34-year-old man with chronic renal and pancreas failure in complicated diabetic disease received a kidney-pancreas transplantation. On the 32nd postoperative day, an acute kidney rejection occurred and resolved with OKT3 therapy. The patient also presented refractory urinary infection by
Immunosuppression is the main risk factor for nocardical infections as well as the majority of nocardical infections occurs in severely immunocompromised patients (with decreased cellular-mediated immunity). The frequency of nocardical infections in solid organ transplant recipients varies between 0.7% and 3% and has mostly been reported in heart, kidney, and liver transplant recipients, and less frequently in lung transplantation [
The infection is usually acquired via inhalation of the microorganisms, which allows the establishment of a focal pneumonitis in 75% of cases and, in the half of these, hematogenous dissemination, or oligo-symptomatic nonapparent manifestations. Forms with cerebral abscess occur in 25%. However, cutaneous dissemination, which occurs in 10%, is most commonly presented as cutaneous abscess. In this cases a cutaneous dissemination is a manifestation of an opportunistic severe disease. Nocardiosis can be an acute, subacute, or chronic suppurative infection.
The 90% of nocardical pneumonias are caused by
Penetrating cutaneous injury can be, although rarely, an inoculation way. Cutaneous nocardiosis can present as an acute superficial skin infection with pustules, abscesses, pyoderma, and cellulitis or as a lymphocutaneous infection [
A 34-year-old man with chronic renal and pancreas failure in complicated diabetic disease received a kidney-pancreas transplantation. The perioperative prophylaxis was ampicillin and cefoxatime; immunosuppressive therapy was made with steroids, antilymphocyte globulin (ALG), and Cyclosporine. On the 32nd post-operative day an acute kidney rejection occurred and resolved with anti-CD3 monoclonal antibody (OKT3) therapy. The patient also presented refractary urinary infection by
During the 50th post-operative day, an intense soft tissue inflammation localized in the first left metatarsus-phalangeal articulation (Figure
Nocardiosis: soft tissue inflammation localized in the left metatarsus-phalangeal articulation, associated with a cutaneous fistula, occurred during the 50th post-operative day.
This case is reported for its rarity in our casuistry, starting from 1985, for its difficult differential diagnosis with other potentially serious infections in immunosuppressed patients (tuberculosis, nontubercular mycobacteriosis, mycosis, other bacterial infections) or rheumatic pathology. The documentation of the infection presupposes noncutaneous dissemination of infection.
In our case report, the elective chemotherapy, established after a definitive and early diagnosis, based on the demonstration of the microorganism on a culture from the purulent material, resulted in the complete resolution of infection.