Disseminated Nocardia infection presenting as hemorrhagic pustules and ecthyma in a woman with systemic lupus erythematosus and antiphospholipid antibody syndrome.

BACKGROUND: Nocardia is an opportunistic pathogen that can cause disseminated infection in immunocompromised hosts. The most common type of skin lesion reported with disseminated Nocardia is a subcutaneous nodule; however, there are reports with unusual cutaneous presentations. Long term corticosteroid treatment is one of the largest risk factors for developing disseminated Nocardia. Initial treatment is empiric as each strain has unique susceptibilities and it takes weeks to speciate and test sensitivities. MAIN OBSERVATIONS: A 66-year-old female on long term corticosteroids for systemic lupus erythematosus (SLE) and antiphospholipid syndrome presented with a polymorphous skin eruption and systemic symptoms concerning for infection. Especially concerning were areas of hemorrhagic pustules on the lower legs, and two ecthymatous lesions on the thigh. Tissue culture Gram stain revealed Gram positive branching filamentous rods concerning for Nocardia. The patient improved with empiric treatment.
CONCLUSIONS: This case of Nocardiosis had unusual cutaneous findings that could have misguided the clinician, but the tissue culture and Gram stain proved to be useful for rapid diagnosis and proper treatment.