Journal of Medical Microbiology (2012), 61, 1168–1173 DOI 10.1099/jmm.0.

038240-0

Case Report Nasal vestibulitis due to Nocardiopsis dassonvillei

Correspondence
Arunaloke Chakrabarti
arunaloke@hotmail.com
in a diabetic patient
Shivaprakash M. Rudramurthy,1 Sumangala B.,2 Prasanna Honnavar,1
Yenigalla Bindu Madhav,2 Munegowda K. C.,2 Ravi D. 3
and Arunaloke Chakrabarti1
1
Mycology Division, Department of Medical Microbiology, Postgraduate Institute of Medical
Education & Research (PGIMER), Chandigarh, India
2
Department of Microbiology, Mandya Institute of Medical Sciences (MIMS), Mandya, Karnataka, India
3
Department of ENT, Mandya Institute of Medical Sciences (MIMS), Mandya, Karnataka, India

Received 22 September 2011
Accepted 1 May 2012
Human infection due to Nocardiopsis, an actinomycete, is rare and the majority of those infections
are due to Nocardiopsis dassonvillei. This agent has been implicated in cutaneous, pulmonary,
eye and disseminated infections. It has never been isolated from the nose or any nasal infection.
We report here a rare case of nasal vestibular abscess due to N. dassonvillei in an adult diabetic
patient. The bacterium was identified on the basis of morphological and biochemical
characteristics, and confirmed by sequencing the 16S rRNA and hsp65 genes. The patient was
successfully treated with clarithromycin and levofloxacin. Though N. dassonvillei infections may be
rare, the study highlights that it may cause a wide spectrum of disease manifestations, and
laboratories should take care to isolate and identify the easily treatable pathogen.

Introduction (MIMS), Mandya, Karnataka, India, with complaints of fever

Bacteria in the genus Nocardiopsis belonging to the class
Actinomycetes are aerobic, spore-forming, Gram-positive,
branching filaments exhibiting aerial mycelia. The genus
Nocardiopsis currently has 33 species and subspecies and
most of them are isolated from soil and marine sediments
(Euzéby, 2011). Human infections due to Nocardiopsis are
rare and are mostly caused by Nocardiopsis dassonvillei.
Nocardiopsis synnemataformans is the only other species of
this genus reported to be associated with human infection
(Yassin et al., 1997). N. dassonvillei has been isolated from
the soil (Meyer, 1976), and implicated in sepsis (Beau et al.,
1999; Lejbkowicz et al., 2005), mycetoma (Ajello et al.,
1987; Sindhuphak et al., 1985), skin (González-López et al.,
2011; Philip & Roberts, 1984; Singh et al., 1991) and
pulmonary (Bernatchez & Lebreux, 1991; Mordarska et al.,
1998) infections and conjunctivitis (Liegard & Landrieu,
1911). It has never been isolated from the nose or nasal
infection. We report here a rare case of nasal vestibular
abscess due to N. dassonvillei in an adult diabetic patient.
Case report
A 55-year-old man presented to the Otolaryngology out-
patient department of Mandya Institute of Medical Sciences
The GenBank/EMBL/DDBJ accession numbers for the 16S rRNA and
hsp65 gene sequences of the Nocardiopsis dassonvillei isolate are
JF264438 and JF264439, respectively.
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and acute pain in the nose for 1 week. On physical
examination, he was febrile and had a tender nose with
erythema on the right nasal area. On examination using a
nasal speculum, a soft mass with abscess was noticed on the
inner surface of the right alae of the nose and he was
diagnosed as having a vestibular abscess. About a month
previously, he had presented with the same complaints to a
private practitioner, who had drained pus from his right
nostril and put him on oral cefuroxime 500 mg twice daily for
10 days. Though the patient responded to the therapy, the
symptoms recurred and he reported to MIMS. Plain X-rays of
his paranasal sinuses and chest were normal. He did not give
any history of foreign body introduction, rhinorrhea or nose
picking. He was a known diabetic but his blood sugar level
was well controlled with an anti-diabetic regimen. Pus was
drained from the vestibular abscess and sent for micro-
biological investigation. Gram stain slide showed Gram-
positive branching filaments, and a modified Ziehl–Neelsen
stain showed partially acid-fast branching filaments along
with coccobacillary forms. The patient was put on co-
trimoxazole for 1 week. However, as his fever persisted,
clarithromycin and levofloxacin were added after a week. The
patient recovered completely after 4 weeks of medication.
Microbiological investigation
The pus was inoculated on blood agar, MacConkey agar
and Löwenstein–Jensen medium. After 24 h of aerobic
038240 G 2012 SGM Printed in Great Britain
 Nasal vestibulitis due to Nocardiopsis dassonvillei

