Clinicopathologic characteristics of Nocardia brain abscesses: Necrotic and non-necrotic foci of various stages

Nocardia brain abscesses are rare bacterial infections associated with a high mortality rate, and their preoperative diagnosis can be difficult for various reasons including a nonspecific clinical presentation. While late-stage nocardial brain abscesses may be radiologically characteristic, early-stage lesions are nonspecific and indistinguishable from another inflammatory/infectious process and other mimics. Despite the paucity of previous histopathological descriptions, histopathological examination is critical for the identification of the pathogen, lesion stage(s), and possible coexisting pathology. In this study, we examined the clinical, radiological and histopathological features of 10 patients with brain nocardiosis. Microscopic findings were analysed in correlation with clinical and radiological features in 9 patients, which revealed that brain nocardiosis was characterized by numerous necrotic and non-necrotic foci of various stages (I-IV) along with Nocardia identification, as well as the leptomeningeal involvement in most cases, and co-infection of brain nocardiosis with toxoplasmosis in 2 patients. The imaging features were characteristic with a multilobulated/bilobed ring-enhancing appearance in 8 patients including 2 patients with multiple lobulated and non-lobulated lesions and 1 patient showing the progression from a non-lobulated to lobulated lesion. These findings suggest that nocardial brain abscesses particularly at late-stages share common characteristics. Nevertheless, given the complex pathologic features, including possible co-infection by other pathogens, nocardial brain abscesses remain a therapeutic challenge.

Pulmonary nocardiosis following nodular bronchiectatic Mycobacterium avium complex pulmonary disease in an immunocompetent patient

A woman in her 70s with a history of nodular bronchiectatic Mycobacterium avium complex pulmonary disease (MAC-PD) presented with an exacerbated productive cough and worsening findings on chest imaging. Although repeated sputum culture tests were negative for acid-fast bacilli and only revealed normal respiratory flora, a bronchoscopy identified Nocardia sp. Consequently, she was diagnosed with pulmonary nocardiosis and was successfully treated with levofloxacin. It is known that pulmonary nocardiosis can manifest in immunocompetent individuals with bronchiectasis. For cases of refractory nodular bronchiectatic MAC-PD, it is vital to consider bronchoscopy to identify potential co-infections, such as Nocardia.

Nocardia Infection With Adrenal Gland Abscess Mimicking Metastatic Lung Cancer on FDG PET/CT

ABSTRACT

We present FDG PET/CT findings of a human immunodeficiency virus-positive patient suspicious for lung cancer with a solitary metastasis to the adrenal gland. Wedge resection of the pulmonary nodules revealed Nocardia infection and a repeat FDG PET/CT imaging after the antibiotic treatment demonstrated complete metabolic response of the adrenal lesion and pulmonary nodules. It should be kept in mind that nocardiosis may present with FDG-avid lesions masquerading as malignancies in immunocompromised patients.

The Findings of Pulmonary Nocardiosis on Chest High Resolution Computed Tomography

Objectives

Pulmonary nocardiosis is a rare opportunistic infection that is often encountered in immunocompromised patients, in particular those with the HIV infection and in solid organ transplant recipients. As the number of immunocompromised patients increase, the number of patients with pulmonary nocardiosis is also expected to increase. This study aimed to analyse both the chest high resolution computed tomography (HRCT) findings of patients with confirmed pulmonary nocardiosis and review the imaging features of pulmonary nocardiosis in the literature.

Methods

This retrospective study was conducted at The Royal Hospital, Muscat, Oman, to identify patients with a diagnosis of pulmonary nocardiosis between January 2006 and January 2019. Accordingly, nine patients with pulmonary nocardiosis were identified, but three patients were excluded as no chest HRCT images were available. Patient clinical presentation was recorded and chest HRCT images were retrospectively reviewed.

Results

A total of six patients were enrolled in this study. All were male and with a mean age of 41 ± 11 years. Three patients were immunocompromised, two of whom had undergone a renal transplant. The main HRCT findings were cavitary nodules/masses, non-cavitary nodules/masses, septal thickening, centrilobular nodules, ground glass opacities, consolidation, pleural effusion, pleural thickening, enlarged lymph nodes and necrotic lymph nodes.

