Pulmonary Nocardia otitidis-caviarum infection in a patient with Cushing's disease]

While Nocardial infections are being diagnosed with increasing frequency, infection with Nocardia otitidiscaviarum remains relatively uncommon. We report a case of pulmonary Nocardia otitidis-caviarum infection in a 35-year-old man with Cushing's disease. This work describes the first case of nocardiosis in Japan caused by Nocardia otitidis-caviarum in Cushing's disease. The patient was admitted to our department because of edema. A diagnosis of Cushing's disease was made on the basis of elevated serum levels of cortisol and adrenocorticotropic hormone (ACTH) and pituitary adenoma was found in a cranial CT scan. One month after admission, chest radiographs showed a large bilateral mass on the lung fields. Nocardia otitidis-caviarum was isolated from the sputum. The patient responded poorly to intravenous PAPM/BP, but later improved after treatment with trimethoprim-sulfamethoxazole, but he died of heart failure and respiratory failure after the initiation of this therapy. This case demonstrated that nocardiosis must be considered in differential diagnosis as an opportunistic infection.     

Molecular diagnosis of fatal Nocardia farcinica pneumonia in an HIV-negative patient

Nocardiosis is a rare and potentially life-threatening infection caused by several species of the Nocardia genus. Most cases occur in immunocompromised patients, and a delay in establishing the diagnosis is common due to the non-specific clinical presentations and the difficulty in cultivating Nocardia. Although the majority of pulmonary nocardiosis cases are caused by Nocardia asteroides, cases of human infection due to N. farcinica are increasingly diagnosed due to recent developments in taxonomy and diagnostic methods. N. farcinica is a separate species from N. asteroides and appears to be more virulent and resistant to antibiotics. Herein, we describe the case of a 65-year-old HIV-negative immunocompromised patient with a fulminant bilateral pulmonary nocardiosis while on empirical treatment with trimethoprim/sulfamethoxazole and imipenem. Post-mortem diagnosis of N. farcinica infection was performed by means of DNA amplification and sequencing of the 65-kDa bacterial heat shock protein.     

Disseminated nocardiosis due to unusual species: two case reports

Pulmonary nocardiosis is the major clinical manifestation of human nocardiosis and disseminated infection can be seen in immunocompromised patients. N. asteroides is the predominant pathogen associated with disseminated diseases. We report 2 cases of pulmonary nocardiosis admitted with disseminated infection, caused by rare species of Nocardia: Nocardia transvalensis and Nocardia cyriacigeorgica.     

Nocardia infection of a joint prosthesis complicating systemic lupus erythematosus

The authors report the case of a 43-year-old woman suffering from severe systemic lupus erythematosus treated with long-term prednisone, who developed Nocardia nova infection on a hip prosthesis. Sepsis occurred about two years after an episode of pulmonary nocardiosis with the same Nocardia species, that was successfully treated by 12 months of antibiotics. A good outcome of the joint infection was observed in response to antibiotics and removal of the prosthesis. Nocardiosis is a rare infection, acting as an opportunistic infection, facilitated in the present case by systemic lupus erythematosus and chronic corticosteroid therapy. Nocardia infections mainly affect the lungs, skin and central nervous system; these last two sites are mostly due to haematogenous spread, a frequent event. Treatment is based on antibiotics, usually continued for 3-12 months, especially because of the risk of relapse. The imipenem-amikacin combination appears to be more effective than trimethoprim sulfamethoxazole. To our knowledge, this is the first case report of Nocardia nova joint prosthesis infection also presenting as late septic spread of pulmonary nocardiosis, complicating corticosteroid-treated systemic lupus erythematosus.     

