Disseminated Nocardiosis: A Rare Infectious Complication Following Non–Heart-Beating Donor Liver Transplantation

Caser Report: A Rare Case of Pulmonary Nocardiosis Caused by Nocardia pseudobrasiliensis After Liver Transplantation

Nocardia is a gram-positive bacillus with the microscopic appearance of branching hyphae and is mainly distributed in the soil. Nocardiosis more frequently occurs in immunosuppressed patients. Since nocardiosis has a high mortality rate, immediate diagnosis and treatment are needed. We report the first case of pulmonary nocardiosis caused by Nocardia pseudobrasiliensis after liver transplantation. A 58-year-old woman underwent living-donor transplantation for primary biliary cholangitis. Seven months after transplantation, she came to our hospital complaining of fever and anorexia. Computed tomography of the lungs showed a 45 mm large nodule affecting the upper lobe of the left lung. We started administering empiric antibiotics and tapering immunosuppression, but the patient's condition gradually worsened, and lung lesions increased. On the fifth day after hospitalization, bacteria developed from sputum cultures were identified as N. pseudobrasiliensis by matrix-assisted laser desorption ionization time of flight mass spectrometry. We started treatment with trimethoprim-sulfamethoxazole. The patient's clinical symptoms and laboratory data improved quickly. After one month of hospitalization, this patient was discharged. Then, the lung lesion almost vanished. Ten years after her transplant, the patient is alive with a well-functioning graft.

Case report: Nocardia farcinica pneumonia in early-stage post liver transplantation

Background

Liver transplantation is a well-established treatment for end-stage liver disease. The evolution of immunosuppressants has supported the recent advances in this field. However, this leads to immunosuppression and increases the risk for infections. Nocardia is an aerobic gram-positive bacillus, which can cause multi-systemic or multi-organ infections. Nocardia is an opportunistic pathogen that principally affects immunosuppressed patients.

Case presentation

Herein, we present a case of Nocardia farcinica pneumonia in a patient at early-stage post-liver transplantation. Following appropriate microbiological tests and imaging, the diagnosis was finally confirmed. A full recovery was achieved after optimal antibiotic therapy of sulfamethoxazole, minocycline, and amikacin.

Conclusions

Nocardia farcinica pneumonia is a rare and life-threatening disease, especially in patients after liver transplantation. Imaging and microbiological tests are helpful for the early diagnosis of the disease. Trimethoprim-sulfamethoxazole (TMP-SMX) as part of first-line therapy for nocardiosis is recommended.

Intra-Abdominal Nocardiosis-Case Report and Review of the Literature

Nocardiosis is primarily an opportunistic infection affecting immunosuppressed individuals, in whom it most commonly presents as pulmonary infection and sometimes cerebral abscesses. Isolated abdominal or retroperitoneal nocardiosis is rare. Here, we report the second case, to our knowledge, of isolated abdominal nocardiosis due to Nocardia paucivorans and provide a comprehensive review of intra-abdominal nocardiosis. The acquisition of abdominal nocardiosis is believed to occur via hematogenous spreading after pulmonary or percutaneous inoculation or possibly via direct abdominal inoculation. Cases of Nocardia peritonitis have been reported in patients on peritoneal dialysis. Accurate diagnosis of abdominal nocardiosis requires histological and/or microbiological examination of appropriate, radiologically or surgically obtained biopsy specimens. Malignancy may initially be suspected when the patient presents with an abdominal mass. Successful therapy usually includes either percutaneous or surgical abscess drainage plus prolonged combination antimicrobial therapy.

Diffuse primary cutaneous infection by Alternaria alternata in a liver transplant recipient with pulmonary nocardiosis: Importance of prompt identification for clinical resolution

Fungal infections are rare in the general population but are an emerging cause of disease in immunosuppressed patients, especially solid organ transplant recipients. Here, we report the case of a female Caucasian liver transplant patient who developed pulmonary nocardiosis two months after an episode of liver rejection. At the time of lung nocardiosis, she was being treated with tacrolimus and corticosteroids and suffered from diffuse papular skin lesions. She was initially suspected of having a cutaneous nocardial infection but culture examination revealed the presence of a dematiaceous fungus; Alternaria alternata. The prompt identification of the fungus and administration of oral Voriconazole resolved the skin infection with complete remission.

Nocardia farcinica Brain Abscess: Report of 3 Cases

BACKGROUND

Central nervous system nocardial infection is a rarely reported disease that usually affects patients with predisposing and debilitating conditions but also the immunocompetent population. The most common variant affecting the brain is Nocardia farcinica. Management of brain nocardiosis is troublesome and requires consideration of the severity of the underlying systemic disease, the difficulties in identifying the bacterium, and the frequent delay in initiating adequate therapy.

CASE DESCRIPTION

We present 3 cases of N. farcinica brain abscess (single, multiloculated, and multifocal) diagnosed in 3 patients with predisposing factors that could be successfully cured. The patients underwent craniotomy, evacuation of the purulent collection, and partial resection of the abscesses' walls. Confirmation of N. farcinica species was achieved using specific polymerase chain reaction sequencing of the 16S ribosome RNA gene. Antibiotic therapy was selected on susceptibility tests and was maintained for 10 months (1 case) and 12 months (2 cases).