Conclusion

Pulmonary nocardiosis shows various findings in a chest CT, the most common of which are pulmonary nodules and masses. Awareness of these findings can help radiologists with a diagnosis in the appropriate clinical settings.

Disseminated nocardiosis caused by Nocardia farcinica in a patient with colon cancer: A case report and literature review

RATIONALE

Nocardiosis is an uncommon and potentially life-threatening infection that usually affects immunocompromised hosts. No clinical guidelines have been established for managing this rare disease, and the optimal treatment modality remains unclear. Nocardia farcinica, a relatively infrequent pathogen of nocardiosis, causes a clinically aggressive infection. In addition to our patient data, our search of the literature for patients who presented with empyema caused by N. farcinica will provide fundamental information for optimal treatment modalities.

PATIENT CONCERNS

A 64-year-old man was diagnosed with empyema, 4 days following surgery for sigmoid colon cancer. Brain lesions were evaluated only after N. farcinica was isolated and identified as the causative pathogen through repeated culture tests.

DIAGNOSES

N. farcinica was isolated from the pleural effusion and confirmed as the pathogen through 16S rRNA sequencing.

INTERVENTIONS

The patient was successfully treated with tube thoracotomy, neurosurgical evacuation, and a combination of trimethoprim/sulfamethoxazole plus imipenem. Long-term antibiotic therapy was required to prevent recurrence.

OUTCOMES

Pyothorax showed a good clinical response to antimicrobial therapy and drainage of pleural effusion, whereas brain abscess did not respond to medical therapy and required surgery. The patient eventually recovered and continued chemotherapy as treatment for sigmoid colon cancer.

LESSONS

Although extremely rare, this report demonstrates the importance of considering Nocardia infection as the differential diagnosis in immunocompromised patients who present with empyema. In particular, because of the N. farcinica infection's tendency to spread and the resistance of the organism to antibiotics, aggressive evaluation of metastatic lesions and standardized support from microbiological laboratories are important. Surgery may be required in some patients with brain abscesses to improve the chance of survival.

Pulmonary Nocardia ignorata Infection in Gardener, Iran, 2017

Nocardia ignorata, which was first described in 2001, is a rare human pathogen. We report a case of pulmonary nocardiosis caused by this bacterium in a 55-year-old man from Iran. The patient, a gardener, had frequent exposure to soil and may have acquired the infection from that source.

Nocardia beijingensis lung mass in an immunocompetent adult

A 47-year-old man was referred for ongoing workup of an enlarging lung mass. Extensive workup of the mass had been unrevealing for several months until cultures grew Nocardia beijingensis He was successfully treated with trimethoprim/sulfamethoxazole and then doxycycline with near-complete resolution of the mass on follow-up. This case presents a rare species of N. beijingensis It highlights the importance of considering nocardiosis in immunocompetent adults and the challenge in initiating targeted treatment due to delayed culture results.

Imaging Findings of Pulmonary Nocardiosis Mimicking Bronchiectasis

Nocardia species usually cause opportunistic infections, and the frequency of these infections is increasing owing to the growing population of immunocompromised hosts. However, Nocardia may sometimes causes an infectious disease in immunocompetent hosts. Herein, we report two cases of pulmonary nocardiasis in immunocompetent individuals, whose chest computed tomography (CT) findings mimicked bronchiectasis. Samples of bronchalveolar lavage (BAL) fluid obtained by bronchoscopy showed filamentous, branching, gram-positive rods, acid-fast filamentous branching rods, and a colony of suspected Nocardia was cultured. Based on 16sRNA and hsp65 gene sequence analysis, case 1 was identified as N. cyriacigeorgica, but case 2 was not matched. The patients responded well to treatment with the combination of sulfamethoxazole and linezolid.

Nocardial spinal epidural abscess with lumbar disc herniation: A case report and review of literature

RATIONALE

Nocardial spinal epidural abscess is rare. The diagnosis is often difficult to make and, if delayed, poses a high risk of long-term disability. Nocardial spinal epidural abscess with severe lumbar disc herniation has not previously been reported.

PATIENT CONCERNS

A 50-year-old man presented with progressive lumbago and leg pain for 6 weeks after receiving acupuncture therapy, and then the patient suddenly occurred urine retention after walking.

