Nocardiosis in a teaching hospital in the Central Anatolia region of Turkey: treatment and outcome

A Rare Case of a Subcutaneous Abscess Caused by Nocardia cyriacigeorgica in an Immunocompetent Patient

Background

Nocardia cyriacigeorgica, which mainly causes pleuropulmonary and disseminated nocardiosis, has been proved to be one of the most common opportunistic pathogens in patients with immunodeficiency, but the cases that cause subcutaneous abscesses in normal individuals are rare and should be paid attention to.

Methods

The clinical data of a patient with cutaneous nocardiosis caused by Nocardia cyriacigeorgica in Zhejiang Provincial People's Hospital were retrospectively analyzed, including clinical manifestations, laboratory examinations, imaging examinations, medication and prognosis.

Results

Magnetic resonance imaging (MRI) showed that there was a 26 mm × 73 mm abscess under the skin. The pus in the abscess was green. Gram staining showed positive branched rod-shaped and undivided hyphae. After culture, small wrinkle dry white small colonies were observed, and it was identified as Nocardia cyriacigeorgica by MALDI-TOF MS.

Conclusion

We report the first case of a subcutaneous abscess caused by Nocardia cyriacigeorgica in an immunocompetent patient. Compared with cutaneous nocardiosis of which approximately 80% caused by Nocardia brasiliensis invasion, infection of Nocardia cyriacigeorgica is more insidious and latent, the features of the lesions are also unique. For this Nocardia cyriacigeorgica clinical isolate, the tested antibacterial drugs are generally sensitive and have an ideal prognosis after treatment with linezolid and timely debridement.

Nocardia farcinica cerebral abscess: A systematic review of treatment strategies

PURPOSE

Nocardia farcinica is an opportunistic pathogen causing mainly pneumonia in immunocompromised patients, complicated in almost one-third of the cases by a thick-walled multiloculated cerebral abscess which induces significant morbidity and mortality. This review aims to assess the optimal treatment strategy for N. farcinica cerebral abscess.

METHODS

Report of a case. Medline database was used to conduct a systematic review from inception to January 2020 looking for English-language articles focused on N. farcinica cerebral abscess, in accordance with the PRISMA guidelines.

RESULTS

The research yielded 54 articles for a total of 58 patients. N. farcinica cerebral abscess displayed three different neuroimaging patterns: a single multiloculated abscess in half of the cases, multiple cerebral abscesses, or a small paraventricular abscess with meningitis. The patients who benefited from surgical excision of the abscess showed a trend towards a lower risk of surgical revision (8% versus 31%, P=0.06) and a lower mortality rate (8% versus 23%, P=0.18) than patients who benefited from needle aspiration. Twenty-two percent of the patients benefited from microbiological documentation from another site with a mortality rate of 23%.

CONCLUSION

Urgent multimodal MRI is necessary in face with clinical suspicion of cerebral nocardiosis. In case of single or multiple small cerebral abscesses, microbiological documentation can be obtained with puncture of pseudotumoral visceral lesions. In case of large or symptomatic cerebral abscess, an aggressive surgical excision seems a reliable option and can be preferred over needle aspiration. Long-term antibiotic therapy with cotrimoxazole is necessary thereafter.

Isolated Nocardiosis, an Unrecognized Primary Immunodeficiency?

Nocardiosis is an infectious disease caused by the gram-positive bacterium Nocardia spp. Although it is commonly accepted that exposure to Nocardia is almost universal, only a small fraction of exposed individuals develop the disease, while the vast majority remain healthy. Nocardiosis has been described as an "opportunistic" disease of immunocompromised patients, suggesting that exposure to the pathogen is necessary, but a host predisposition is also required. Interestingly, increasing numbers of nocardiosis cases in individuals without any detected risk factors, i.e., without overt immunodeficiency, are being reported. Furthermore, a growing body of evidence have shown that selective susceptibility to a specific pathogen can be caused by a primary immunodeficiency (PID). This raises the question of whether an undiagnosed PID may cause nocardiosis affecting otherwise healthy individuals. This review summarizes the specific clinical and microbiological characteristics of patients with isolated nocardiosis published during the past 30 years. Furthermore, it gives an overview of the known human immune mechanisms to fend off Nocardia spp. obtained from the study of PIDs and patients under immunomodulatory therapies.

