Fig. 6.13 A-C. Nocardial infection of the lower limbs. The femora, fibula, and tibia show the same exuberant periosteal bone reaction with underlying sclerosis. The soft tissue swelling and nodulation can be seen, particularly in the lower leg. (Patients from South America, courtesy of Professer Harold Jacobson and Dr. Ceballas Labat)

Fig. 6.14 A-F. Nocardiosis of the ankle and feet. A A 32-year-old Indian male with swelling of the left foot and multiple nodular sinuses: there was a thick purulent discharge. There were a few sinuses on the right foot also. B A radiograph shows multiple areas of destruction in all the bones of the left foot, with intense periosteal new bone, particularly around the metatarsals. There are irregular lytic areas 215 mm in diameter. The tarsal joints have been affected. Because the lower leg was infected also, an above-the-knee amputation was planned but the patient absconded with a few month's supply of drugs. C On his return most of the sinuses had dried up, the swelling had subsided and the tibia and fibula had improved. He had extensive bilateral pulmonary infection also, but this had regressed. D-F This patient was not so fortunate and his foot was amputated, the standard treatment until the difference between the true and the false fungi was recognized. D A gross specimen of the foot after amputation. E The radiograph shows multiple confluent intercommunicating abscess cavities involving the bones and soft tissues. F Cross-sections of the foot show the confluent microabscesses and the multiple smooth wall communicating cavities.

Fig. 6.15 A-C. Three South American patients with severe Nocardia brasiliensis infections of the ankle and feet. (Courtesy of Professor Harold Jacobson and Dr. Ceballas Labat)

Fig. 6.16 A-I. Nocardia often infects the facial bones and paranasal sinuses, and may spread elsewhere in the skull. A A young Indian child with a Nocardia infection which started in the paranasal sinuses: there is thick granulation tissue discharging pus from multiple sinuses, one of which affects the frontal bone. There is unilateral proptosis, involvement of orbital walls on both sides (B), particularly on the left, and thickening of the left maxillary antrum. Part of the bone in the roof of the left orbit has been destroyed and the left orbital fossa has become smaller. As seen in the lateral view (C) there is marked sclerosis of the frontal bone. D, E Similar supraorbital sclerosis and thickening in a patient from South America. The orbital floor is also beginning to thicken and the orbit is becoming smaller. F, G Widespread nocardial infection in the skull of an African patient from Kenya who has Hodgkin's lymphoma. H, I Another African patient, from South Africa, with an even more advanced nocardial infection of the skull. (D, E courtesy of Professor Harold Jacobson; H, I courtesy of the University of Capetown Radiology Library)