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Microbes & Immunity A case of cutaneous Nocardia farcinica

immunocompetent patient with only skin involvement prior to the initiation of TMP-SMX. A literature review
can be managed with empiric monotherapy (TMP-SMX from 2017 of Nocardia species susceptibilities comments
versus LZD) while awaiting antibiotic susceptibility and on historical fluoroquinolone resistance especially in
then transitioned to the targeted oral regimen based N. farcinica being as high as 50%. The patient may have
21
on sensitivities. Based on common susceptibilities, 3 benefited from those additional weeks of therapy with an
– 6 months of TMP-SMX remains the gold-standard effective antibiotic based on lab data; however, based on
course of treatment. Other options include minocycline evidence from many other cases, fluoroquinolones are not
or amoxicillin-clavulanate (AMC) depending on considered first-line therapy. Surveillance for up to a year
sensitivities. As noted in Table 1, there is susceptibility to is recommended for recurrence evaluation. Secondary
4
fluoroquinolones (moxifloxacin and ciprofloxacin) and prophylaxis is generally not considered necessary for
the patient received two 2-week courses of ciprofloxacin immunocompetent patients. The treatment algorithm for
lung disease or disseminated infection with or without
Table 2. Distribution of immunocompromised patients with CNS involvement recommends using multidrug regimen
different immunodeficiency types for initial treatment and once sensitivities resume, therapy
can be narrowed accordingly. Secondary prophylaxis is
Type of Treatment Number Ref. reserved for severely immunocompromised patients or
immunodeficiency with of
corticosteroid patients in conjunction with removal of implants or devices for
4
s patients with bacteremia or endocarditis. According
Various autoimmune Yes 4 Merinopoulos et al. 6 to these criteria, the patient in this case received
disorders* Auzary et al. 7 inappropriate management more than 2 months after
Yokota et al. 8 the initial diagnosis, after she had already had several
Granier et al. 9 debridement procedures and four cultures growing
Hematopoietic cell Yes 1 Hemmersbach-Miller N. farcinica.
transplant et al. 5
Part of the inappropriate management could be
Leprosy Yes 1 De Nardo et al. 10 due to the slow growing nature of Nocardia as well
Lymphoma No 2 Malani et al. 11 as resistance patterns that are not commonly known
Torres et al. 12
Multiple myeloma No 1 Angeles et al. 13 outside of the infectious disease specialty. In the case
described, the first aerobic wound culture was collected,
Nephrotic syndrome Yes 2 Gao et al. 2 requiring re- incubation due to insufficient growth, and
Zhu et al. 14 was ultimately identified as N. farcinica 6 days later. The
Solid organ Yes 8 Hemmersbach-Miller patient had been discharged on empiric cephalosporins
transplant et al. 5
Rees et al. 15 by then. No sensitivities were listed with the initial
Ghandour et al. 16 cultures. Repeat cultures a month later similarly identified
*Cogan’s syndrome, aplastic anemia, systemic sclerosis/polymyositis N. farcinica within 6 days and sensitivities came back
and bullous pemphigoid. 1 month after that. N. farcinica has inherent resistance to

Table 3. Immunocompetent cases of cutaneous nocardiosis caused by N. farcinica
Case report Patient Type of wound Mode of transmission Treatment Outcome
description
Schiff et al. 17 54-year- old, Non- healing Infected after being I.V. AMK for 2 weeks followed by I.M. Complete resolution of lesion
male lesion of right face struck with a shovel amikacin for 6 weeks (intolerant to including long-term follow-up
TMP-SMX) for 2 years
Bosamiya 37-year- old, Left leg lesion with Accidentally infected due TMP-SMX for 6 – 12 months Complete resolution of cutaneous
et al. 18 male lymphatic spread to occupation as a farmer lesions of left leg and right
to right elbow elbow within 7 days of initiating
treatment
Acuner 37-year- old, Non- healing Infected due to arm Incision and drainage of abscesses for Resolution of clinical symptoms
et al. 19 male skin lesions and laceration from grease 5 times with concomitant after 1 month of second course of
recurrent muscle canister TMP-SMX over 5 months, followed TMP- SMX; negative ultrasound
abscesses of right by 10 days of I.V. AMK and I.V. IMI, findings for abscesses; only
forearm followed by 1 month of TMP- SMX revealing scar tissue
Abbreviations: AMK, Amikacin; I.M.: Intramuscular; IMI: Imipenem; I.V.: Intravenous; TMP-SMX: Trimethoprim/sulfamethoxazole.

Volume 2 Issue 4 (2025) 147 doi: 10.36922/mi.5189