CONCLUSIONS

Brain nocardiosis needs to be suspected primarily (though not exclusively) in immunocompromised patients presenting with neurologic deficit and harboring intracerebral lesions resembling brain tumors. Early identification of the specific species is paramount in order to initiate long-term antibiotic therapy, acknowledging the inherent resistance of N. farcinica to third-generation cefalosporins and its susceptibility to trimethoprim-sulphamethoxazole. According to the literature, surgical excision or aspiration of the brain abscess seems to provide good chances of eradication of the disease. In our experience, successful outcome was achieved with subtotal resection and prolonged and adequate antibiotic therapy.

"Primary" nocardial brain abscess in a renal transplant patient

Background

Intracranial abscesses are rare among transplant recipients, and Nocardia is responsible for less than 2 % of them. Nocardiosis, a chronic infection and is difficult to treat. Primary infection involves lungs and eventually disseminates. Primary nocardial abscesses are rare and we report a case from Sri Lanka.

Case presentation

A 38 year old Sri Lankan, who has received his 2nd ABO matched live donor transplantation, which was complicated with perinephric hematoma and massive transfusion syndrome. He presented with fever, worsening headache and papilledema. An urgent magnetic resonance image (MRI) showed an occipital abscess with midline shift. Craniotomy and drainage followed by 3 week course of imipenem and levofloxacin, which rendered him symptom free. After 12 months he has stayed recurrence free. Imaging and bacteriology of the respiratory tract failed to demonstrate Nocardia infection.

Conclusion

Isolated (Primary) nocardial brain abscess are rare, and have an excellent response to medical therapy. We achieved a good response from a relatively short course of antibiotics (not using sulfonamides, due to allergy), where long courses of antibiotic had been the norm.

Nocardia farcinica brain abscess: epidemiology, pathophysiology, and literature review

BACKGROUND

Infections caused by Nocardia farcinica are potentially lethal because of the organism's tendency to disseminate and resist antibiotics. Central nervous system involvement has been documented in 30% of infections caused N. farcinica.

METHODS

Case report and review of the literature.

RESULTS

A case of primary brain abscess caused by N. farcinica, identified by 16SrRNA sequencing, is presented, and 39 cases reported previously in the literature are reviewed. Our patient underwent a neuronavigation-guided right frontal craniotomy and was treated with trimethoprim/sulfamethoxazole and amoxicillin-clavulanic acid for 12 mo. He showed marginal improvement in his prior left hemiparesis at the last review 14 months later.

CONCLUSION

Cases of N. farcinica infections are being reported increasingly because of recent changes in taxonomy and diagnostic methodology. This change in epidemiology has implications for therapy because of the organism's pathogenicity and natural resistance to multiple antimicrobial agents, including third-generation cephalosporins. Any delay in starting appropriate antibiotic therapy can have adverse consequences.

Pleuro-Pulmonary Nocardiosis as Opportunistic Infection in a Patient with Chronic Hepatitis C under Combination Treatment with Pegylated Interferon, Ribavirin, and Boceprevir

Nocardiosis is an infrequent but serious pulmonary infection caused by Gram-positive aerobic actinomycetes. In this paper, we report on a 48-year-old patient with pleuropulmonary nocardiosis and cirrhosis due to chronic hepatitis C virus infection treated with triple antiviral treatment complicated by prolonged neutropenia.

Molecular identification and susceptibility pattern of clinical Nocardia species: Emergence of Nocardia crassostreae as an agent of invasive nocardiosis

BACKGROUND

Nocardia species are rare, opportunistic organisms that cause disease in both immunocompetent and immunocompromised individuals.

OBJECTIVE

To investigate the clinical presentations of various Nocardia infections based on the 16S ribosomal RNA gene of the isolate, as well as related risk factors and susceptibility patterns to antimicrobial agents.

METHODS

Thirteen patients with a diagnosis of nocardiosis were included in the present study. Seven Nocardia species were identified by 16S ribosomal RNA. Susceptibility testing was performed using six antimicrobial agents.

RESULTS

Five patients were immunocompromised, and eight were immunocompetent with predisposing factors including cystic fibrosis, tuberculosis and ophthalmic infections. Nocardia caused pulmonary infections in eight patients (61.5%), invasive systemic infections in three patients (23%) and local (ophthalmic) infections in two patients (15.4%). In the patients with pulmonary disease, nocardiosis was caused by six species (Nocardia cyriacigeorgica, Nocardia otitidiscaviarum, Nocardia farcinica, Nocardia carnea, Nocardia testacea and Nocardia asiatica). The seventh species identified in the present study was Nocardia crassostreae.

DISCUSSION

N crassostreae is a multidrug-resistant organism that was reported to be an emerging human pathogen causing invasive nocardiosis in a patient with non-Hodgkin's lymphoma. N farcinica was isolated from blood in a patient with breast cancer. None of the Nocardia isolates were resistant to linezolid. One N otitidiscaviarum isolate was a multidrug-resistant organism. All patients in the present study were treated with the appropriate antibiotics and their condition resolved without further sequelae.

CONCLUSIONS

The present study is the first report on N crassostreae as a human pathogen. The detection of multidrug-resistant species necessitate molecular identification and susceptibility testing, and should be performed for all Nocardia infections. Nocardiosis manifests various clinical features depending on the Nocardia species and underlying conditions.