The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Stephanie V. Sherman, M.D., Editor

Sporotrichoid Nodular Lymphangitis

from Nocardia brasiliensis
A B

A
75-year-old woman presented to the infectious diseases clinic Luca Pipito, M.D.
with a 10-day history of painful lesions on the right hand and forearm. The Antonio Cascio, M.D., Ph.D.
nodules had first appeared on the back of her hand at the site of a thorn Universita di Palermo
puncture she had sustained while gardening. The lesions had spread up the hand Palermo, Italy
along a red streak and then had appeared on the forearm. Physical examination antonio.cascio03@unipa.it
was notable for a serpentine array of firm, tender nodules on the dorsum of the
right hand with overlying erythema but no drainage (Panel A). On the dorsal side
of the right forearm, there were two tender, erythematous nodules, with overlying
ulceration of the more proximal one (Panel B). Lymphadenopathy was noted in the
right axilla. An aspiration of the hand lesion was performed. Bacterial culture of
the aspirate grew filamentous, gram-positive, acid-fast branching rods that were
subsequently identified as Nocardia brasiliensis. A diagnosis of sporotrichoid nodular
lymphangitis was made. Nodular lymphangitis occurs when infectious subcutane-
ous nodules spread proximally from the site of inoculation along lymphatic chan-
nels. The syndrome occurs in sporotrichosis but also in similar-appearing sporo-
trichoid infections with nocardia species, Mycobacterium marinum, and Leishmania
braziliensis. After a course of trimethoprim–sulfamethoxazole, the lesions resolved.
DOI: 10.1056/NEJMicm2213996
Copyright © 2023 Massachusetts Medical Society.

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