A case of pulmonary nocardiosis cured by early sulfamethoxazole-trimethoprim therapy]

A 46-year-old man had been given 40mg prednisolone daily for systemic lupus erythematosus. He complained of fever and general fatigue and chest computed tomography revealed wide-spread consolidation with multiple cavity formation in his left lung. Pulmonary nocardiosis was clinically suspected because we detected nocardia from Gram staining of sputum. He was cured by sulfamethoxazole-trimethoprim, Imipenem/Cilastatin, although a cavity with a slightly thickened wall in the left lung remained. Nocardia asteroides was cultured from sputum and pulmonary nocardiosis was diagnosed. The present case was pulmonary nocardiosis that spread with multiple and extensive cavity formation. A good outcome was obtained by early treatment with sulfamethoxazole-trimethoprim.     

Acute respiratory distress syndrome caused by pulmonary nocardiosis in a patient with systemic lupus erythematosus

Nocardia is a gram-positive bacillus that infects mainly immunodepressed patients. Its association with lupus erythematosus has been described only occasionally and we have found no reports in the literature of an association between lupus and acute respiratory distress syndrome due to pulmonary nocardiosis. We present such a case and discuss the mechanisms that make this lung infection so virulent as well as its epidemiological and microbiological characteristics, clinical presentation, diagnosis, and treatment.     

Nocardia transvalensis infection in an immunocompetent patient reported from Turkey

Pulmonary nocardiosis is a rare infection mostly occurs in patients with immunosuppressive conditions. We report an immunocompetent case of pulmonary Nocardia transvalensis from Turkey, presented with bilateral pneumonia and bronchial dilatation treated six months with trimethoprim-sulfamethoxazole.     

Nocardia infection in SLE: A case series of three patients

ObjectivesNocardia infections have been described in immunosuppressed patient including patients with systemic lupus erythematosus (SLE). There are only a few case series in patients with SLE. Thus we studied the clinical presentations, organ involvement, treatment and outcome of cases of nocardial infection in the SLE patients.MethodsRecords of SLE patients who attended our rheumatology clinic in the last 25 years were reviewed and cases of nocardial infection were identified and data was collected from case records.ResultsThree cases of nocardiosis were found in our lupus series, giving a prevalence of 0.2%. Brain involvement was seen in all 3, whereas pulmonary and subcutaneous abscess was found in two patients each. All patients were managed with antibiotics and one patient required surgical drainage. All recovered without any morbidity.ConclusionNocardial infection, though rare in SLE has a good outcome. Involvement of brain, skin and lung together in a patient with background of immunosuppression should raise a suspicion of nocardial infection.     

A case of systemic lupus erythematosus complicated by Nocardia farcinica]

We report a patient with systemic lupus erythematosus (SLE) complicated with nocardiosis. This case is very important that the complication of nocardiosis in SLE is very rare and the treatment to both SLE and nocardiosis is very difficult. A twenty-one-year old female was admitted to our hospital because of thoracic empyema and active lupus nephritis. Her medical history revealed that the diagnose of SLE was made when she was 18 with lymphocytopenia, proteinuria, positive antinuclear antibodies, and high titer of antibodies to native DNA. She was treated with prednisolne 60 mg daily and became better. Proteinuria appeared again in September 1995 and she was admitted to the former hospital. Renal biopsy proved diffuse proliferative glomeluronephritis (WHO IVb). She was treated with 1 g per day of methylprednisolone for 3 days and succeeded with 60 mg day of prednisolone. In early November she developed left chest pain and fever and chest X-ray demonstrated left pleural effusion. Antibiotics, antituberculosis, and antifungal therapy failed to subside her pleuritis and it turned to empyema. Then she was transferred to our hospital for further treatment. Nocardia farcinica was detected from the aspirated pleural fluid obtained at the former hospital. Drainage and intrathoracic impenem injection were effective. While long usage of minocycline was continued for the nocardiosis, 500 mg of cyclophosphamide pulse therapy to lupus nephritis was administrated. Two weeks later a new pulmonary lesion with left chest pain and liver abscess developed. Administration of trimethoprim-sulfamethoxazole subsided the nocardiosis. She was discharged with 1 g per day of proteinuria the prescribed 13 mg per day of prednisolone and continuous TMP-SMZ intake for nocardial infection. When immunosuppressive therapy must be given to the immunocompromised host, a more potent therapy must be added to avoid infection.     

Pulmonary nocardiosis in a patient receiving immunosuppressive agent

A 20-year-old woman receiving corticosteroid treatment for systemic lupus erythematosus developed pulmonary nocardiosis with hydrophneumothorax. The organism identified as Nocardia asteroides resisted to sulfonamide and cotrimoxazole but sensitive to chloramphenicaol and streptomycin in vitro. She seemed to respond to chloramphenicol but subsequently had peritonitis and succumbed later.     

Nocardiosis in patients with systemic lupus erythematosus. The Singapore Lupus Study Group

Nocardia, a gram positive variably acid-fast aerobic bacterium is an opportunistic pathogen in immunocompromised hosts. We present 5 cases of nocardiosis in patients with systemic lupus erythematosus. We emphasize the clinical features, radiologic findings, and antibiotic sensitivity. Lung involvement was the predominant manifestation; others include brain abscess, retinitis, thyroiditis, and diaphragmatic infiltration. We describe the first cases of pulmonary nocardiosis presenting as pneumothorax and the use of fine needle aspiration cytology in diagnosing nocardial thyroiditis.     

