PMC8024659_01
Clinical pictures. A, Erythematous nodules on dorsum of the left hand, initial presentation. B, Same lesions after 10 days of doxycycline, second presentation. C, Same lesions after trimethoprime-sulfamethoxazole, resolution.
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A 30-year-old male with psoriasis and psoriatic arthritis on recent regimen addition of Apremilast 6 months ago, presented with pain and erythematous nodules on the dorsum of his hands, trunk, abdomen, shoulders, and back after returning from a warm climate vacation (Fig. 1A). Ten days later, the patient presented to the emergency department with aggravation of lesions swelling, induration and pain despite completing the doxycycline course (Fig. 1B). HIV testing, chest X-ray and head computed tomography scan - all were negative. He was started on sulfamethoxazole-trimethoprim DS 1 tablet three times a day with significant clinical improvement (Fig. 1C).
Skin biopsy of the abdominal lesion, histomorphology. A, Non-specific perivascular inflammation (H&E, 2x). B-C, Perivascular lymphocytic and interstitial neutrophilic infiltrate (H&E, 10x and 20x). D, Tissue culture, gram-positive branching rods (Gram stain, 40x).
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A 2 mm x 2 mm punch biopsy of an abdomen lesion was obtained and demonstrated perivascular infiltrate of lymphocytes as well as an interstitial neutrophilic infiltrate suggestive of infection (Fig. 2A-C). Ultimately, tissue culture grew gram-positive branching rods (Fig. 2D), which was identified as Nocardia nova by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS).