An unusual presentation of primary
cutaneous nocardiosis at a rare site: Succesful treatment with a modified Welsh regimen
Praveen Kumar S MD DNB, T K Sumathy MD MNAMS, A L Shyam Prasad MD, Gayathri Devi D R MD, K N Shivaswamy MD DNB, C Ranganathan MD DVD
Dermatology Online Journal 17 (12): 1
INTRODUCTION: Primary cutaneous nocardiosis can present in various forms. Clinically, it can present as acute infection (abscess or cellulitis), mycetoma, or sporotrichoid infection. Mycetoma over the back is rare. CASE REPORT: We herein describe a case of primary cutaneous nocardiosis presenting as a mycetoma, caused by Nocardia brasiliensis. The patient had extensive lesions over the back, which can be attributed to the fact that the patient, being an agriculturist, has been exposed to recurrent trauma while carrying firewood and soiled sacks. He responded well to a modified Welsh regimen. Initially, within 2 cycles, the patient showed dramatic improvement clinically, wherein the sinuses, granulation tissue, and induration were no longer apparent. However, the patient showed a small discharging sinus at the end of 3rd pulse, so a total of 6 cycles were given. An additional 2 months of maintenance phase treatment with cotrimoxazole and rifampicin were given. On follow-up, the patient showed no recurrence at 6 months. CONCLUSION: We report a case of primary cutaneous nocardiosis presenting as a mycetoma on the back. Enlisting the help of a microbiologist allowed us to isolate the causative organism. Early recognition and prompt treatment prevents unwarranted surgical debridement and complications.
A 30-year-old male farmer presented with a 4-year history of multiple painful, draining sinuses and nodules on the back. A history of trauma with a wooden splinter of a mat was elicited. The lesion initially started as a small pustule that progressed over 4 years to involve the whole of his back. On examination, a hyperpigmented indurated plaque studded with multiple granulomatous nodules, discharging sinuses, and scars were seen over the upper back. Local lymph nodes were inconspicuous. A KOH preparation from the discharge did not show any fungal elements. A gram stain of the pus revealed long, beaded gram-positive branching filaments.
The patient was started on a modified Welsh regime. Six cycles of simultaneous administration of amikacin (15 mg/kg/day) divided into two daily doses for 3 weeks and cotrimoxazole (7 and 35 mg/kg/day) continuously for 5 weeks were administered. A gap of 2 weeks was given after each cycle of amikacin. The patient was monitored regularly with blood counts, renal function tests, liver function tests, and pure tone audiometry. Within 2 cycles the induration, granulation tissue, discharge, and sinuses were not clinically apparent .
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