Primary Cutaneous Nocardiosis in a Patient Taking Adalimumab Therapy for Crohn’s Disease

INTRODUCTION The introduction of biologic immunomodulators, in particular antibodies targeted against tumor necrosis factor alpha (TNF-alpha), has revolutionized treatment of Crohn’s disease. However, this comes at the expense of a higher risk for opportunistic infections due to a generalized immunosuppressive effect. Bacterial and opportunistic infections are well-known complications of anti-TNF agents.1,2 Nocardia has been reported rarely among patients on anti-TNF agents.3 TNF plays a role in the clearance of norcardia in animal models.4 Immunosuppression, anti-TNF treatment in particular, may favor growth and dissemination of nocardia. Pulmonary and cutaneous nocardiosis has been reported in Crohn’s disease patients on infliximab.5,6 Nocardiosis has been reported with adalimumab therapy in rheumatoid arthritis patients.7,8 Our search did not reveal any cases of nocardiosis while on adalimumab therapy in Crohn’s disease patients. Crohn’s disease patients receiving biologic agents, in particular, tumor necrosis factor (TNF)-alpha inhibitors are immunosuppressed and are prone to develop opportunistic infections. We report a rare case of primary cutaneous nocardiosis in an immunocompromised patient on chronic anti-TNF for underlying severe Crohn’s disease.