DIAGNOSES

Clinical examination revealed sign of cauda equina syndrome. Magnetic resonance imaging (MRI) revealed a Lumbar(L)4 to L5 disc herniation, L3 to Sacrum(S)1 epidural abscess, and L2 to S1 paravertebral abscess. The causative organism was Nocardia farcinica.

INTERVENTIONS

An urgent paravertebral abscess debridement and right L4 to L5 laminectomy were performed. Simultaneously, the disc tissue protruding into the spinal canal was removed, as well as irrigation and drainage. And antimicrobial treatment was continued for 12 months.

OUTCOMES

Fortunately, the patient was able to walk with a cane and urinate autonomously without a catheter, although this remained difficult 7 days after surgery. After 1 year of treatment, the patient has recovered completely and returned to work.

LESSONS

Nocardial spinal epidural abscess with severe lumbar disc herniation is extremely rare. Pain from spinal degenerative diseases often masks the early symptoms of spinal infection. It's worth noting that invasive treatment of spine is a way of causing spinal nocardial infection.

Disseminated nocardiosis complicated by multiple brain abscesses and pleural empyema in a young diabetic man: a case report

Nocardiosis is a life-threatening infection usually affecting immunocompromised patients. Very rarely it presented with intracranial abscesses and pleuro-parenchymal infections. We herein report a very challenging case of a 34-year-old obese and diabetic man affected by disseminated nocardiosis with multiple brain abscesses and pleural empyema. Despite rare, this entity should be taken into account by the pathologists and urgently communicated to clinicians in order to promptly start an effective treatment.

[Lung cavities caused by Nocardia cyriacigeorgica in an immunosuppressed boy]

The identification of nodules and/or cavitations in the chest X-ray of a chronically or acute ill patient will rise the suspicion of tuberculosis. However, it is important to be aware of pulmonary nocardiosis as a rare but important differential diagnosis, especially in case of no hilar adenitis. In this case report, we describe a six-year-old boy receiving prednisolone due to nephrotic syndrome, who developed pneumothorax because of pulmonal nocardiosis. The prognosis is good in case of early diagnosis and antibiotic treatment.

Clinical and radiographic characteristics of pulmonary nocardiosis: clues to earlier diagnosis

Background and objectives

Pulmonary nocardiosis (PN) is a rare but life-threatening disease that is caused by Nocardia spp. The aim of this study was to characterize the common risk factors, clinical features, imaging findings, treatment and outcomes of PN, which are useful for an early diagnosis and patient management.

Methods

From January 2009 to June 2013, a retrospective study was performed on all PN cases that were diagnosed at our hospital.

Results

The study included 17 patients who were diagnosed with PN. Of these patients, 4 developed concomitant disseminated disease. A male predominance was observed among the patients with PN (76.47%). The most common risk factors were corticosteroid therapy (64.71%), diabetes mellitus (29.41) and chronic lung disease (23.53%). Cough and fever were the most common symptoms (94% and 71%, respectively). One or more nodules or masses (82.35%) and consolidations (58.82%) were the most frequent radiologic abnormalities, and cavitation mostly occurred within two weeks. The median time to diagnosis was 25 days. Overall, the mortality rate was 18.75% for PN, and death was most frequent among patients who received immunosuppressive drugs. For the patients with central nervous system involvement, the mortality rate was 50%.

Conclusion

PN remains a rare opportunistic infection that mainly affects immunocompromised patients. A high clinical index of suspicion is necessary for an early diagnosis and timely treatment in immunocompromised patients who present with new nodules or masses evolving into cavitation in a short amount of time.

[Pulmonary nocardiosis associated with the treatment of severe liver injury]

Nocardia infection is a fatal complication in compromised hosts and is often associated with a poor prognosis. Here we report the case of a 42-year-old man with acute liver injury treated with steroids who developed pulmonary nocardiosis. Pulmonary computed tomography was performed followed by bronchoscopy, which confirmed the diagnosis of pulmonary nocardiosis. This facilitated expedient and successful treatment of the pulmonary infection. Computed tomography is a useful tool for screening respiratory tract infection in immunocompromised patients, such as those with acute liver injury.

