Lymphocutaneous Nocardiosis

1. Pathophysiology
   1. Filamentous gram-positive bacteria
   2. Causes Nodular Lymphangitis
      1. Nocardia brasiliensis most common etiology
2. Exposure risks
   1. Soil or plant debris (e.g. gardening)
   2. Splinters
3. Signs
   1. Primary lesion follows one to six week incubation
      1. Tender nodular lesion develops at inoculation site
   2. Secondary lesions
      1. Erythematous Papules, Nodules develop up lymph chain
      2. Lesions ulcerate and drain purulent fluid
      3. Sinus tracts may form
   3. Other findings
      1. Fever
      2. Tender regional adenopathy occur
4. Differential Diagnosis
   1. See Nodular Lymphangitis
5. Labs
   1. Microscopic examination
      1. Gram Negative Bacteria
      2. Partially acid-fast organism
   2. Culture (slow growth may require several weeks)
      1. Routine fluid culture
      2. Culture of biopsied tissue
6. Management
   1. TMP-SMZ DS (Septra DS or Bactrim DS): preferred
      1. Dose: 2 DS tablets PO tid for three months
      2. Complete Blood Count weekly (lower dose if cytopenia)
   2. Alternative antibiotics (based on sensitivity)
      1. Minocycline 100 mg PO bid for three months
      2. Amikacin
      3. Carbapenem antibiotics
      4. Quinolone antibiotics
7. References
   1. Burgert (1999) Infect Dis Clin Pract 8:27-32
   2. Tobin (2001) Am Fam Physician 63:326-32