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CASE REPORT

The history holds the key in this gardener with a skin infection
Staphylococci and streptococci are the most common causes of skin infectionsbut when the patient is immunocompromised, keep other causative organisms in mind as well.

Tara A. Lykowski, MMS, PA-C; Emil R. Orpilla, MMS, PA-C; Richard J. Hayek, MD

CASE The patient is a 75-year-old retired white male with a 3day history of a papular abscess on and cellulitis of the ulnar aspect of the fifth digit on the right hand. He had presented to the emergency department (ED) and was referred to orthopedic surgery for consultation. At the consultation, the patient reported increased redness, streaking, and moderate pain associated with the papule. He denied nausea, vomiting, diarrhea, vertigo, diaphoresis, dyspnea, fever, or chills. He also denied any neuropathy of the affected hand or any use of topical or oral medications for the current problem. The patient stated he was unaware of any recent trauma to the area. On further inquiry, the patient described himself as an avid gardener and said that he had been working in the garden. His medical history was significant for hypertension, acid reflux disease, and diet-controlled diabetes mellitus. Physical examination of the right hand revealed erythema along the ulnar aspect of the fifth digit surrounding the papule. Metacarpal-phalangeal flexion was limited as a result of the swelling. The rest of the examination was within normal limits, with no apparent lymphadenopathy. Three-view radiographs were obtained, and these showed no foreign body and no acute bony abnormalities. The WBC count was normal on the CBC at 9.1 109/L, but the neutrophil percentage was mildly increased at 68.9%. A chest film demonstrated a questionable left infrahilar peribronchitic infiltrate. IV vancomycin had been started in the ED, with a differential diagnosis that included infection with methicillinresistant Staphylococcus aureus, methicillin-sensitive S aureus, Sporothrix schenckii, and Nocardia species. At the orthopedic consultation, vancomycin was discontinued and IV cefazolin was initiated. After a discussion with the orthopedic surgeon, the patient agreed to surgical incision, inspection, and debridement of the wound. During the procedure, the wound was debrided to the level of the tendon; the tendon remained

intact, with no noteworthy communication to the tendon sheath. Cultures were taken, and the wound was left open and packed with iodoform gauze. The wet-to-dry dressings were changed 3 times a day, and treatment with cefazolin was continued. The cultures revealed rare leukocytes, as well as a coagulase-negative Staphylococcus species. Diphtheroid bacilli and Nocardia species were also identified. Repeat postoperative three-view radiographs did not contribute any relevant information. Three days after surgery, lymphangic streaking was noted along the proximal aspect of the patients right arm. In addition, there was inflammation and redness over the fourth metacarpal and dorsum of the right hand (see Figure 1). The patient was taken back to the operating room for a second incision and drainage procedure. The wound was debrided of necrotic tissue, and cultures were repeated. These cultures confirmed infection with Nocardia. IV cefazolin was discontinued, and IV trimethoprim-sulfamethoxazole (TMP-SMX) was started. CT of the chest was obtained to rule out pulmonary involvement or dissemination. Aside from interstitial

FIGURE 1. Infection spreads to the dorsum of the hand.

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CASE REPORT | Cutaneous nocardiosis

fibrosis and scarring, which had been seen on a CT scan obtained 3 years previously, no significant lymphadenopathy or lesions were noted. The patient was discharged home on a regimen of oral TMP-SMX and given a follow-up appointment with the surgeon in 5 days. The wounds were open but clean, with granulation tissue present. No erythema was present, and there was no sign of abscess. Flexion of the metacarpal-phalangeal joint was about 50%. Delayed primary closure was scheduled and completed without incident. Follow-up was continued with an infectious disease specialist. One month after surgical debridement and antibiotic therapy, the patient was in good condition with no apparent continuance of infection.
DISCUSSION

Skin infections have multiple causes, and the history and physical examination often help to narrow the differential diagnosis, as occurred in this case. Our patient was immunocompromised as a consequence of diabetes mellitus. During the history, he also revealed that he was an avid gardener. This vital information led us to include Nocardia infection in our differential diagnosis.

FIGURE 2. Nocardia asteroides

Cutaneous nocardiosis causes cellulitis, ulcerations, pyoderma and subcutaneous abscess, and nodular lymphangitis.
Nocardia are gram-positive bacteria produced by aerobic actinomycetes; the organism is an environmental saprophyte that occurs in soil, water, and organic matter1,2 (see Figure 2). Streptococci and staphylococci are more predominant as causative agents in cutaneous infection; however, the clinician should maintain a high index of suspicion for Nocardia infection when dealing with immunocompromised patients who have localized trauma that involves wound contact with soil, water, or organic matter.3 The diagnosis of Nocardia infection is made via culture.

