Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

Rare Sporotrichoid Lymphocutaneous Nocardiosis Yasmine Sanhaji OMS-III, Dalton McGee, OMS-III, Dr. Stanley Miller, MD VCOM-Carolinas, Spartanburg, South Carolina

Introduction

Results

Discussion

References Diagnostic Pearls • Consider Nocardia in treatment-resistant infections • Soil exposure history is crucial • Immunocompetent status doesn't exclude infection Clinical Management • Obtain cultures when standard antibiotics fail • Watch for characteristic ascending lymphangitis • Extended antibiotic therapy needed Take-Home Message Early recognition and appropriate cultures are essential for proper diagnosis and treatment of nocardial infections, regardless of immune status Key Findings • Nocardia brasiliensis infection confirmed in immunocompetent host with soil exposure • Classical ascending lymphangitis with observable response to TMP-SMX after three days Clinical Pearls • Culture confirmation essential for diagnosis • Extended therapy (3-6 months) prevents relapse • Thorough exposure history crucial • Early cultures guide appropriate treatment • Extended treatment necessary despite initial improvement Ayoade, F., Mada, P., Joel Chandranesan, A. S., & Alam, M. (2018). Sporotrichoid skin infection caused by Nocardia brasiliensis in a kidney transplant patient. Diseases, 6 (3), 68. https://doi.org/10.3390/diseases6030068 5 Centers for Disease Control and Prevention. (2004). Nocardia species isolates surveillance data 1995-2004 18 Inamadar, A. C., & Palit, A. (2003). Sporotrichoid pattern of cutaneous nocardiosis. Indian Journal of Dermatology, Venereology and Leprology, 69 , 33-34 5 UpToDate. (2024). Nocardia infections: Epidemiology, clinical manifestations, and diagnosis 15 We would like to acknowledge Spartanburg Regional Hospital System and their Infectious Diseases team in managing this case and their additional input for this report. We would also to thank the patient for their consent for this report. Acknowledgements Conclusions

Nocardia brasiliensis, a soil borne opportunistic pathogen, typically causes localized cutaneous infections following traumatic inoculation in immunocompromised patients. This case highlights a rare clinical presentation of lymphocutaneous nocardiosis in an immunocompetent patient that mimicked sporotrichosis, complicating early recognition and management. Following a minor laceration while working in soil, our patient developed ascending lymphangitis with nodular lesions unresponsive to empiric antibiotics. This case highlights the progression of minor injuries to severe infections, emphasizing targeted antimicrobial therapy and the need to differentiate sporotrichoid nocardiosis from Sporothrix schenckii for early diagnosis in immunocompetent patients. Research Question: How can sporotrichoid lymphocutaneous nocardiosis be accurately differentiated from Sporothrix schenckii infection in immunocompetent patients to improve early diagnosis and management? Patient Profile: • 49-year-old immunocompetent male • Initial injury: Soil-contaminated laceration during construction work Clinical Progression: • Initial presentation: Right ring finger paronychia, 2 weeks post injury • Development of ascending erythema and regional lymphadenopathy • Multiple cutaneous nodules appeared with sporotrichoid pattern Diagnostic Findings: • Confirmed Nocardia brasiliensis via wound cultures • Acid-fast branching filamentous bacteria identified • Imaging excluded pulmonary involvement Treatment Course: • Initial treatment: Unresponsive to cephalexin and mupirocin • Definitive therapy: Trimethoprim-Sulfamethoxazole (TMP/SMX) initiated after culture confirmation • Treatment duration: Prescribed for 3-6 months due to high relapse risk Methods

Table 1. The clinical progression that documents the patient's journey from initial incident to successful treatment..

Laboratory/Im aging Results WBC: 13.1, CRP: 6.6 1.6cm ovoid fluid intensity lesion N. brasiliensis culture positive Blood cultures negative

Interventions Keflex, mupirocin, Epsom soaks I&D, empiric antibiotics Switched to Bactrim Continued Bactrim 3-6 months

Timeline Clinical Findings

Right ring finger paronychia post-soil exposure Ascending erythema, lymphadenopathy Multiple subcutaneous nodules, lymphangitis

Initial Presentation Hospital Day 1-3 Hospital Day 4-7

Improved finger infection, residual nodules

Discharge Plan

Figure 1. This image shows the initial paronychia and the ascending erythema.

Table 2. Differential diagnoses with associated features, findings, and treatments.

Suspected Diagnosis Nocardia brasiliensis Sporothrix schenckii MRSA infection Standard cellulitis

Laboratory Findings

Treatment Response

Key Clinical Features

Gram positive, acid-fast bacilli Fungal cultures negative Blood cultures negative Elevated WBC

Sporotrichoid pattern, soil exposure

Responsive to TMP-SMX No response to itraconazole No response to vancomycin

Similar lymphatic spread Skin/soft tissue infection

Failed standard antibiotics

Initial presentation

Figure 2. This image shows the subcutaneous nodules.

2025 Research Recognition Day

74