Cutaneous Nocardia arthritidis infection in an orthotopic liver transplant recipient

Nocardiosis is a potentially life-threatening infection that affects both immunocompetent and immunosuppressed hosts. We discuss a case of an elderly gentleman with history of orthotopic liver transplantation who presented with cellulitis of his left forearm. When he did not respond to the typical antibiotic coverage for bacterial cellulitis, skin biopsy was performed. N. arthritidis was identified as the pathogen, a relatively newly identified human pathogen first described to cause human disease in 2004.

Pulmonary infection caused by Nocardia cyriacigeorgica in a patient with allergic bronchopulmonary aspergillosis: A case report

RATIONALE

Nocardia species is known as conditional pathogenic bacteria. Among Nocardia species, pulmonary infection caused by Nocardia cyriacigeorgica associated with Aspergillus fumigatus complex lung disease is rarely reported.

PATIENT CONCERNS

A 55-year-old female with a history of productive cough with recurrent expectoration for 20 years presented with increasing cough for 12 months. The patient presented complaining of respiratory symptoms including increasing cough with yellow phlegm, poor appetite, and generalized fatigue for a week prior to admission.

DIAGNOSES

Nocardia cyriacigeorgica pneumonia was identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and 16S rRNA gene sequencing.

INTERVENTIONS

Combined treatments (trimethoprim-sulfamethoxazole and meropenem) were administered after identification of N cyriacigeorgica.

OUTCOMES

The respiratory symptoms of the patient had improved both clinically and radiologically after 4 weeks of antibacterial therapy.

LESSONS

Early precise diagnosis and prompt combined therapy are of vital importance in severe Nocardia pulmonary infection.

Nocardiosis from 1888 to 2017

The genus Nocardia is an aerobic bacterium, Gram-positive and catalase positive that is in Nocardiaceae family. This bacterium first described by Edmond Nocard in 1888 and is not in human commensal bacteria. To date, nocardiosis incidence is increasing due to increase population growth rate, increase in patients with immune disorder diseases and immunocompromised patients. We surveyed taxonomic position, isolation methods, phenotypic and molecular identification at the genus and species levels, antibiogram, treatment and epidemiology in the world from 1888 to 2017.

Central nervous system nocardiosis in Queensland: A report of 20 cases and review of the literature

Nocardia infection of the central nervous system (CNS) is an uncommon but clinically important disease, often occurring in immunocompromised individuals and carrying a high mortality rate. We present 20 cases of microbiologically proven CNS nocardiosis diagnosed in Queensland from 1997 to 2015 and review the literature from 1997 to 2016.Over 50% of cases occurred in immunocompromised individuals, with corticosteroid use posing a particularly significant risk factor. Nine (45%) patients were immunocompetent and 3 had no comorbidities at time of diagnosis. Nocardia farcinica was the most frequently isolated species (8/20) and resistance to trimethoprim-sulfamethoxazole (TMP-SMX) was found in 2 isolates. Overall, 35% of our patients died within 1 year, with the majority of deaths occurring in the first month following diagnosis. Interestingly, of the 7 deaths occurring at 1 year, 6 were attributed to N farcinica with the seventh isolate being unspeciated, suggesting the virulence of the N farcinica strain.

Nocardia arthritidis as a cause of disseminated nocardiosis in a patient with chronic lymphocytic leukemia

A case of disseminated nocardiosis caused by Nocardia arthritidis in an immunocompromised patient with a history of chronic lymphocytic leukemia and rheumatoid arthritis is presented. This report highlights the use for multilocus sequence typing (MLST) in addition to single gene molecular sequencing to identify rare Nocardia species.

