior to presentation he noticed sudden worsening and subsequently lost 35 lbs. MRI revealed diffuse soft tissue swelling with innumerable collections, extending to the deep musculature, myositis and tenosynovitis. CT showed left axillary lymphadenopathy. The patient underwent I+D with tissue biopsy showing suppurative inflammation with associated scattered foci of filamentous bacterial forms which was also seen with AFB, Fite, GMS, Gram, and PAS stains. Tissue culture confirmed the diagnosis and identified the species as Nocardia wallacei (N. wallacei). Excision of the lymph node was performed with pathology showing follicular and paracortical lymphoid hyperplasia and negative lymph node culture. The patient was treated for mycetoma with several months of Augmentin and Bactrim with resolution of the lesions. N. wallacei was first identified as a subspecies of Nocardia in 2008 through molecular sequencing. Though this species was previously considered part of the Nocardia transvalensis complex, since 2008, reported cases of N. wallacei have primarily consisted of patients with pulmonary nocardiosis, some with intracranial dissemination. To our knowledge only two cases of mycetoma or primary cutaneous nocardiosis due to N. wallacei have been reported in the literature. We present a case of cutaneous nocardiosis due to N. wallacei, with a six-year latency from traumatic inoculation, successfully treated with a prolonged course of Augmentin and Bactrim.

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