Table 1. Phenotypic characteristics of N. dassonvillei

Characteristic NCCPF-260045 Type strain*

Decomposition of:
Adenine + +
Casein + +
Tyrosine + +
Hypoxanthine + +
Xanthine + +
Urea 2 V
Aerial hyphae + +
Colour of aerial hyphae White White, yellow, grey
Colour of substrate hyphae Brown Brown, orange, yellow
Growth at 45 uC + +
Gram stain Gram-positive Gram-positive
Acid fastness Partially acid-fast 2
Susceptibility to lysozyme + +
Catalase production + +
Carbon substrate assimilation test
D-Glucose + +
D-Galactose + V
Trehalose + +
Sucrose + +
Maltose + V
Cellobiose + +
Xylose + +
Raffinose 2 2
myo-Inositol 2 2

*As compiled by Beau et al. (1999). V, Variable.

incubation, rough, non-haemolytic colonies were observed
on blood agar. The colonies were dry, coarsely wrinkled,
folded, whitish with well-developed substrate mycelium
after 72 h. White and dry colonies grew on MacConkey
agar. On Löwenstein–Jensen medium, cream-coloured,
dry, rough and wrinkled colonies were noticed. Gram
stain and acid-fast stain of all the colonies showed similar
microscopical features as on direct smears. Antibiotic
susceptibility testing was performed by the disc diffusion
method (Gombert, 1982). The isolate was susceptible to
doxycycline, clarithromcycin, linezolid, levofloxacin and
co-trimoxazole and resistant to imipenem and cephalexin.
The isolate was provisionally identified as Nocardia species
and sent to the National Culture Collection of Pathogenic
Fungi (NCCPF), at the Postgraduate Institute of Medical
Education and Research (PGIMER), Chandigarh, India, for
species identification.
At the reference centre, biochemical and molecular char-
acterizations of the isolate were performed. The results of the
biochemical reactions are described in Table 1. Molecular
identification was done by amplifying the 16S rRNA gene (La
Scola et al., 1998; Weisburg et al., 1991) using the universal
primer pairs 16sF (59-GCTTAACACATGCAAGTCG-39)
and 16sR (59-GAATTCCAGTCTCCCCTG-39), and the
hsp65 gene (Rodrı́guez-Nava et al., 2006) using the primer
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pairs HSP65F (59-ACCAACGATGGTGTGTCCAT-39) and
HSP65R (59-CTTGTCGAACCGCATACCCT-39). Sequencing
reactions were performed with a Big Dye Terminator Cycle
Sequencing kit, version 3.1 (Applied Biosystems), for both
the strands. All the sequencing reactions were purified and
analysed on an ABI 3130 Genetic Analyzer (Applied Bio-
systems). For each gene, the consensus sequences were
prepared from the sequence obtained by forward primer and
reverse primers with the help of Seqman software. The
consensus sequences were compared with the sequences in
the GenBank DNA database. The 16S rRNA gene sequence
of the isolate showed 99 % identity with the sequence of N.
dassonvillei subsp. dassonvillei strain NBRC 15404 (GenBank
accession no. AB184655). The hsp65 gene sequence showed
99 % identity with the sequence of the type strain of N.
dassonvillei subsp. dassonvillei, strain DSM 43111 (GenBank
accession no. CP002040.1). The GenBank accession num-
bers of the 16S rRNA and hsp65 gene sequences of the isolate
are JF264438 and JF264439, respectively, and the isolate
has been deposited at NCCPF, PGIMER, Chandigarh, as
NCCPF-260045.
The evolutionary history was inferred using the neighbour-
joining method (Saitou & Nei, 1987). The bootstrap
consensus tree inferred from 1000 replicates (Felsenstein,
1985) was taken to represent the evolutionary history of the
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S. M. Rudramurthy and others

