Vulvar Nocardiosis in the Setting of dVIN: A High-Risk Infection

Nocardia is a Gram positive, aerobic, partially acid-fast filamentous bacteria of the order Actinomycetales. It is a saprophytic organism found in environmental contaminants such as soil and decomposing organic matter. Primary cutaneous nocardiosis is uncommon and may occur through contamination of a wound or through inhalation of the organism with dissemination to multiple organ systems, including the skin. Vulvar nocardiosis is an exceedingly rare manifestation of Nocardia. Described is a patient with a history of lichen sclerosus, differentiated vulvar intraepithelial neoplasia (dVIN), and recurrent vulvar squamous cell carcinoma requiring multiple resections and biopsies who presented with recurrent firm, white, nodular lesions on the right labia and right inferior clitoris. Histopathology of the right inferior clitoral lesion demonstrated dVIN. The right labia majora lesion also revealed dVIN and a dermal epithelioid granuloma with central vacuoles filled with filamentous to small, fragmented forms suggestive of bacteria. Ziehl-Neelsen AFB stain was negative. Gram stain, Gomori methenamine silver (GMS), and FITE stains were positive. The staining pattern of the filamentous and beaded forms supports a diagnosis of Nocardia. Vulvar nocardiosis in the setting of dVIN and history of multiple vulvar surgeries has not been described in the literature to date. This case demonstrates the importance of maintaining atypical infections on the differential for nonhealing vulvar wounds. Timely treatment is crucial to improve outcomes, particularly in the setting of multiple surgical procedures in patients at high risk for infectious complications.