Localized cutaneous Nocardia brasiliensis mimicking foreign body granuloma

Nocardia brasiliensis is recognized in the United States as an infectious agent of the skin that may present as an abscess, ulcer, or granuloma with or without "sporotrichoid" spread, and rarely causes systemic disease. Treatment with trimethoprim/sulfamethoxazole is usually curative. We present a patient with multiple erythematous, painful, draining nodules that developed thirty-six months after trauma and subsequent contamination with soil in Bermuda. A foreign body granuloma was suspected clinically, and excision was performed followed by recurrence of the lesions. Histologic examination and culture were consistent with nocardiosis. Differential diagnosis of foreign body granulomas also should include infection with N. brasiliensis even after a long incubation period. Culture and drug susceptibility testing of affected tissue should be performed for diagnosis and management.