Disseminated nocardiosis due to Nocardia otitidiscaviarum:A case report and literature review

Rationale: Disseminated nocardiosis due to Nocardia otitidiscaviarum is rarely reported in immunocompetent hosts.Patient concerns: A 59 year old male patient complained of painful soft tissue swellings and fever for two days.Diagnosis: Disseminated nocardiosis due to Nocardia otitidiscaviarum. Interventions: Initial antimicrobial therapy with imipenem and trimethoprim/sulfamethoxazole was switched to 6 weeks of trimethoprim/sulfamethoxazole, linezolid and tigecycline after sensitivity test results were available. Thereafter, the patient was switched to maintenance trimethoprim/sulfamethoxazole and moxifloxacin. Prednisolone was gradually tapered.Outcomes: Soft tissue swelling and pain disappeared and the patient was discharged uneventfully.Lessons: Disseminated nocardiosis due to Nocardia otitidiscaviarum should be suspected in immunocompetent hosts with risk factors such as medication with prednisolone. Early identification of the causative species and susceptibility results is crucial given the diverse resistance patterns amongst various Nocardia species.     

Pulmonary nocardiosis due to Nocardia otitidiscaviarum in an immunocompetent host- a rare case report

Nocardiosis is a localized or disseminated infection caused by soil-borne aerobic actinomycetes. Pulmonary nocardiosis is a rare infection mostly occurring in immunocompromised patients. We reported a case of 36 year old immunocompetent non-smoker female patient with no premorbid illness who presented with fever, cough with scanty sputum, hemoptysis, left sided chest pain and exertional dyspnea for two weeks. There was no past history of tuberculosis, diabetes mellitus or steroid therapy. Chest X-ray showed homogenous peripherally based opacity in the left upper zone. Bronchoscopy was done and brushing sent for culture, which showed colonies with features of Nocardia species after 48 hours. Further phenotypic characterization revealed it to be Nocardia otitidiscaviarum. Patient was treated with cotrimaxazole for six months after which complete recovery was evidenced symptomatically and radiologically. We report this case to emphasize the fact that among the Nocardia species, Nocardia otitidiscaviarum as causative agent of pulmonary disease is rarely reported even in immunocompromised individuals.     

Chest wall destruction: unusual presentation form of pulmonary nocardiosis

Nocardia spp infection is associated with immunosuppresion states, neoplasms and immunosuppresors and glucocorticoids prolonged treatments. Pulmonary involvement is the most typic feature and the dissemination to chest wall and subcutaneous cellular tissue is uncommon. We report one case of pulmonary nocardiosis by Nocardia asteroides, in a diabetic patient without others risk factors, manifested as a chest wall abscess with fifth rib destruction. The treatment with cotrimoxazol after lesion drainage was successful. We review the literature and remain the different diagnostic and therapeutics attitudes.     

Pulmonary Nocardiosis in a Non-Hodgkin's Lymphoma Patient

Nocardiosis is an opportunistic infection especially in immunocompromised patients. Lungs are the most common infection sites and therapy poses some difficulties. We describe a case of pulmonary infection with Nocardia asteroides in a non-Hodgkin's lymphoma patient. Although the mortality from pulmonary nocardiosis is high in immunocompromised patients, our patient was successfully treated with trimethoprim-sulfamethoxazole (TMP/SMZ) and amikacin. Maintenance therapy with TMP/SMZ was continued for 1 year. This case supports the importance of the long-term maintenance treatment after the initial combination therapy. Received: June 10, 2001 · Revision accepted: December 8, 2001     

Disseminated nocardiosis after unrelated bone marrow transplantation

Nocardiosis is a rare bacterial infection occurring mainly in patients with deficient cell‐mediated immunity. Although disseminated nocardiosis after allogeneic hematopoietic stem cell transplantation (allo‐HSCT) is a rare complication, it is associated with high mortality. Moreover, after allo‐HSCT, nocardiosis may be mistaken for other bacterial or fungal infections because clinical and radiographic findings of pulmonary, cerebral, and cutaneous nocardiosis lesions are non‐specific. Here, we report a case of disseminated nocardiosis (caused by Nocardia abscessus) with skin, pulmonary, liver, lymph node, and multiple brain abscesses in a patient after allo‐HSCT. The patient initially responded clinically and radiographically to imipenem/cilastin and trimethoprim‐sulfamethoxazole therapy. Clinicians should be aware of the possibility of nocardiosis in allo‐HSCT recipients who are treated with multiple immunosuppressive agents to control chronic graft‐versus‐host disease. Accurate diagnosis and identification of disseminated nocardiosis is important to ensure administration of the correct antibiotic regimen.     