Nocardiosis can manifest in many forms, with pulmonary infection being the most common.4 Pulmonary nocardiosis usually occurs secondary to inhalation. Nocardiosis can also be classified as extrapulmonary, CNS, or cutaneous.5,6 The risk of this infection is increased in immunocompromised patients, such as those with a history of diabetes mellitus or malignancy, those taking corticosteroids, transplant recipients, and those with tuberculosis or HIV disease.7 Cutaneous nocardiosis can manifest in the following clinical subtypes: primary cutaneous, lymphocutaneous, cutaneous involvement from a disseminated focus, and mycetoma.5 The patient in this case presented with primary cutaneous nocardiosis secondary to gardening, resulting in the direct inoculation of the organism.7 The cutaneous form of nocardiosis causes cellulitis, ulcerations, pyoderma, subcutaneous abscess, skin pustules, and nodular lymphangitis.5,8 Since Nocardia infections manifest similarly to streptococcal and staphylococcal infections, they may be treated empirically with antibiotics and incised and drained without cultures ever being taken; thus, Nocardia infections may be underreported.3 Because 2% of people with disseminated nocardiosis present with skin lesions, it is imperative to rule out systemic disease.7 Chest radiography is the primary test used to rule out pulmonary involvement.

TEACHING POINTS
Streptococci and staphylococci are more predominant than Nocardia species as causative

COMPETENCIES

agents in cutaneous infection; however, the clinician should maintain a high index of suspicion for Nocardia infection when dealing with immunocompromised patients who have localized trauma that involves wound contact with soil, water, or organic matter. Nocardiosis can be classified as pulmonary, extrapulmonary, CNS, or cutaneous. The cutaneous form of nocardiosis causes cellulitis, ulcerations, pyoderma, subcutaneous abscess, skin pustules, and nodular lymphangitis. Primary cutaneous nocardiosis can resolve spontaneously or may require antibiotic treatment. Sulfonamides have been the preferred agent since the 1940s, and TMP-SMX has been proven effective against Nocardia organisms. Surgical incision and drainage is an effective concomitant treatment measure.

Medical knowledge Interpersonal & communication skills Patient care Professionalism Practice-based learning and improvement Systems-based practice

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Kwangshin Kim / Photo Researchers, Inc.

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Clinicians should note that the cure rates for Nocardia infections involving the skin and soft tissue are almost 100 percent.
Primary cutaneous nocardiosis can resolve spontaneously or may require antibiotic treatment.7 Sulfonamides have been the preferred treatment for this infection since the 1940s,2 and TMP-SMX has been proven to be effective against Nocardia organisms. For patients with primary cutaneous nocardiosis, a 1- to 3month course of antibiotic therapy can be curative,2 with the duration of therapy ranging from 6 weeks for minor infection to as long as 1 year for severe infection.3 Surgical incision and drainage is also an effective concomitant treatment measure. Clinicians should note that cure rates for nocardiosis involving the skin and soft tissue are almost 100%; nevertheless, the outcome of treatment for this infection depends on the health of the host (particularly on whether the patient is immunocompromised), the extent of disease, and the site of infection.2

CONCLUSION

Clinicians often find that determining the cause of a skin infection is challenging. The history and physical examination can provide relevant information. In most cases, culture is required for a definitive diagnosis and optimal treatment. Nocardiosis should be kept strongly in mind when an immunocompromised patient presents with a skin infection. JAAPA
Tara Lykowski practices with orthopedic surgeon Richard Hayek at Northwest Orthopaedics and Sports Medicine, Chicago, Illinois. Emil Orpilla practices in orthopedic surgery at Resurrection Medical Center in Chicago. The authors have indicated no relationships to disclose relating to the content of this article. REFERENCES 1. Kontoyiannis DP, Ruoff K, Hooper DC. Nocardia bacteremia: report of 4 cases and review of the literature. Medicine (Baltimore). 1998;77(4):255-267. 2. Sorrell TC, Mitchell DH, Iredell JR. Nocardia species. In: Mandell G, Dennett J, Dolin R, eds. Principles and Practices of Infectious Diseases. Philadelphia, PA: Elsevier; 2005:2916-2913. 3. Shook B, Rapini RP. Nocardiosis. Updated June 6, 2007. eMedicine Web site. http://www. emedicine.com/derm/topic297.htm. Accessed August 1, 2008. 4. Beaman BL, Beaman L. Nocardia species: host-parasite relationships. Clin Microbiol Rev. 1994; 7(2):213-264. 5. Lerner PI. Nocardiosis. Clin Infect Dis. 1996; 22(6):891-905. 6. Lederman ER, Crum NF. A case series and focused review of nocardiosis: clinical and microbiologic aspects. Medicine (Baltimore). 2004;83(5):300-313. 7. Kofteridis D, Mantadakis E, Mixaki I, et al. Primary cutaneous nocardiosis in 2 patients on immunosuppressants. Scand J Infect Dis. 2005;37(6-7):507-510. 8. Threlkeld SC, Hooper DC. Update on management of patients with Nocardia infection. Curr Clin Top Infect Dis. 1997;17:1-23.

