Case Presentation: A 52-year-old male presented to the emergency department multiple times the month prior to admission with progressively worsening right ankle and wrist pain, generalized myalgia, fatigue and worsening hoarseness of voice. His past medical history was notable for acute lymphoblastic leukemia (in remission for 2 years) complicated by aspergillus pneumonia. On the presentation requiring admission the patient was septic with tachycardia, tachypnea, a lactate of 2.3 and white blood cell count of 17,000. On physical exam, dermatological findings included multiple subcutaneous nodules of the anterior chest, upper extremities, and thighs bilaterally, additionally erythema and edema of the right lateral ankle. Respiratory exam revealed mild respiratory distress with diminished lung sounds bibasilarly, with audible inspiratory and expiratory wheeze, and 5-6 word dyspnea. His clinical course included a culture of an aspirate of a superficial nodule that demonstrated nocardia. Imagining studies confirmed disseminated nocardiosis, with involvement of the lungs and brain as well as several intramuscular abscesses. Cardiac involvement was ruled out by transesophageal echocardiogram. Acute lymphoblastic leukemia recurrence was ruled out by flow cytometry. His course also included multiple incision and drainage procedures with placement of vacuum assisted closure dressings. He was empirically started on meropenem and Bactrim. Culture and sensitivity demonstrated “Nocardia vulneris” a rare and newly identified species. After clinical improvement, he was discharged on Bactrim DS and ceftriaxone (IV home infusion). Since discharge his hoarseness has abated, tolerance to ambulation improved and skin lesions resolved.
Discussion: Nocardia is gram positive branching rod found in soil and decaying vegetation and infects predominantly immunocompromised hosts. However, in this case we report a disseminated infection in an immunocompetent patient. Common sites of infection include pulmonary, cutaneous and the central nervous system. Infection is rare with an estimated incidence of 500-1000 cases annually. Prognosis varies depending on species, site and extent of infection. Nocardia vulneris is a novel species initially identified in 2014 from 8 isolates submitted to the Special Bacteriology Reference Laboratory. All strains of Nocardia vulneris to date have carbapenem resistance. The case was additionally atypical in that frequently nocardiosis presents as a pulmonary disease and here presented with hoarseness of voice, joint pain and myalgia.
Conclusions: Nocardia can manifest in any organ and could easily be overlooked on initial presentation if atypical. While frequently seen in immunocompromised patients, infection is not solely confined to this population. Furthermore, as antibiotics susceptibility varies, performing culture and sensitivity on the particular species is critical in determining the appropriate treatment options.