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Nocardia brasiliensis infection mimicking juvenile idiopathic arthritis in a 4-year-old girl.

Authors
Type
Published Article
Journal
PEDIATRICS
0031-4005
Publisher
American Academy of Pediatrics
Publication Date
Volume
132
Issue
5
Identifiers
DOI: 10.1542/peds.2012-3086
PMID: 24127474
Source
Medline
Keywords
  • Nocardia
  • Arthritis
  • Juvenile Idiopathic Arthritis
  • Oligoarthritis Subtype
  • Septic Arthritis
  • Trimethoprim–Sulfamethoxazole

Abstract

Nocardia are ubiquitous environmental saprophytes that cause pneumonia and disseminated disease in immunocompromised patients. They can also cause localized cutaneous and soft tissue infections in healthy people after direct percutaneous inoculation. Nocardia arthritis is rare in both forms of the disease. Here we present the first published case of a child with septic arthritis caused by N brasiliensis. Importantly, this otherwise well 4-year-old girl had no known history of trauma but presented with transient cutaneous lesions and a 6-week history of arthritis involving the right fourth digit proximal interphalangeal joint without accompanying fever or raised systemic inflammatory markers. She received a diagnosis of juvenile idiopathic arthritis and underwent antiinflammatory and immunosuppressant therapy. After 2 months she developed frank septic arthritis, which necessitated a surgical joint washout, from which an intraoperative swab grew N brasiliensis. The patient received 6 months of high-dose trimethoprim-sulfamethoxazole and remains well more than 4 years after treatment. This unusual case highlights the importance of considering an indolent infection from slow-growing organisms, including Nocardia, when diagnosing the oligoarthritis subtype of juvenile idiopathic arthritis. This is especially relevant when a single joint is involved and response to antiinflammatory therapy is suboptimal because antiinflammatory agents may mask evolving signs of infection.

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