The Surgical Patient

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cancer and should be considered as a viable approach to treating selected patients with early-stage NSCLC. JAAPA
Andrea McNiel and Shanda Blackmon practice in the Department of Thoracic Surgery at The Methodist Hospital, Houston, Texas. The authors have indicated no relationships to disclose relating to the content of this article. Steve Wilson, PA-C, department editor REFERENCES 1. Cancer Facts and Figures 2008. American Cancer Society Web site. http://www.cancer.org/ downloads/STT/2008CAFFfinalsecured.pdf. Accessed August 1, 2008. 2. McKenna RJ Jr, Wolf RK, Brenner M, et al. Is lobectomy by video-assisted thoracic surgery an adequate cancer operation? Ann Thorac Surg. 1998;66(6):1903-1908. 3. Swanson S, Herndon JD II, DAmico TA, et al. Video-assisted thoracic surgery lobectomy: Report of CALGB 39802a prospective, multi-institution feasibility study. J Clin Oncol. 2007;25(31): 4993-4997. 4. Nomori H, Horio H, Naruke T, Suemasu K. What is the advantage of a thoracoscopic lobectomy over a limited thoracotomy procedure for lung cancer surgery? Ann Thorac Surg. 2001;72(3): 879-884. 5. Iwasaki A, Shirakusa T, Kawahara K, et al. Is video-assisted thoracoscopic surgery suitable for resection of primary lung cancer? Thorac Cardiovasc Surgeon. 1997;45(1):13-15. 6. Roviaro G, Varoli F, Vergani C, et al. Long-term survival after videothoracoscopic lobectomy for stage I lung cancer. Chest. 2004;126(3):725-732. 7. Shigemura N, Akashi A, Funaki S, et al. Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: a multi-institutional study. J Thorac Cardiovasc Surg. 2006;132(3):507-512. 8. Walker WS, Codispoti M, Soon SY, et al. Long-term outcomes following VATS lobectomy for nonsmall cell bronchogenic carcinoma. Eur J Cardiothorac Surg. 2003;23(3):397-402. 9. Sugiura H, Morikawa T, Kaji M, et al. Long-term benefits for the quality of life after videoassisted thoracoscopic lobectomy in patients with lung cancer. Surg Laparosc Endosc Percutan Tech. 1999;9(6):403-408. 10. Ng T, Ryder BA. Evolution to video-assisted thoracic surgery lobectomy after training: initial results of the first 30 patients. J Am Coll Surg. 2006;203(4):551-557.

Careful preoperative evaluation is critical when deciding whether to perform VATS lobectomy. The indications for a VATS procedure include tumors smaller than 6 cm and a negative mediastinal lymph node evaluation either by node sampling or imaging studies. Contraindications to VATS lobectomy include the presence of T3 lesions, endobronchial involvement, central (hilar) tumors, and lobar or hilar nodes adherent to pulmonary vessels.2 Performing advanced reconstructive procedures like sleeve resections is difficult but possible with VATS lobectomy. The need for chest wall reconstruction precludes thoracoscopic lobectomy because of the large incision required to obtain clear margins and reconstruct the chest wall. In conclusion, VATS lobectomy has been demonstrated to reduce postoperative pain and allow for earlier return to normal activity when compared to open thoracotomy, and it may improve the delivery of postoperative chemotherapeutic drugs to tissue. Studies have reported decreased postoperative morbidity and mortality in experienced centers. VATS lobectomy also has been shown to have similar oncologic outcomes with regard to survival and time to disease progression when compared to open thoracotomy. In summary, VATS lobectomy has been proven to be an adequate surgical approach to lung

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