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。     

Nocardiosis: a review.

Infections caused by Nocardia species are infrequent but challenging to clinicians. They cause a wide variety of diseases in both normal and immunocompromised patients. In recent years, the number of case reports has been increasing, and this can be attributed to the improvements in diagnostic capabilities and the higher clinical index of suspicion accompanying the increased prevalence of immunosuppressed patients. The treatment of nocardiosis also requires expertise. This report reviews the epidemiology, physiopathology, clinical manifestations, diagnosis and treatment of this aerobic bacterial disease.     

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.     

Abscess of adrenal gland caused by disseminated subacute Nocardia farcinica pneumonia. A case report and mini-review of the literature

Background  

Infections caused by Nocardia farcinica are uncommon and show a great variety of clinical manifestations in immunocompetent and immunocompromised patients. Because of its unspecific symptoms and tendency to disseminate it may mimic the clinical symptoms and radiologic findings of a tumour disease and the diagnosis of nocardiosis can easily be missed, because there are no characteristic symptoms.     

肺奴卡菌病最新诊治进展

肺奴卡菌病是奴卡菌引起的严重感染，近年来发病率有上升趋势。病死率较高，早期诊断及有效的治疗是改善预后的关键。本文就肺奴卡菌病的病原学及危险因素、临床表现、治疗进展予以综述。     

Actinomycosis and nocardiosis of the lung.

Actinomyces and Nocardia species are frequently overlooked pulmonary pathogens until their presence is histologically proved. These infections often are not considered in the differential diagnosis of lung disease because of the spectrum of their presentation, the similarity of their appearance to other granulomatous or neoplastic diseases, and coexistence of these infections with other pulmonary conditions. Pulmonary actinomycosis is characterized by pulmonary consolidation, frequently with cavitation and spread to contiguous tissues without regard for normal anatomic barriers. The appearance often is confused with that of bronchogenic carcinoma or other granulomatous infections, especially tuberculosis. Pulmonary nocardiosis most frequently develops in immunocompromised patients, and the incidence of this infection is increasing. The radiographic manifestations of nocardiosis are pleomorphic, but early recognition is essential to initiate appropriate therapy.     

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。     

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.     

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.     

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.     

Pulmonary nocardiosis: risk factors, clinical features, diagnosis and prognosis

PURPOSE OF REVIEW: Pulmonary infection by Nocardia spp. has been recognized for the past 100 years. The number of cases of pulmonary nocardiosis reported in the literature is increasing, and in some cases, a diagnosis is reached even postmortem. This increase is partly due to the growing number of patients with depressed cellular immunity. The diagnosis of this infection, which has a high rate of mortality, is usually delayed, due to a nonspecific clinical-radiological presentation and the difficulties in cultivating the bacteria. This review analyzes the current situation, in order to better understand this infection and enhance awareness and clinical suspicion that would lead to further specific microbiological studies and treatment. RECENT FINDINGS: The number of case series in the literature is increasing. This development may be due to an absolute increase in the number of immunocompromised patients, but also to improvements in laboratory techniques and molecular methods to detect nocardiosis. SUMMARY: It is important to keep in mind, and suspect the presence of pulmonary nocardiosis in the immunodepressed patients with clinical pulmonary infection. Furthermore, the laboratory should be notified when Nocardia is suspected in a clinical specimen so that measures can be taken to optimize recognition and recovery of the organism.     

An intrarenal abscess as presenting symptom of an infection with Nocardia farcinica in a patient after renal transplantation

Abstract: A 52-year-old man presented 8 months after transplantation with an intrarenal mass, which proved to be caused by an infection with Nocardia farcinica . Because of the potential fatal course of nocardiosis, transplantectomy was performed and long-term antibiotic treatment was instituted. Three-and-a-half years later, this patient underwent successful re-transplantation under co-trimoxazole prophylaxis. At present, more than 1 year after his second transplant has been performed, there are no signs of recurrence of Nocardia infection. To our knowledge, this is the first report of a patient with nocardiosis with an intrarenal abscess as presenting symptom.     

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.     

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.     

Pulmonary and psoas muscle nocardiosis in a patient with lupus nephritis: a case report and review of the literature

The incidence of nocardiosis is increasing with the expansion of immunosuppressive therapy and improvement of laboratory diagnostic methods. Nocardiosis could be fatal in the compromised host. Some Nocardia species are known to be multi-drug resistant. Thus, early recognition and identification of Nocardia species are important for patient treatment and outcome. Recently, we treated a patient with pulmonary and psoas muscle nocardiosis in a woman taking prednisolone for lupus nephritis; the isolated organism was Nocardia farcinica identified by polymerase chain reaction-restriction fragment length polymorphism testing.     