Pulmonary nocardiosis associated with cerebral abscess successfully treated by co-trimoxazole: a case report

Nocardiosis is an acute or chronic infectious disease caused by the soil-borne filamentous bacteria belonging to the genus Nocardia. The organisms opportunistically infect both immunocompromised and immunocompetent individuals. The lungs are the primary site of infection and brain abscess is, by far, the most common complication following nocardial metastasis from pulmonary lesions. Although surgical intervention must always be considered in the treatment of nocardial brain abscess, it can obviously be cured by antibiotic therapy alone. This report describes a case infected by Nocardia cyriacigeorgica. Identification of the infectious agent was achieved by conventional and semi-nested PCR techniques. A 55-year-old woman with fever was referred to the infect disclinic of Imam Khomeini hospital in Tehran and was hospitalized after clinical assessment. She was a kidney transplant recipient for 4 years and was taking immunosuppressive treatment including azathioprine and methylprednisolone. Follow-up of the patient by CT scan revealed pulmonary infection and cerebral lesions. Specimens of the brain lesions contained filamentous bacteria. The patient received a combination of co-trimoxazole and ceftriaxone and brain abscesses as well as lung inflammation disappeared gradually during the course of antibiotic therapy within 3 months. The patient was discharged from the hospital after 2 months of therapy.

[Thoracic nocardiosis - a clinical report]

Nocardia genus microorganisms are ubiquitous, Gram positive aerobic bacterias, responsible for disease mainly in immunocompromised hosts, with cellular immune response commitment. Inhalation is the main form of transmition and pulmonary disease is the most frequent presentation. Dissemination may occur by contiguity and also via hematogenous. The clinical and imaging presentation is not specific, and diagnosis is obtained after identification of Nocardia bacteria in biological samples. Since there are no reliable studies that indicate the best therapeutic option, treatment should be individualized and based on antimicrobial susceptibility testing. Surgical drainage should also be considered in all patients. The authors present a clinical case of a patient with thoracic nocardiosis, and make a short literature review on the theme.

[Pulmonary nocardiosis and sarcoidosis]

Infectious complications are rarely observed in the course of sarcoidosis. Only small series or cases reports of infection are described in sarcoidosis. Corticosteroids-induced immune suppression, pulmonary fibrosis and T-CD4 lymphopenia, are often present. Pulmonary nocardiosis is an important cause of opportunistic infection in immunosuppressed patients, and the incidence of this infection is increasing. Pulmonary nocardiosis manifests as an acute, subacute or chronic infection with a marked tendency towards remissions and exacerbations. We report a case of pulmonary nocardiosis in a patient with sarcoidosis followed for pulmonary fibrosis receiving corticosteroids. During the investigation of pyrexia and dyspnea, evidence of Nocardia spp. infection was found in the bronchial secretions. Six months of trimethoprim/sulfamethoxazole therapy ensured further resolution of this pleuropulmonary infection. Pulmonary nocardiosis is exceptional in sarcoidosis and mainly occur, in patients receiving corticosteroids, and with CD4+ T-lymphocytopenia. Sarcoidosis by itself does not appear to be a risk factor of opportunistic infection.

Severe pneumonia caused by Nocardia farcinica and complicated by Staphylococcus haemoliticus superinfection

It is reported the case of a subject 54 years old, painter, drinker and smoker who after an episode of cooling and the occurrence of widespread pain was taking its own initiative, cortisone and analgesics from approximately 30 days. The symptoms worsened and the patient was hospitalized. Chest X-ray and CT scan showed an extensive opacity in the left upper lobe with excavations in the context and also some nodular opacities excavated in the contralateral lung. In the first eight days after admission, the clinical picture despite empirical antibiotic therapy worsened towards adult respiratory distress syndrome (ARDS). On the ninth day after the admission, strains of Nocardia farcinica and Staphylococcus haemoliticus were isolated from the sputum. The targeted therapy (trimethoprim-sulfamethoxazole, amikacin, etc.) induced a rapid improvement of the clinical picture that was resolved in 6 months. Pneumonia caused by Nocardia farcinica is rare but its identification is necessary to set an appropriate therapy.

