Indan Journal of Medical Research Indan Journal of Medical Research Indan Journal of Medical Research Indan Journal of Medical Research
  Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login  
  Home Print this page Email this page Small font sizeDefault font sizeIncrease font size Users Online: 648       

   Table of Contents      
CLINICAL IMAGES
Year : 2016  |  Volume : 143  |  Issue : 1  |  Page : 118-119

Disseminated nocardiosis in a patient with sarcoidosis


Department of Medicine, Jawaharlal Nehru Institute of Postgraduate Medical Education & Research, Dhanvantri Nagar, Gorimedu, Puducherry 605 006, India

Date of Web Publication14-Mar-2016

Correspondence Address:
Srinivas Rajagopala
Department of Medicine, Jawaharlal Nehru Institute of Postgraduate Medical Education & Research, Dhanvantri Nagar, Gorimedu, Puducherry 605 006
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-5916.178625

Rights and Permissions

How to cite this article:
Rajagopala S, Dangeti G. Disseminated nocardiosis in a patient with sarcoidosis . Indian J Med Res 2016;143:118-9

How to cite this URL:
Rajagopala S, Dangeti G. Disseminated nocardiosis in a patient with sarcoidosis . Indian J Med Res [serial online] 2016 [cited 2019 Dec 12];143:118-9. Available from: http://www.ijmr.org.in/text.asp?2016/143/1/118/178625

A 64 year old male with well-controlled diabetes mellitus and fibrocystic sarcoidosis on steroids presented to the department of Pulmonology, Manipal Hospitals, Bengaluru, India, in October 2013 with a one week history of discharging ulcer and skin rash, and one day history of seizures with altered sensorium. His medications included oxygen at 1l/min, insulin, aspirin, 15 mg prednisolone, pantoprazole and calcium. Clinical examination showed a 2x2.5 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 [Figure 1]. Repeat computed tomography of the chest did not show any new consolidation or cavitation [Figure 2], but confirmed stage IV sarcoidosis. CT-head showed multiple space occupying lesions [Figure 3]A; magnetic resonance imaging of the head revealed multiple enhancing intracranial ring lesions [Figure 3]B. Cerebrospinal fluid examination showed 400 polymorphs/µl, elevated protein (105 mg/dl) and depressed sugar values (45 mg/dl, corresponding blood glucose 145 mg/dl) with normal adenosine deaminase levels (3 U/l, normal <8 U/l). Biopsy from nodules showed necrosis with lympho-mononuclear dermal infiltration and Grocott's stain revealed filamentous branching structures. Discharge from the ulcer showed long thin filamentous forms suggesting Nocardia that was confirmed on modified acid-fast staining [Figure 4]A; cultures were confirmed to be Nocardia asteroides [Figure 4]B. t0 he patient was treated with phenytoin, ceftriaxone, amikacin and oral trimethoprim-sulphamethaxazole. Insulin and oxygen were continued and prednisolone tapered. Neurological abnormalities normalized by one week. At 12 months follow up, the patient was well.
Figure 1. 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.

Click here to view
Figure 2. 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.

Click here to view
Figure 3. Contrast enhanced computed tomography (CECT) of the head shows an enhancing hypoattenuated lesion over the left parietal lobe (a black arrow in Figure. 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.

Click here to view
Figure 4. (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

Click here to view



   Acknowledgment Top


The authors thank Dr Vikas, department of Radiology, Manipal Hospitals, Benguluru for help in reporting the neuroradiology of this index patient and Dr Srivatsav Lokeswaran, department of Pulmonary Medicine, for help in patient management.

Conflicts of Interest: None.




    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
   Acknowledgment
    Article Figures

 Article Access Statistics
    Viewed536    
    Printed6    
    Emailed0    
    PDF Downloaded227    
    Comments [Add]    

Recommend this journal