96 N. exhalans AY028325
65 N. valliformis AY336503
69 N. metallicus AJ420769
82 N. alba subsp. prasina X97884

28 N. alkaliphila AY230848
85 N. listeri X97887

N. alba subsp. alba X9788

34 N. tropica AF105971
96 N. umidischolae AY036001

N. lucentensis X97888
81 N. synnemataformans NR029343
27

87 N. dassonvillei X97886
66 N. dassonvillei JF264438 (NCCPF-260045)
72
N. aegyptia AJ539401

N. halototerans AJ290448

67 N. quinghaiensis EF597511
94
100 N. arvandica EU410477
79 N. sinuspersici EU410476

N. nikkonensis AB491226
N. salina AY373031
79
94 N. xinjiangensis AF251709

90 N. kunsanensis AF195412
100
N. litoralis EU583726
N. trehalosi AF105972

85 N. composta AF360734

73 N. potens FM253114

86 N. baichengensis AY619716
67 96 N. halophila AJ421018

N. chromatogenes AY619715
54 N. arabia EF095149

34 N. gilva AY619712

99 N. rhodophaea AY619714
97 N. rosea AY619713
Nocardia asteroides NR 041856

0.01

Fig. 1. Phylogram of the currently known Nocardiopsis species generated using the Maximum Composite Likelihood method
based on 16S rRNA gene sequence data. The percentage of replicate trees in which the associated taxa clustered together in
the bootstrap test (1000 replicates) is shown next to the branches. The tree is drawn to scale, with branch lengths in the same
units as those of the evolutionary distances used to infer the phylogenetic tree. Nocardia asteroides NR 041856 was used as
outgroup.

taxa analysed (Felsenstein, 1985). Branches corresponding
to partitions reproduced in fewer than 50 % bootstrap
replicates were collapsed. The percentage of replicate trees
in which the associated taxa clustered together in the boot-
strap test (1000 replicates) is shown next to the branches
(Felsenstein, 1985). The tree was drawn to scale, with branch
lengths in the same units as those of the evolutionary
distances used to infer the phylogenetic tree. The evolutionary
distances were computed using the Maximum Composite
Likelihood method (Tamura et al., 2004) and were in the
units of the number of base substitutions per site. All
positions containing alignment gaps and missing data were
eliminated only in pairwise sequence comparisons (pairwise
deletion option). There were a total of 1564 positions in the
final dataset. Phylogenetic analyses were conducted in
MEGA4 (Tamura et al., 2007) (Fig. 1).

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Table 2. Salient features of reported human infections caused by N. dassonvillei

NK, Not known.

Site(s) of Reference Age (in Risk factor Presenting manifestation Laboratory investigations Therapy Outcome
disease years)/sex

Cutaneous Philip & Roberts 71/M Injury with potato Cellulitis of arm, swelling Morphology, biochemical tests, Surgical debridement Improved
(1984) fork while and discoloration of dorsum cell wall analysis Co-trimoxazole
gardening of right hand
Sindhuphak et al. 39/M NK Multiple nodules and draining Morphology, biochemical tests, Co-trimoxazole Not mentioned
(1985) sinuses on the anterior aspect cell wall analysis (CDC, Atlanta)
of right leg (mycetoma)
González-López et 57/M Toothpick injury Several noduloulcerative lesions along Morphology, 16S rRNA gene Minocycline Improved
al. (2011) the flexor aspects of the left hand and sequence analysis
forearm in a sporotrichoid fashion
Singh et al. (1991) NK NK NK NK NK NK
Lungs Bernatchez & NK NK NK NK NK NK
Lebreux (1991)
Mordarska et al. NK NK Suppurative pulmonary infection Morphology, chemotaxononomic NK NK
(1998) study, GC content, DNA–DNA
reassociation
Eye Liegard & Landrieu NK NK NK NK NK NK
(1911)
Disseminated Beau et al. (1999) 60/M Rheumatoid Cholangitis Morphology, G+C content, Piperacillin, Recovered
spondylitis and cell wall fatty acid profile, 16S ciprofloxacin

