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Open Access Case report

Left thigh phlegmon caused by Nocardia farcinica identified by 16S rRNA sequencing in a patient with Leprosy: a case report

Pasquale De Nardo1*, Maria Letizia Giancola1, Salvatore Noto2, Elisa Gentilotti1, Piero Ghirga1, Chiara Tommasi1, Rita Bellagamba1, Maria Grazia Paglia1, Emanuele Nicastri1, Andrea Antinori1 and Angela Corpolongo1

Author Affiliations

1 “Lazzaro Spallanzani” National Institute for Infectious Diseases-IRCCS, Via Portuense 292, Rome, 00149, Italy

2 Azienda Ospedaliera Universitaria “San Martino”, Largo R. Benzi 10, Genoa, 16132, Italy

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BMC Infectious Diseases 2013, 13:162  doi:10.1186/1471-2334-13-162

Published: 4 April 2013

Abstract

Background

In recent years, Nocardia farcinica has been reported to be an increasingly frequent cause of localized and disseminated infections in the immunocompromised patient. However, recent literature is limited. We report a case of left thigh phlegmon caused by N. farcinica that occurred in a patient with Leprosy undergoing treatment with prednisone for leprosy reaction.

Case presentation

We describe the case of left thigh phlegmon caused by Nocardia farcinica in a 54-year-old Italian man affected by multi-bacillary leprosy. The patient had worked in South America for 11 years. Seven months after his return to Italy, he was diagnosed with Leprosy and started multi-drug antibiotic therapy plus thalidomide and steroids. Then, during therapy with rifampicin monthly, minocycline 100 mg daily, moxifloxacin 400 mg daily, and prednisone (the latter to treat type 2 leprosy reaction), the patient complained of high fever associated with erythema, swelling, and pain in the left thigh. Therefore, he was admitted to our hospital with the clinical suspicion of cellulitis. Ultrasound examination and Magnetic Resonance Imaging showed left thigh phlegmon. He was treated with drainage and antibiotic therapy (meropenem and vancomycin replaced by daptomycin). The responsible organism, Nocardia farcinica, was identified by 16S rRNA sequencing in the purulent fluid taken out by aspiration. The patient continued treatment with intravenous trimethoprim/sulfamethoxazole and imipenem followed by oral trimethoprim/sulfamethoxazole and moxifloxacin. A whole-body computed tomography did not reveal dissemination to other organs like the lung or brain.

The patient was discharged after complete remission. Oral therapy with trimethoprim/sulfamethoxazole, moxifloxacin, rifampicin monthly, clofazimine and thalidomide was prescribed to be taken at home. One month after discharge from the hospital the patient is in good clinical condition with complete resolution of the phlegmon.

Conclusion

N. farcinica is a rare infectious agent that mainly affects immunocompromised patients. Presentation of phlegmon only without disseminated infection is unusual, even in these kinds of patients. In any case, a higher index of suspicion is needed, as diagnosis can easily be missed due to the absence of characteristic symptoms and the several difficulties usually encountered in identifying the pathogen.

Keywords:
Nocardia; Hansen’s disease; Phlegmon