[Nocardiosis: A retrospective case series of 19 patients]

INTRODUCTION

Nocardiosis are uncommon. The diagnosis may be difficult, with significant morbidity and mortality, often occurring on frail patients. Few data are available in France.

METHODS

A retrospective single center study was conducted from 2002 to 2014 and included all patients with at least one positive microbiological sample for Nocardia with a follow-up in our hospital.

RESULTS

Nineteen patients, including 15 men, were included with a mean age of 58 years (25-85). Seventeen had a risk factor (lung diseases [13], corticosteroids [12], solid neoplasia [2], HIV infection [2], diabetes mellitus [3], kidney transplant [2], lymphopenia [1]). Infections' locations were: pulmonary (12), brain (3), skin (2), lymph node (1) and corneal (1). The slow growth leads to a median of 35 days for a positive result (3-95). Nine species were identified. Fifteen patients (79%) received one or more lines of antibiotics including: cotrimoxazole (9), amoxicillin (7) cefotaxime/ceftriaxone (7) imipenem (3), or amikacin (3). The average duration of antibiotic therapy was 207 days. Four patients did not receive antibiotics due to a late result or a bacterial co-infection masking nocardiosis. Five patients died (26%) including 2 with cerebral nocardiosis. Six patients were cured, 4 suffered a relapse, 4 had an unknown evolution, and 1 was still treated.

CONCLUSION

Our study shows that nocardiosis is a disease difficult to treat. A better understanding of this type of infection is necessary.

Pulmonary infiltrate and painful nodular leg lesions in a patient with membranous glomerulonephritis

Nocardia otitidis-cavarium is rarely isolated as an infectious pathogen in the western world. We report on a 71-year-old Caucasian man with membranous glomerulonephritis who presented with several seemingly unrelated clinical symptoms that, after laborious diagnostics, turned out to be caused by disseminated infection with N. otitidis-cavarium. This case highlights the variable clinical presentations that can occur in nocardial infections and underscores the need to search for rare pathogens in patients taking immunosuppressive medication.

Nocardia mikamiia Novel Species Causing Disseminated Nocardiosis: A Literature Review of Disseminated Nocardiosis

Nocardiais an uncommon Gram-positive organism. It typically appears as delicate filamentous Gram-positive branching rods. In the United States it was estimated to be approximately 500 to 1000 new cases per year. The organism causes disease in immunocompromised individuals with pulmonary infection representing the most common site of infection.Nocardia mikamiihas been a recently isolated pathogen and not many cases of disseminated infection with this organism has been reported in the literature; we present a case of disseminated nocardiosis (mikamii sp.) in an immunocompromised patient. We also present a literature review on nocardiosis.

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.

Endobronchial nocardiosis in an 11-year-old child

Pulmonary nocardiosis is a rare infection and overwhelmingly limited to immunocompromised individuals. Endobronchial nocardiosis is even more rare. Nocardiosis is rarely seen in immunocompetent hosts mostly as cutaneous infection. Here we report an immunocompetent child with endobronchial nocardiosis presenting as nonresolving pneumonia and lung abscess. To our knowledge, this is the first case reported in the literature of endobronchial nocardiosis in a child.

Disseminated Nocardia farcinica: literature review and fatal outcome in an immunocompetent patient

BACKGROUND

Nocardia farcinica is a gram-positive, partially acid-fast, methenamine silver-positive aerobic actinomycete. Nocardia spp. are opportunistic pathogens, and N. farcinica is the least common species of clinical importance.

METHODS

Review of the recent literature and description of a immunocompetent patient with no known risk factors who contracted fatal N. farcinica sepsis.

RESULTS

Positive pre-mortem and post-mortem cultures from the lung and synovium correlated with acute bronchopneumonia and synovitis at autopsy. Colonies of filamentous bacteria, which were not apparent in conventional hematoxylin and eosin-stained sections, were observed with gram and methenamine silver stains, but acid-fast stains were negative. A literature review revealed that disseminated N. farcinica often is associated with an underlying malignant tumor or autoimmune disease (88% of patients). Chemotherapy or corticosteroid treatments are additional risk factors.

