PMC4822357_01
Photomicrographs of the skin lesions showing a 2 x 2.5 cm ulcer with clean base and serous discharge over the left thigh. Multiple 2 x 3 cm reddish non-pruritic papules were present over both lower limbs and abdomen.
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F1
Multiple 2 x 3 cm reddish non-pruritic papules were present over both lower limbs and abdomen (Fig. 1).
Computed tomography (CT) of chest confirmed upper lobe predominant honey-combing and septal thickening (A) and large calcified right paratracheal, sub-carinal, bilateral hilar and paraaortic lymphadenopathy (B) consistent with prior diagnosed stage IV sarcoidosis. No cavitation, consolidation or evidence of pulmonary nocardiosis was seen.
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F2
Repeat computed tomography of the chest did not show any new consolidation or cavitation (Fig. 2), but confirmed stage IV sarcoidosis.
Contrast enhanced computed tomography (CECT) of the head shows an enhancing hypoattenuated lesion over the left parietal lobe (a black arrow in Fig. 3A). Magnetic resonance imaging (MRI) of the head showing multiple enhancing ring lesions (arrow) in the cerebrum, cerebellum and brain stem (B) which were hyperintense on T1 and T2-weighted images with extension into the lateral ventricles.
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F3
CT-head showed multiple space occupying lesions (Fig. 3A); magnetic resonance imaging of the head revealed multiple enhancing intracranial ring lesions (Fig. 3B).
(A). Modified acid-fast staining (x 40) of the aspirate from the discharging ulcer showing presence of long thin filamentous forms suggesting Nocardia. Cultures grew buffy colonies (B) that were typed biochemically as Nocardia asteroides.
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F4
Discharge from the ulcer showed long thin filamentous forms suggesting Nocardia that was confirmed on modified acid-fast staining (Fig. 4A); cultures were confirmed to be Nocardia asteroides (Fig. 4B).