Case Number : Case 2531 - 19 March 2020 Posted By: Saleem Taibjee

mixed inflammatory cells with neutrophils, histiocytes, lymphocytes and plasma cells are seen. giant cells are seen

I am concerned with amebae Naegleria fowleri,  Bala muthiamandrillaris species, may be a PAS stain and GMS stain

if negative rule out vasculitis

Thinking of EED, but there are plasma cells and there is also a brain abscess...so my spot is tertiary syphilis!

Interesting suggestion by Vincenzo! complete infectious work up is needed.

Work up for infectious etiology. Deep fungal infections including Cryptococcus can cause brain abscess and skin lesions.

Yes, you are all on the right lines. This was an unusual infection.

In addition to skin histology, fresh skin was also sent to our Microbiology reference laboratory.

The Microbiology lab report reads: "The hsp65 target is positive and sequencing has identified Nocardia cerradoensis". Our local microbiologists concluded that the clinical presentation was indeed consistent with Nocardia.

I had already scrutinised the special stains very carefully. The Wade-Fite is shown below. I found a solitary focus of staining, and prior to the Microbiology report was uncertain whether this staining represented artefactual stain deposit or mycobacteria. But in hindsight I did then wonder if perhaps this is Nocardia? Have any of you seen examples of this?

no sir, not seen a case or nocardia stained like this

do you have GMS stain

Sorry, no we don't have that

Cool case, thank you!