CONCLUSIONS

Trimethoprim-sulfamethoxazole typically is the first-line therapy for N. farcinica; treatment with amikacin and imipenem-cilastatin is used less often (7% of patients). Despite aggressive therapy, we observed that the death rate (39%) associated with N. farcinica in recent publications was eight percentage points higher than reported in a review from 2000.

A fatal case of pulmonary nocardiosis

Pulmonary nocardiosis is a serious, most often considered an opportunistic infection affecting the respiratory tract. Even though it is more common in immunocompromised hosts, it is not infrequently seen in immunocompetent patients as well. The aerosol route is the main portal of entry in to the body. Molecular techniques have revolutionised the identification of Nocardia species. However such tests are limited to referral laboratories. The radiographic appearances of Nocardia infection vary from a small nodule to bilateral infiltrates with cavitation. Traditionally sulphonamides have been considered the treatment of choice. However, resistance to sulphonamides is increasingly recognised. Carbapenems and linezolid have been found to be uniformly active against all the pathogenic species of Nocardia that affect human beings. The authors report a case of pulmonary nocardiosis in an immunocompetent patient, in whom the infection relentlessly progressed to florid sepsis despite prompt institution of right antibiotics. Florid sepsis relating to pulmonary nocardiosis is rare.

Pulmonary nocardiosis: a comparative analysis of Nocardia asteroides and non-asteroides species

Our study compares the risk factors, clinical presentations and outcomes of pulmonary infections caused by Nocardia asteroides and non-asteroides species. We performed a retrospective cohort study comparing pulmonary infections by both species in patients presenting to a tertiary care hospital in Karachi, Pakistan. Forty-one patients were identified with pulmonary nocardiosis, with 58.5% belonging to the N. asteroids complex. The most common clinical findings were fever and a cough for both groups, with lobar infiltrates being the most common finding on chest radiographs. In vitro testing showed a sensitivity of all species to trimethoprim-sulfamethoxazole (TMP-SMZ), aminoglycosides, ceftriaxone and imipenem. The majority of the patients were treated with TMP-SMZ in combination with other drugs. The results of our study suggest that there is no significant difference in the risk factors, presentations and outcomes of pulmonary infections by N. asteroides and non-asteroides species. Immunocompromised patients are more likely to have unfavorable outcomes.

Pulmonary nocardiosis: computed tomography features at diagnosis

PURPOSE

To review the computed tomography (CT) imaging features of pulmonary nocardiosis (PN) at the time of initial presentation.

MATERIALS AND METHODS

All patients from 1991 to 2008 with PN were identified (n=105). Patients without CT scan available at initial presentation were excluded (n=52). For the remaining 53 patients, standardized radiographic features were recorded. The patients were grouped by predisposing condition. Analysis includes descriptive summary statistics as well as associations among radiographic findings, associated findings, and host characteristics. Parametric and nonparametric statistical methods were used.

RESULTS

Median age of the patients was 52 years (range, 6 to 82 y). Some form of immunosuppression was present in 83% of the cases. Preexisting structural abnormalities of the lung were uncommon (bronchiectasis, 7; chronic obstructive pulmonary disease, 3). Twenty (38%) patients had interstitial opacities. Airspace disease was seen in 34 (64%) cases. Thirty (57%) cases revealed discrete nodules, 25 patients had 1 to 6 nodules (mean, 2), and 5 patients had fewer than 6 nodules, with the mean size of the largest nodule being 1.67 cm. Masses were seen in 11 patients (21%), 9 of whom had concomitant nodules. Cavitary lesions, including nodules, masses, or airspace disease, occurred in 40% of the cohort. Mediastinal lymphadenopathy was present in 8 (15%) patients. Fifteen patients (28%) had pleural effusions; the effusions were unilateral in 10 patients. Analysis of radiographic associations with patient groups found discrete nodules to be more often associated with immunosuppression compared with the nonimmunosuppressed group (66% vs. 11%; P=0.0067).