Long-term treatment of persistent disseminated Nocardia cyriacigeorgica infection

In this paper a disseminated persistent Nocardia cyriacigeorgica infection in an immunocompetent patient is described. The patient's long-term treatment, as well as its implications for managing similar cases in the future, is emphasized. Presenting with high fever, multiple nodules, and ulcerative cutaneous lesions of body sites, the patient was treated with various antimicrobials. Under combined therapy, empyema and arthritis, leading to disseminated nocardiosis, were seen. The overall treatment course was 28 months. It can be concluded that the choice of the antibiotics and optimal duration of treatment are uncertain; therefore the treatment of nocardiosis requires expertise.     

Successful treatment of disseminated nocardiosis complicated by cerebral abscess with ceftriaxone and amikacin: case report.

We report the case of an 85-year-old female patient who suffered from disseminated Nocardia asteroides infection complicated by a cerebral abscess. Treatment with amikacin for 2 weeks and ceftriaxone for 6 weeks led to complete recovery, and there was no recurrence of disease over a follow-up period of 12 months after therapy. The use of ceftriaxone in combination with amikacin might significantly shorten the duration of treatment for patients with disseminated nocardiosis. This combination of antibiotics merits further investigation with use of a larger sample of patients.     

Nocardial infections: report of 22 cases

Twenty-two cases of nocardial infections were diagnosed in our city between 1977- 1998. All patients whose clinical specimens showed Nocardia spp. at Gram stain, which were further confirmed by culture, were selected to be included in the study. Data from patients who were cured were compared with those from patients who died by statistical tests using EPIINFO version 6.04 software. Six isolates were identified as Nocardia asteroides complex, one as Nocardia asteroides sensu stricto and other as Nocardia brasiliensis. We had 17 cases of lung nocardiosis, being one out of them also a systemic disease. Other four cases of systemic nocardiosis were diagnosed: nocardial brain abscesses (one); nocardiosis of the jejunum (one); multiple cutaneous abscesses (one); and a case of infective nocardial endocarditis of prosthetic aortic valve. One patient had a mycetoma by N. brasiliensis. Fifteen (68.2%) out of 22 patients were immunosuppressed, being most (93.3%) by high-doses corticotherapy. Mortality by nocardial infection was 41%; mortality of systemic nocardiosis was 60%. Nocardiosis has a bad prognosis in immunosuppressed patients and also in non-immunosuppressed patients if the diagnosis is delayed. We propose that the delay in diagnosis should be examined in larger series to document its influence in the prognosis of the disease.     

Pulmonary nocardiosis re-visited: experience of 35 patients at diagnosis

Pulmonary infection by Nocardia is an uncommon opportunistic infection in humans. Thirty-five patients with pulmonary nocardiosis were identified in two tertiary referral hospitals. A retrospective review of the patient characteristics, clinical and laboratory features including antimicrobial susceptibility at diagnosis was carried out. Radiological features derived from chest radiographs and CT scans were also documented. In our population, the predominant risk factors were immuno-compromised state, corticosteroid therapy, and underlying pulmonary pathology. The presenting features were similar to those previously described but disseminated infection was not common. The radiological changes were diverse and non-specific. Nocardia asteroides was the commonest species. Most Nocardia isolates were susceptible to imipenem, ceftriaxone, amikacin, and cotrimoxazole. Co-existing microbial agents are common and reflect the underlying complex disorders.     

Pulmonary nocardiosis: clinical experience in ten cases.

