Track: Case Reports

Abstract:

We report a rare case of Nocardia vinacea infection in a 64-year-old immunosuppressed male
with a history of liver transplantation who presented with a 2 cm verrucous, crusted plaque on an
erythematous base located on the right inferior frontal forehead, present for several months.
Biopsy revealed exuberant pseudoepitheliomatous hyperplasia with subepidermal neutrophilic
vesicles, suggestive of an infectious process. Grocott methenamine silver (GMS) staining
demonstrated focal areas containing possible branching rods. Tissue culture and PCR analysis
confirmed Nocardia vinacea, a rarely reported species not previously documented in facial
cutaneous disease. The patient was treated successfully with moxifloxacin 400 mg daily for six
months. Nocardia species are aerobic, gram-positive, filamentous, weakly acid-fast bacteria that are
widely distributed in soil, water, and decomposing vegetation. They are opportunistic pathogens
most commonly causing pulmonary or disseminated disease in immunocompromised
individuals. Cutaneous nocardiosis is relatively uncommon and typically involves the
extremities, with N. brasiliensis, N. asteroides, and N. farcinica being the most frequently
implicated species. Facial involvement is rare, and N. vinacea has not been previously described
in this context. Because Nocardia infections can mimic a wide range of infectious, inflammatory,
and neoplastic dermatoses, early biopsy and tissue culture are essential. Modified acid-fast and
GMS stains may aid in identification while awaiting culture and PCR confirmation. While
trimethoprim-sulfamethoxazole remains first-line treatment, alternative agents such as
fluoroquinolones may be effective. This case expands the clinical spectrum of Nocardia vinacea
and highlights the need to consider nocardiosis in the differential diagnosis of persistent
verrucous plaques in immunocompromised patients.

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Sherren White