CONCLUSION

The CT presentation of PN is heterogeneous. Airspace disease appeared most frequently (in 64% of the cases), and nodules were present in 57% of the cases. Nocardiosis should be considered in the differential diagnosis of immunosuppressed patients with new nodules or masses.

Respiratory disorders in the Middle East: a review

The spectrum of pulmonary pathology in the Middle East is as versatile as its civilizations and cultures. In this review, we outline the key challenges confronting pulmonologists in the Middle East. We shed light on the diverse conditions commonly encountered in the region, from the centuries-old illnesses of tuberculosis, to contemporary problems such as lung complications from chemical warfare. We specifically highlighted unique aspects related to respiratory illnesses in the Middle East, for example, climate factors in the desert region, cultural habits, for example, water-pipe smoking and disorders unique to the region, such as Behçet's disease. Pulmonologists are also faced with the consequences of modernization, including large immigrant population and associated social and health issues, rising incidence of obesity and sleep apnoea, and drug-resistant tuberculosis. Tackling these health issues will require an integrated approach involving public health, primary care as well as specialist pulmonology input, taking into consideration the unique cultural and environmental factors to ensure effective management and compliance to medical care.

Nocardiosis: updated clinical review and experience at a tertiary center

Nocardiosis is a rare opportunistic disease that affects mainly patients with deficient cell-mediated immunity, such as those with acquired immunodeficiency syndrome (AIDS) or transplant recipients. Pulmonary disease is the most common presentation in immunosuppressed patients and approximately one-third have a disseminated disease. Primary cutaneous nocardiosis is more frequently observed in immunocompetent patients with direct inoculation of the organism through professional exposure. The diagnosis can be challenging, as signs and symptoms are not specific and a high index of clinical of suspicion is necessary. Although gram stain, modified acid-fast stain, and cultures remain as the standard diagnostic tools, novel molecular techniques have changed the taxonomy of these organisms and, in some instances, have facilitated their identification. The disease has a marked tendency to recur and a high morbidity and mortality rate in immunosuppressed patients. Treatment is usually prolonged and an associated antibiotic treatment is preferred for severe disease. Although sulfonamides in combination with other antibiotics are still the treatment of choice, other associations such as imipenem plus amikacin are preferred in some centers. Linezolid is a useful alternative therapeutic agent due to its oral availability and activity against most of the isolates studied. Twenty-eight cases of nocardiosis were diagnosed at our center between January 1989 and April 2009. We report the epidemiologic characteristics of Nocardia spp. observed in our institution and discuss the risk factors, clinical features, diagnosis, and management of the disease.

Cerebellar nocardiosis and myopathy from long-term corticosteroids for idiopathic thrombocytopenia

Infection of the central nervous system with Nocardia sp. usually manifests as supratentorial abscesses. Supratentorial and cerebellar abscesses from infection with Nocardia sp. following immunosuppression with long-term corticosteroids for idiopathic thrombocytopenia (ITP) have not been reported. An 83 years-old, human immunodeficiency virus (HIV)-negative, polymorbid male with ITP for which he required corticosteroids since age 53 years developed tiredness, dyspnoea, hemoptysis, abdominal pain, and progressive gait disturbance. Imaging studies of the lung revealed an enhancing tumour in the right upper lobe with central and peripheral necrosis, multiple irregularly contoured hyperdensities over both lungs, and right-sided pleural effusions. Sputum culture grew Nocardia sp. Neurological diagnostic work-up revealed dysarthria, dysphagia, ptosis, hypoacusis, tremor, dysdiadochokinesia, proximal weakness of the lower limbs, diffuse wasting, and stocking-type sensory disturbances. The neurological deficits were attributed to an abscess in the upper cerebellar vermis, myopathy from corticosteroids, and polyneuropathy. Meropenem for 37 days and trimethoprime-sulfamethoxazole for 3 months resulted in a reduction of the pulmonary, but not the cerebral lesions. Therefore, sultamicillin was begun, but without success. Long-term therapy with corticosteroids for ITP may induce not only steroid myopathy but also immune-incompetence with the development of pulmonary and cerebral nocardiosis. Cerebral nocardiosis may not sufficiently respond to long-term antibiotic therapy why switching to alternative antibiotics or surgery may be necessary.