Nasal vestibulitis due to Nocardiopsis dassonvillei

arterial rRNA gene sequence analysis
hypertension
Lejbkowicz et al. 3 years NK Fever, respiratory distress with Morphology, biochemical Trimethoprim and Recovered
(2005) productive cough tests gentamicin
Nasal Present case 55/M Diabetes mellitus Fever, soft mass with acute Morphology, biochemical tests, Clarithromycin and Improved
vestibulitis pain and erythema on the DNA sequencing of the 16S levofloxacin
right nasal area rRNA and hsp65 genes
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S. M. Rudramurthy and others
Discussion
Nasal vestibulitis is a common infection in children and
adults and is developed following nose picking, excessive
cleaning of the nostrils or vigorous blowing of the nose.
Occasionally the disease may be secondary to foreign
bodies within the nasal cavity (Figueiredo et al., 2006). The
damage to the protective epithelial lining of the vestibule
due to the above-mentioned activities may lead to infection
and inflammation. Staphylococcus aureus being a common
resident in the nose usually causes this infection following
injury to the nasal epithelium. The patients present with
pain, tenderness, swelling and erythema. Other than S.
aureus, the causative agent of this condition is not known.
However, the early treatment of such patients is important
to prevent the danger of the infection spreading to the
cavernous sinus through the draining veins.
Nocardiopsis species, described by Meyer in 1976, are found
predominantly in saline or alkaline soil water and organic
matter (Tang et al., 2003). Species in the genus Nocardiopsis
are described as aerobic, nocardiform substrate and aerial
filaments having meso-2,6-diaminopimelic acid without
madurose in their cell wall. The classification of Nocar-
diopsis to the species level is confusing due to the merging of
a few existing species and description of novel species. At
present, there are 33 accepted species and subspecies of
Nocardiopsis (Euzéby, 2011). However, only N. dassonvillei is
recognized as a human and animal pathogen. N. synnema-
taformans was isolated from the sputum of a renal transplant
recipient, but could not be established as the responsible
pathogen (Yassin et al., 1997).
The taxonomy of N. dassonvillei has undergone several
changes. It was previously known as Actinomadura dasson-
villei (Brocq-Rousseu, 1904; Lechevalier & Lechevalier,
1970) or Streptothrix dassonvillei or Nocardia dossonvillei
(Brocq-Rousseu, 1904; Liegard & Landrieu, 1911). Human
infection by N. dassonvillei has ranged from conjunctivitis
(Liegard & Landrieu, 1911) and cutaneous infections (Ajello
et al., 1987; González-López et al., 2011; Philip & Roberts,
1984; Sindhuphak et al., 1985; Singh et al., 1991), to
pulmonary (Bernatchez & Lebreux, 1991; Mordarska et al.,
1998) and disseminated (Beau et al., 1999; Lejbkowicz et al.,
2005) infections. The rarity of reports of human infection
may be attributed to the difficulty in identifying it in the
routine diagnostic laboratory. Identification of N. dasson-
villei can be established on the basis of morphology,
biochemical tests and chemotaxonomic characteristics,
especially the cell wall chemotype. However, N. dassonvillei
also exhibits phenotypic variation and needs a large panel of
biochemical tests. Molecular identification by sequencing of
the 16S rRNA gene is the standard approach for identifica-
tion. We confirmed the identity of our isolate by molecular
techniques. Due to the very close percentage similarity of the
16s rRNA gene sequence of N. dassonvillei with that of other
species, sequencing of this gene alone may not be sufficient
to delineate the species and subspecies. As the full genome
sequence of N. dassonvillei is available in GenBank, we
also sequenced the hsp65 gene, which is targeted for the
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identification of Nocardia and Mycobacterium species. This
gene may also be a good target for identification of
Nocardiopsis species after evaluation of more isolates.
Previously, Nocardiopsis alborubida, Nocardiopsis antarctica
and N. dassonvillei were considered separate species.
However, DNA–DNA hybridization data and the results of
biochemical tests indicated that N. alborubida (DSM 40465),
N. antarctica (DSM 43884) and N. dassonvillei (DSM 43111)
represent a single species designated N. dassonvillei (Yassin
et al., 1997). The similarity of the 16S rRNA gene sequences
among N. alborubida, N. antarctica and N. dassonvillei is
99.5 % (Rainey et al., 1996). As per the current classification
of Euzéby (2011), there are three subspecies of N. dassonvillei,
namely N. dassonvillei subsp. albirubida, N. dassonvillei
subsp. prasina and N. dassonvillei subsp. dassonvillei. Our
isolate was identified as N. dassonvillei subsp. dassonvillei.
N. dassonvillei is not reported as a normal commensal in
the nose or elsewhere in the body. As this agent is
predominantly present in the soil and our patient is a
farmer, the infection might have occurred due to accidental
inoculation of the organism in the nose by either a soiled
hand or inhalation. The other possibility may be accidental
inoculation during incision and drainage by the private
practitioner. Infection is known to be acquired by trau-
matic inoculation of the organism from soil or organic matter
(Ajello et al., 1987; Philip & Roberts, 1984; Sindhuphak et al.,
1985). In addition, ingestion of spores may be the other
mode of acquiring infection. Though diabetes was appa-
rently controlled in this patient, it may be considered an
additional risk factor.
The antibiotic susceptibility pattern of N. dassonvillei is not
well established. While comparing the susceptibility of our
isolate with that of a blood isolate reported by Lejbkowicz
et al. (2005), similar susceptibility patterns for aminoglyco-
sides, cotrimoxazole (both sensitive) and cephalosporins
(resistant) were observed. However, in contrast to our
isolate, the blood isolate (Lejbkowicz et al., 2005) was
resistant to quinolones. Cotrimoxazole appears to be the
choice of therapy for infection caused by N. dassonvielli
(Table 2), though our patient required additional clarithro-
mycin and levofloxacin for a complete cure. Cephalosporins
may not be beneficial in the management of N. dassonvillei
infection. We also observed that our patient did not respond
to the initial therapy with cefuroxime.
The present study highlights that N. dassonvillei may cause
a wide spectrum of disease manifestations, and laboratories
should take care to isolate and identify the easily treatable
pathogen.
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