Disseminated nocardiosis after pulmonary collapse: a case report

A 24-year-old Thai woman receiving corticosteroid treatment for systemic lupus erythematosus, developed pulmonary nocardiosis after pulmonary collapse. The correct diagnosis was reached when dissemination had occurred which was characterized by two subcutaneous abscesses and acute uveitis of the right eye. Gram stain of sputum and pus revealed delicate, branching, Gram-positive filamentous mycelia which were identified as Nocardia asteroides on culture. Subcutaneous abscesses and exophthalmos disappeared after one week of therapy and she made an uneventful recovery.     

High prevalence of infections in patients with systemic lupus erythematosus and pulmonary haemorrhage

The main objective of this study is to describe the presence of infections in patients with pulmonary haemorrhage and systemic lupus erythematosus. Patients with systemic lupus erythematosus and pulmonary haemorrhage were thoroughly evaluated in the first 48 hours with imaging plus bronchoscopy and bronchoalveolar fluid analysis. If needed, videoassisted thoracoscopy and lung biopsy were performed too. In all, search for bacterial, mycobacterial and fungal infections proceeded. Appropriate blood, bronchoalveolar fluid and tissue cultures were taken. Patients were treated with antibiotics and corticosteroids in case of infection. Otherwise, they received initial intravenous methylprednsiolone pulses for 3 days as standard therapy for pulmonary haemorrhage in systemic lupus erythematosus. Additional treatment with immunosuppressives was further decided by the treating physicians. Fourteen events in 13 patients were evaluated. In eight events (57%), an infection was demonstrated. Aetiological agents included Pseudomonas sp. and Aspergillus fumigatus. Four patients died, three of them because of the pulmonary infection and one because of cerebral haemorrhage secondary to severe systemic hypertension, 48 hours after methylprednisolone treatment. Patients with systemic lupus erythematosus and pulmonary haemorrhage have a high prevalence of infections. The influence of pulmonary haemorrhage in the setting of systemic lupus erythematosus needs further study to establish adequate treatment and to reduce the high mortality of this complication.     

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。     

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.     

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.     

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.     

Potential nosocomial disseminated infection due to Nocardia asteroides after a prosthesis insertion in an immunocompetent patient

Nocardia infections are rare and usually occurred in immunocompromised patients with systemic dissemination from a lung infection. We report a case of an immunocompetent patient in whom Nocardia asteroides had cause psoas and cerebral abcess without pulmonary infection, a short period after a hip prosthesis insertion. The clinical history is highly suggestive of a hospital-acquired infection.     

Pulmonary nocardiosis during immunosuppressive therapy for idiopathic pulmonary fibrosis

Nocardiosis is a subacute or chronic suppurative infection caused by Nocardia species. Although it is more common in immunocompromised hosts, idiopathic pulmonary fibrosis (IPF) has not been recognized as a predisposing factor for nocardial infection. We report a case of IPF, in which pulmonary nocardiosis developed during treatment with prednisolone and cyclophosphamide. The risk of pulmonary nocardiosis may be increased in cases of IPF on immunosuppressive therapy. Since IPF often accompanies lung carcinoma, it is important to correctly differentiate nocardiosis from carcinoma.     

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.     

Bird fancier's lung complicated by pulmonary nocardiosis

We report the case of an 84-year-old male who was admitted to the hospital with persistent cough and dyspnea. An initial chest X-ray revealed pulmonary infiltrates. Nocardia asteroides was detected in sputum, and the patient was treated with antibiotics. However, his symptoms did not completely resolve. He was admitted multiple times, and his symptoms relapsed after every discharge. He was finally suspected of having hypersensitivity pneumonitis and was diagnosed with bird fancier''s lung. Pulmonary nocardiosis is likely to develop in patients with chronic pulmonary disorders, such as COPD, as well as in immunosuppressed hosts. To our knowledge, this is the first report of a case of bird fancier''s lung complicated by pulmonary nocardiosis.     

La pyomyosite : une complication infectieuse du lupus érythémateux systémique

Pyomyositis is a primary pyogenic muscular infection. It has been originally described in the tropics. Presenting signs and symptoms are not specific. It is frequently misdiagnosed in the early stages. We report the case of a 47-year-old woman with systemic lupus erythematosus treated with corticosteroids who presented a thigh pyomyositis evidenced by echography and MRI. Outcome was uneventful after antibiotics and surgical drainage. Pyomyositis is increasingly described among immunocompromised people, including lupus patients treated with corticosteroids.     

Pulmonary nocardiosis in a patient treated with corticosteroid therapy

We report a case of pulmonary nocardiosis in a 69-year-old man with rheumatoid arthritis who was receiving corticosteroid treatment. The patient received prednisolone for rheumatoid arthritis and antibiotics for his fever and pneumonia in another hospital, but the response to the therapy was poor. After admission to our hospital, he improved following treatment with imipenem/cilastatin for Nocardia asteroides. Pulmonary nocardiosis is difficult to diagnose and should be considered in the differential diagnosis, especially in an immunocompromised host.     

Severe thrombocytopenic purpura due to rubella infection in a patient with systemic lupus erythematosus

We report the case of a woman suffering from systemic lupus erythematosus who developed a severe thrombocytopenic purpura (platelet count < 1 x 10(9)/l) secondary to rubella infection. The search for antiplatelet antibodies revealed transient circulating anti-GPIIb-IIIa and anti-GPIb-IX platelet antibodies. After a few weeks, bound anti-GPIIb-IIIa antiplatelet antibodies were still detectable and they persisted several months after recovery, probably in relation to a mild autoimmune thrombocytopenia related to systemic lupus erythematosus. To our knowledge, this is the first case report of severe thrombocytopenic purpura due to rubella in an adult with systemic lupus erythematosus.