A 45-year-old man presented to a local urgent care medical center in Roanoke, Virginia, with complaints of pain and a swelling on his right wrist. The patient reported having scratched his right wrist while playing paintball in eastern Virginia 3 weeks prior. He reported slipping while running through a swamp and received a small cut on the volar aspect of his right wrist. Two weeks later, he noticed a pimple-like lesion developing at the same site on his right wrist. The lesion quickly grew in size and then ulcerated. The patient's temperature was 36.3 C (97.3 F). On physical examination, a large abscess, 1 inch x 4 inches in diameter was noted on the volar aspect of his right wrist, with erythema spreading along the anterior surface of his distal forearm (Figures 1 and 2). A chain of enlarged and tender lymph nodes was palpable going up the arm and surrounding the right axillary area.
Because of the severity of his condition, the patient was taken to the emergency room at Carillion Medical Center, where surgical drainage of the abscess was carried out and the pus was sent for culture and sensitivity testing. The emergency room physician suspected the patient had a methicillin- resistant Staphylococcus aureus infection and the patient was prescribed tetracycline, trimethoprim-sulfamethoxazole, and vancomycin. Blood tests revealed a peripheral white blood cell count of 5,500/mm3 (normal 4,000-10,500/mm3) with a differential of neutrophils, lymphocytes, and monocytes of 55.9%, 33.3%, and 6.2%, respectively (normal 42%-75%, 21%-51%, and 2%-13%, respectively). Laboratory studies revealed a hemoglobin of 14.0 g/dL (normal 13-16 g/dL), a hematocrit of 41.2% (normal 37%-49%), and a platelet count of 223,000/mm3 (normal 130,000-400,000/mm3). Urine analysis was negative for blood, leukocytes, protein, and glucose. A comprehensive metabolic panel revealed total protein of 6.6 g/dL (normal 6.0-8.3 g/dL), albumin of 4.6 g/dL (normal 3.2-5.5 g/dL), glucose of 77 mg/dL (normal 70-99 mg/dL), creatinine of 1.03 mg/dL (normal 0.5-1.4 mg/dL), calcium of 9.7 mg/dL (normal 8.5-10.7 mg/dL), total bilirubin of 0.3 mg/dL (normal <1.3 mg/dL), aspartate transaminase of 21 IU/L (normal 10-42 IU/L), and alanine transaminase of 20 IU/L (normal 10-60 IU/L). Three days later, culture of pus yielded colonies of Nocardia brasiliensis. After consultation with the infectious disease service, the tetracycline and vancomycin were stopped and the patient was continued on double-strength oral trimethoprim-sulfamethoxazole tablets (800-160 mg) once every 12 hours for 30 days. The patient reported remarkable improvement in his symptoms by day 5 after initiation of treatment with trimethoprim-sulfamethoxazole. Most of the lymphatic spread had resolved and only some erythema and swelling were seen at the area of the original lesion. A chest X-ray was reported as normal.
Four weeks later, the patient returned for follow-up of his cutaneous nocardiosis infection. The site on his wrist was completely closed and there was no longer any erythema present. The patient retained a residual scar at the infection site (Figure 3). His axillary lymph nodes were still enlarged and tender. The patient continued on double-strength oral trimethoprim-sulfamethoxazole tablets (800-160 mg) every 12 hours for a further 60 days. On follow-up after 2 months, the patient reported that he was doing well.