Prevalence of pulmonary nocardiosis in a tuberculosis hospital in Amritsar, Punjab

The prevalence of pulmonary nocardiosis in a tuberculosis and chest diseases hospital in Amritsar is reported. Of 1510 sputum samples cultured from 1016 patients, 67 sputa originating from 16 patients were found to be positive for the Nocardia asteroides species complex. Based upon repeated isolation of N. asteroides from the respiratory tract, its microscopic demonstration in KOH wet mounts or stained smears of sputum and clinical evaluation of patients, 14 cases of pulmonary nocardiosis were diagnosed. This gave a prevalence of 1.4% pulmonary nocardiosis in the tuberculosis hospital. The prevalence of the disease was found to be 1.3% in the males as against 1.5% in the females. Of the various clinical categories of patients investigated, pulmonary tuberculosis with sputum negative for acid-fast bacilli (AFB) yielded the highest prevalence of 3.2%, followed by 1.3%, 1.2%, 1.1% and 0.5% in pneumonia, chronic obstructive pulmonary disease (COPD), bronchiectasis and pulmonary tuberculosis with sputum positive for AFB, respectively. Type IV cutaneous hypersensitivity to nocardin was observed in 19 of 908 (2%) patients tested, whereas only a solitary positive reactor was found among 260 healthy volunteers. Twelve of 19 nocardin positive reactors (63%) had unequivocally proven pulmonary nocardiosis. The nocardin skin test gave false negative results in two nocardiosis patients. More comprehensive investigations are warranted in order to evaluate the nocardin skin test as an additional aid for the diagnosis of nocardiosis. Barring a solitary exception, the nocardiosis patients were successfully treated with sulphadiazine or trimethoprim-sulphamethoxazole (TMP-SMZ) combination. To the best of our knowledge, this is the largest series of pulmonary nocardiosis patients in a prospective study as yet reported from India. The observations underscore the point that nocardiosis warrants greater attention in the differential diagnosis of bronchopulmonary diseases.     

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.     

Nocardial infection as a complication of AIDS: report of six cases and review

Nocardiosis has been increasingly recognized as a serious infection among persons who otherwise appear healthy and among those with underlying chronic disease, neoplasms, and immunosuppression. Nocardial infection as a complication of AIDS has been reported infrequently. Six patients with AIDS and nocardiosis were identified at one New York City hospital from January 1980 through March 1989. Sites of nocardial infection in these patients included the lungs, brain, esophagus, and suprarenal and paraspinal masses. Mycobacteria, fungi, viruses, and bacteria other than Nocardia species caused concomitant infections in three patients. Three patients died of nocardiosis. Because of such factors as the growth properties of Nocardia species, the presence of other organisms, the common use of sulfonamides for treatment of patients with AIDS, and a low index of suspicion among physicians, the incidence of nocardiosis as a complication of AIDS may possibly be underreported. Early recognition of nocardial infection may lead to an improved prognosis.     

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.     

A case report of pulmonary nocardiosis successfully treated with a combination of sulfamethoxazole-trimethoprim (ST) and sparfloxacin]

We encountered a case of pulmonary nocardiosis that responded dramatically to combined ST and sparfloxacin treatment. A 55-year-old woman presented with fever, cough and yellowish sputum. She had been under treatment with oral prednisolone (15 mg per day) since July 1997 after a diagnosis of Evans syndrome. A high fever of 39.8 degrees C was noted on January 30, 1998. The patient was hospitalized for bloody sputum, bilateral hypochondriac pain and evidence of infiltrative opacities in the left lower lobe on chest radiography. Bacterial pneumonia was suspected, and she was treated with piperacillin, but her clinical symptoms did not improve. Sputum culture and serologic examination failed to lead to a definitive diagnosis. Nocardia farcinica was isolated by culturing tissue obtained by CT-guided transcutaneous pulmonary biopsy, leading to a diagnosis of pulmonary nocardiosis. The results of an MIC test for antimicrobial agents led to treatment with a combination of ST and sparfloxacin, and the clinical symptoms improved. These clinical observations suggest that, when pneumonia is diagnosed in patients who have been receiving oral steroids for a prolonged period, pulmonary nocardiosis should be considered in the differential diagnosis to enable selection of appropriate antimicrobial agents.