BACKGROUND: Pulmonary nocardiosis is an infrequent infection whose incidence seems to be increasing due to a higher degree of clinical suspicion and the increasing number of immunosuppressive factors. OBJECTIVE: To study the predisposing factors, clinical characteristics, diagnostic procedures, treatment and progress of pulmonary nocardiosis (PN). METHODS: Review of 10 patients (9 male, 1 female, mean age 61) with PN in a 600-bed teaching hospital, diagnosed from 1992 to 1999. RESULTS: Associated diseases observed were chronic obstructive pulmonary disease (COPD) in 6 patients, human immunodeficiency virus (HIV) infection in 3 and polymyalgia rheumatica in 1. Four patients had received oral corticotherapy for COPD for over a year (mean dose 13 mg/day of prednisone or equivalent). The main reason for consultation was an increase in dyspnea in the patients with COPD (6/6) and fever in those with HIV (3/3). Mean time between onset of symptoms and diagnosis was 5 weeks. In 8 patients, the infection occurred outside the hospital setting. The infection was restricted to the lung in 9/10; in the remaining case, the central nervous system (CNS) and subcutaneous tissue were affected. Lobar or multilobar consolidation was the most frequent radiographic pattern found (6/10). Sputum culture was positive when performed (8 cases). Diagnosis was made or confirmed by bronchoscopy (bronchoaspirate or protected specimen brush) in 5 patients. Germs isolated were: Nocardia asteroides (8/10), Nocardia farcinica (1/10), Nocardia otitidiscaviarum (1/10). Cotrimoxazole was the most used empirical treatment (6/10). Resolution was achieved in 5 cases. Four subjects died: 1 HIV patient with disseminated nocardiosis, and 3 COPD patients, 2 of whom had received long-term corticotherapy. Illness recurred in only 1 case, due to failure to comply with treatment. CONCLUSIONS: (1) In our geographical setting Nocardia presents as a subacute or chronic pulmonary infection, mainly outside the hospital. (2) It tends to affect only the lung. (3) Diagnosis requires a high clinical suspicion, and can be made on the basis of a sputum culture. (4) Nocardia tends to attack patients with underlying COPD, or immunodepressed patients treated with glucocorticoids, or patients with HIV infection. (5) Mortality is high in both COPD and HIV patients. (6) In our area, cotrimoxazole seems to be the most commonly prescribed treatment.     

Localized subcutaneous Nocardia farcinica abscess in a woman with overlap syndrome between systemic scleroderma and polymyositis

Nocardia farcinica is an increasingly common cause of human infection in Europe. We observed an isolated nodular subcutaneous abscess due to N. farcinica in the forearm of a young patient with overlap syndrome between systemic sclerosis and polymyositis. Despite in vitro resistance to trimethoprim-sulfamethoxazole, this oral combination completely resolved the lesion within 3 weeks and was maintained for 6 months. The spectrum of cutaneous nocardiosis in the immunocompromised host is discussed.     

诺卡菌感染患者44例的临床特征及其预后

目的:了解诺卡菌感染患者的临床特征及预后。方法:回顾性分析2013年1月至2019年7月于上海复旦大学附属华山医院感染科诊治的44例诺卡菌感染患者的临床资料,包括一般临床表现、基础疾病、使用糖皮质激素情况、实验室检查指标(包括血常规、降钙素原、C反应蛋白、淋巴细胞亚群等)、影像学改变、菌种鉴定、治疗与转归。根据感染类型分为单纯肺部感染组、肺外单个器官感染组和播散性感染组。两组间比较采用曼-惠特尼U检验,多组间比较采用Kruskal-Wallis H检验。结果:44例诺卡菌感染患者中,14例为单纯肺部感染,17例为肺外单个器官感染(其中中枢神经系统感染9例,皮肤软组织感染6例,腹腔脓肿1例,尿路感染1例),13例为播散性感染(其中血流感染4例,中枢神经系统合并肺部或皮肤软组织感染6例,肺部合并皮肤软组织感染3例)。34例患者合并基础疾病,27例患者正在使用糖皮质激素或免疫抑制剂。11例单纯肺部感染患者的主要表现为咳嗽、咳痰;肺外单个器官感染和播散性感染患者的主要表现为发热。诺卡菌菌种以巴西、星形、鼻疽诺卡菌为主。白细胞计数和中性粒细胞比例正常或轻度升高42例,血小板计数正常或轻度下降41例,红细胞沉降率升高19例,降钙素原升高21例,C反应蛋白升高34例,铁蛋白升高18例。34例患者检测了淋巴细胞亚群,其中15例CD4+T淋巴细胞下降,14例CD8+T淋巴细胞升高,7例B淋巴细胞升高,7例B淋巴细胞下降,8例自然杀伤细胞下降。单纯肺部诺卡菌感染患者血红蛋白高于肺外单个器官感染患者,差异有统计学意义(U=0.095,P=0.025)。影像学表现以脓肿、炎症渗出为主。治愈或好转40例,1例仍在治疗,死亡3例。结论:累及各部位的诺卡菌病的临床表现无特异性,经过规范治疗可降低诺卡菌病的病死率。     

