Page 153 - MI-2-4

Microbes & Immunity A case of cutaneous Nocardia farcinica

Nocardia farcinica represents approximately 10% of
nocardiosis cases. N. farcinica is a culprit for primary
2
cutaneous nocardiosis and resistant to several commonly
used antibiotics. We present a rare case of post-operative
cutaneous nocardiosis with delay in therapy resulting
in prolonged non-healing wound. This report aims to
emphasize the necessity to execute proper diagnosis,
treatment, and monitoring for patients with N. farcinica
infection limited to the skin/soft tissue.

2. Case presentation
A 57-year-old female with non-healing wound presented
to the infectious disease clinic. The patient has a history of
insulin-dependent type 2 diabetes with hemoglobin A1c
(HbA1c) of 10.8% and tobacco dependence. The patient
was diagnosed with trigger finger, suspected to be due Figure 1. Palmar surface of the patient’s left hand
to ganglion cysts and Dupuytren’s disease for which she
underwent elective outpatient cyst removal on the flexor be related to a camping trip shortly after the trigger finger
tendon of her left third finger, as well as trigger finger release, as the patient used well water at the campsite to
release of the flexor tendon of the left thumb. Following wash her hands. She did not engage in gardening work
the procedure, she had three surgical wounds, two of nor had exposure to soil in other settings. Laboratory data,
which (middle finger of the left arm and left third finger) imaging findings, past medical history, and medication list
healed well, but the left thumb wound persisted. She was were reviewed for signs of immunodeficiency. She had a
prescribed two 10-day courses of cephalexin for presumed normal complete blood count and differential, normal
postoperative infection at 2 and 5 weeks postoperatively. kidney and liver function, and elevated blood sugar with
Despite this, the patient presented to the emergency room high HbA1c of 10.8%. Her medication list included:
at post-operative week 5 for pain, swelling and purulent Insulin lispro correctional scale with meals, lisinopril
drainage at the base of her left thumb. She was admitted 20 mg daily, gabapentin 600 mg 3 times daily as needed,
for observation, underwent incision and drainage in the venlafaxine 75 mg daily, pantoprazole 40 mg daily, and
operating room, with operative note describing small zolpidem 10 mg at bedtime. She was prescribed extended
amount of purulent drainage, and the wound was loosely antibiotic therapy with trimethoprim-sulfamethoxazole
closed with two sutures. During the admission, she was (TMP-SMX) twice daily based on susceptibilities in
afebrile, did not have leukocytosis, but did have mildly Table 1. The duration of treatment was up to 3 – 6 months,
elevated sedimentation rate (60 mm/h, reference range 0 depending on the response to therapy. Unfortunately, she
– 30 mm/h) and C-reactive protein (1.3 mg/dL, reference did not follow up in the infectious disease clinic after the
range 0.0 – 1.0 mg/dL). She was treated with 6 days of initial appointment; however, there is documentation from
ceftriaxone and discharged with instructions to complete a routine endocrinologist visit 4 months later indicating no
4 more days of cefuroxime. Gram staining of the purulent wounds were seen on examination.
fluid revealed few white blood cells and no organisms, and
the growth of N. farcinica was detected in culture. 3. Discussion
Over the next 2 months, the wound persisted to drain, Nocardia is a Gram-positive, catalase-positive, weakly
and cultures of drainage sent on post-operative week 9, 10, acid-fast, aerobic actinomycete notable for its branching
and 13 all grew N. farcinica. The patient underwent another filamentous form. It is an environmental pathogen,
3
operative debridement during post-operative week 10. most frequently found in soil, but also in fresh and
In this time frame, she completed an additional 10 days salt water. There are many species of Nocardia that are
of cefuroxime and two 2-week courses of ciprofloxacin, clinically relevant. Nocardiosis manifests in different
prescribed by her hand surgeon. She was referred to the organ systems depending on the subspecies and host.
infectious disease clinic on post-operative week 15 for a non- Lung involvement is the most common and usually
healing, painful wound with black eschar and joint swelling occurs in immunocompromised patients as a result of
in the setting of cutaneous nocardiosis despite multiple Nocardia asteroides infection. Also common among
short courses of antibiotics and debridement (Figure 1). immunocompromised patients is CNS involvement or
The source of persistent nocardiosis was hypothesized to dissemination of disease to multiple organs, often from a

Volume 2 Issue 4 (2025) 145 doi: 10.36922/mi.5189