PMC5739172_01
Primary cutaneous nocardiosis mycetoma type at the initial visit (A), at admission (B), and after 6 weeks of combination intravenous antibiotic treatment (C).
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The patient had several discrete, minimally tender, firm, skin-colored to erythematous, dome-shaped papulonodules, some with central serosanguinous crusts, along with numerous atrophic, ovoid-stellate scars with open sinus tracts and seropurulent crusts (Fig 1, A). The next week on close follow-up, a continued review of systems revealed new-onset right shoulder pain and increased tumefaction at her posterior neck (Fig 1, B). At 6 weeks of treatment, the last sinus draining serosanguinous fluid resolved, and there was marked resolution of the tumefaction at her posterior neck (Fig 1, C).
Nocardia brasiliensis obtained from culture, displaying partially acid-fast, beaded, branching, filamentous bacilli. (Original magnification: x1000.)
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A high degree of clinical suspicion for primary cutaneous nocardiosis was maintained, and additional cultures eventually grew branching Gram-positive rods, later identified as N. brasiliensis (Fig 2).