1例盖尔森基兴诺卡菌血流感染病原学诊断报告

目的 加强对诺卡菌病的认识,以提升其临床诊疗水平。方法 回顾分析乐山市人民医院肾病内科的1例盖尔森基兴诺卡菌血流感染的临床资料,包括临床表现、实验室检查、影像学检查、诊疗情况等。结果 此病人的临床表现及影像学检查缺乏特异性,检验人员镜检发现其革兰氏染色涂片结果为革兰阳性、分枝状长杆菌,细菌的16S rRNA测序分析证实为盖尔森基兴诺卡菌。结论 诺卡菌病多发生于机体免疫受损及合并慢性基础疾病的人群,临床表现和影像学缺乏特异性,诊断需依赖于病原学检查,合格标本的采集和革兰氏染色对诺卡菌病是早期诊断及正确治疗的重要步骤。     

A case of liver nocardiosis associated with Crohn's disease while treating infliximab

A 23-year-old man, complaining of chronic diarrhea, was given a diagnosis of Crohn's disease. He responded well to steroid therapy and infliximab administration. However, high fever appeared on the 28th day of hospitalization, and CT scan revealed multiple liver abscesses. Gram-positive branched rods were harvested by ultrasonography guided puncture examination. As Nocardia infection was suspected, sulfamethoxazole-trimethoprim was started immediately, and his clinical course improved dramatically. Afterwards, Nocardia farcinica was isolated from the culture of the liver abscess. This case is the first report of liver nocardiosis associated with Crohn's disease. Generally, Nocardia infection can be successfully treated by sulfamethoxazole-trimethoprim therapy. Liver nocardiosis is very rare but could be an important complication for patients with Crohn's disease.     

Intracranial Nocardia recurrence during fluorinated quinolones therapy

Nocardia infection is a well-recognized complication in renal transplant recipients and other immunocompromised hosts. It is mostly a primary pulmonary infection, which can disseminate to other organs in half of the cases. Nocardiosis is a life-threatening infection. Therefore, an efficient long-lasting treatment must be rapidly administered. We report 1 case of disseminated nocardiosis with pulmonary involvement, brain lesions, and bone lesions in a renal transplant patient, who was treated with stereotactic aspiration in association with high dose of trimethoprim/sulfamethoxazole (TMP/SMX) and imipenem, changed, after 3 weeks to moxifloxacin. First, clinical manifestations decreased after surgical drainage and combination therapy with the 2 antimicrobial agents, but later the patient developed a recurrence of brain lesions during treatment with quinolones. Consequently, the patient was again treated with TMP/SMX and imipenem, after which the patient recovered. It is surprising that moxifloxacin was efficient in vitro and the antimicrobial concentration in the central nervous system was high, yet the nocardial abscess recurred under this therapy.     

Nocardia asteroides pneumonia, subcutaneous abscess and meningitis in a patient with advanced malignant lymphoma: successful treatment based on in vitro antimicrobial susceptibility.

Nocardia asteroides pneumonia, subcutaneous abscess and meningitis without brain abscesses developed in a patient with advanced non-Hodgkin's lymphoma, who had received corticosteroid therapy and cancer chemotherapy for a long time. At the time of nocardial pneumonia, profound lymphocytopenia and hypogammaglobulinemia was seen. The severely immunosuppressed condition most likely accounted for the uncommon infection, nocardiosis. The organism isolated from the sputum, subcutaneous abscess and cerebrospinal fluid was strongly resistant to cotrimoxazole, which is the recommended standard treatment, but it was susceptible to imipenem (IPM) and erythromycin (EM) in an in vitro antimicrobial susceptibility study. The patient's nocardiosis responded well to chemotherapy including IPM and EM.