Nocardia cyriacigeorgica, an emerging pathogen in the United States

Nocardia cyriacigeorgica is recognized as an emerging pathogen in many parts of the world. We present the first case description of invasive N. cyriacigeorgica pulmonary infection in the United States identified to the species level by 16S rRNA and hsp65 sequence analysis. A subsequent retrospective molecular screening of recent Nocardia clinical isolates at our New York City medical center yielded an additional six N. cyriacigeorgica isolates. Because routine laboratory algorithms for the phenotypic identification of Nocardia species are limited in practice, the true prevalence of N. cyriacigeorgica infections may be greater than currently appreciated. Indeed, we present evidence confirming that N. cyriacigeorgica is coincident with the unofficial species designation Nocardia asteroides complex antimicrobial susceptibility pattern type VI and distinct from the N. asteroides sensu stricto strain ATCC 19247(T). As nocardial species identity can predict antimicrobial susceptibility and guide clinical management, we offer simplified phenotypic and molecular protocols to assist the identification of N. cyriacigeorgica.

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.

Determination of antimicrobial susceptibility patterns of Nocardia spp. from clinical specimens by Etest

Susceptibilities to 11 antimicrobial agents were determined by Etest for 93 Nocardia isolates from clinical specimens and 15 type strains belonging to different Nocardia spp. All isolates were susceptible to trimethoprim-sulphamethoxazole, amikacin and linezolid, but susceptibilities of the various Nocardia spp. to beta-lactams, aminoglycosides, ciprofloxacin and clarithromycin varied markedly. Overall, there was a good correlation between the drug resistance patterns and the species identification established by conventional phenotypic tests and 16S rDNA sequencing. Among the different species encountered, Nocardia farcinica and Nocardia brasiliensis displayed the most multiresistant profiles, with resistance to imipenem occurring mainly among isolates of N. brasiliensis and Nocardia abscessus. The species variability in susceptibility profiles and the numerous recent taxonomic changes means that in-vitro susceptibility tests may be a complementary tool for the identification of Nocardia isolates from human clinical specimens. Further studies on a larger number of species from more diverse geographical sources, including species that are found less commonly among clinical isolates, are required to validate and extend the results.

Actinomycoses and Nocardia pulmonary infections

PURPOSE OF REVIEW

Actinomycosis and nocardiosis are uncommon pulmonary infections with distinct morphologic features. Both infections most commonly present as chronic, debilitating illnesses with radiographic manifestations simulating lung cancer or tuberculosis. Immunocompromised hosts, however, may develop fulminant disease resembling acute bacterial pneumonia. The purpose of this review is primarily to review the clinical features, diagnosis, and management of actinomycosis and nocardiosis.

RECENT FINDINGS

Treatment of actinomycosis is usually simple, requiring long-term, high-dose intravenous penicillin. Short-course chemotherapy, however, has recently been reported to be successful. Pulmonary nocardiosis is an important cause of opportunistic infection in immunosuppressed patients, and the incidence of this infection is increasing. The sulfonamides are still first-line agents in the management of nocardiosis, but resistance is most common among N. farcinica and N. otitidiscaviarum isolates. Carbapenems should be used as an alternative treatment for severely ill patients. Broth microdilution, E-test (AB Biodisk, Solna, Sweden) and BACTEC (Becton Dickinson, Sparks, Maryland, USA) radiometric method may be more useful in the routine clinical laboratory for antimicrobial testing of aerobic actinomycetes.

SUMMARY

The practical distinction between the two diseases is in the matter of therapy. Diagnosis depends on a high degree of suspicion so as to alert the microbiology and pathology laboratories to employ special methods to identify the organisms. Early recognition and prompt treatment usually results in complete cure.