Case Number : Case 942 - 31st January Posted By: Guest

Foreign body by a plant thorn with superadded nocardia and other bacteria.

Abscess determined by an infected splinter.

Agree, infected foreign body granulomatous reaction

[quote name='Guest' timestamp='1391165936']
Foreign body by a plant thorn with superadded nocardia and other bacteria.
[/quote]
Besides a plant thorn it could be a splinter of wood. Faraco's stain should be positive in nocardiosis, too.

The special stain is a PAS. I have asked the dermpathpro team to post a couple more special images for your interest.

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE942_RAC6688x10_Polar.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE942_RAC6688x60_Gram.jpg[/img]

Nocardiosis (primary cutaneous) secondary to trauma by foreign body.

Nocardia is the infectious organism with this foreign body,,,

Nocardiosis secondary to splinter trauma.

This is a nice case!
1. Wood splinter given the parallel arrays of tubules (xylem), with fibrosis and plasma-cell rich inflammatory reaction.
2. Actinomycete infection (very likely Nocardia spp., given extensive branching of the filaments).
I think the images show a subtle beaded Gram+ pattern on Gram stain that is common to see for the actinomycetes like Nocardia.

(Example: Gram stain image with beaded pattern: [url="http://http://path.upmc.edu/cases/case226/images/micro15.jpg"] http://path.upmc.edu/cases/case226/images/micro15.jpg[/url] ).
[img]http://path.upmc.edu/cases/case226/images/micro15.jpg[/img]

[i]This is taken from an educational case report of systemic Nocardia infection (from my alma mater, University of Pittsburgh). It has a brief discussion of Nocardia and related actinomycete staining properties and identification, including possibility of misleading false-negative staining for Gram and modified AFB stains:[/i]
[i] Case Discussion: [url="http://path.upmc.edu/cases/case226/dx.html"]http://path.upmc.edu...ase226/dx.html[/url][/i]
[i] Case Report: [url="http://A%2075%20Year%20Old%20Female%20with%20Bilateral%20Pneumonia"] [/url][/i][url="http://path.upmc.edu/cases/case226.html"][size=4]A 75 Year Old Female with Bilateral Pneumonia[/size][/url]

Thank you so much for the contributions. I reported this as a splinter with filamentous bacteria (actinomyces-like). I have always thought histology for bacteria can only take us so far and seems reading Jim's very helpful case discussion that was right! I will ask for the Gram stain to come back and photograph it under oil to see if I can see the beading but suspect not as I was aware of Nocardia doing that. I have seen very few cases (that I was aware of) of culture confirmed cutaneous nocardiosis.

Re-examined under oil and I am not convinced much beading. Unfortunately area cut-out so Faraco-Fite stain unhelpful.