Empyema thoracis due to nocardiosis and Mycobacterium tuberculosis mixed infections in an AIDS patient

A 26-year-old Thai man presented with progressive dyspnea for four months and right pleuritic chest pain two days before admission. The chest radiograph showed massive right pleural effusion. Thoracentesis was done, and the culture grew Nocardia spp as well as positive strain for acid-fast bacilli. An anti-HIV test was reactive, with a CD4 count of 12 cells/mm3. The patient was treated with inter-costal tube drainage (ICD) inserted for empyema thoracis. The antimicrobials used trimethoprim-sulfamethoxazole and anti-TB drugs CAT-1 orally. One month later, anti-retroviral therapy with HAART was initiated. At follow-up after 6 months, he was healthy appearing, with a nearly normal chest radiograph.

An HIV-infected patient with Nocardia asteroides bilateral pneumonia

Pneumonia remains a concern for persons with long-standing HIV infection. We present a case of a 43-year-old HIV-infected woman with bilateral pneumonia whose presentation suggested the cause was a bacterial pathogen. A chest of radiograph and CT scan of the chest revealed infiltrates and adenopathies, but this did not help in the differential diagnosis. A Gram stain of a sputum specimen revealed gram-positive filamentous rods, and infection with Nocardia asteroides was diagnosed. The patient was started on a regimen of ceftriaxone and trimethoprim/sulfamethoxazole and experienced significant improvement within a few days.

[Pulmonary nodules in a patient on long-term steroid treatment]

We report on a patient who was chronically treated with steroids. She simultaneously developed pulmonary nocardiosis as well as a soft tissue infection and osteomyelitis by mycobacterium abscessus. Both infections are rare, but more frequently occur in immunocompromised hosts. The patient was healed after 12 month of adequate antibiotic treatment.

[Pulmonary nocardiosis with a large solitary cavitary nodule caused by Nocardia cyriacigeorgica in a patient receiving corticosteroid therapy]

Nocardiosis is a rare disease generally caused by members of Nocardia asteroides complex, particularly in immunosupressed patients. Nocardia cyriacigeorgica is a newly described member of this complex. In this article, a case of pulmonary nocardiosis with a large solitary cavitary nodule caused by N. cyriacigeorgica, in a patient receiving corticosteroid therapy was presented. A 29 years old male patient receiving prednisolone for 5 months was admitted to our hospital with fever, cough, right thoracic pain and night sweats. Computed tomography scan of chest demonstrated a large solitary cavitary nodule in the right lower lobe. Gram stained smear of the sputum revealed gram-positive, beaded, branched filamentous bacilli. On the third day of his admission, a catalase positive, oxidase negative and immotile bacilli, compatible with Nocardia spp., were isolated from the sputum sample taken at the day of admission. The isolated bacterium was identified as N. cyriacigeorgica by reference laboratory (Lyon, France). Oral trimethoprim (320 mg/day) and sulfamethoxazole (1600 mg/day) therapy given for three months, resulted in complete cure of the lesion without any sequela. This was the fourth case of pulmonary nocardiosis caused by N. cyriacigeorgica reported from Turkey. Microbiological examination of sputum is the most important tool for the diagnosis. Treatment with appropriate antibiotics may achieve complete cure even in large cavitary lesions. In conclusion, pulmonary nocardiosis should be considered in differential diagnosis of solitary cavitary nodules, especially in immunocompromised patients.

Pulmonary nocardiosis presenting as fungal ball--a rare entity

Pulmonary intracavitary infection caused by Nocardia is an opportunistic infection and is believed to be a rare entity. We describe a case report of a patient with culture positive Nocardia asteroides who presented with complaints of cough and expectoration with episodes of haemoptysis and dyspnoea. The diagnosis of nocardiosis was made by microscopic examination of the surgically resected portion of the lung and confirmed on culture.

Epithelioid haemangioendothelioma of the lung presenting with pulmonary nocardiosis

Epithelioid haemangioendothelioma of the lung is a rare tumour, originally described as intravascular bronchioalveolar tumour. The typical clinical findings are those of bilateral multiple pulmonary nodules in young or middle aged Caucasian women. Pulmonary nocardiosis is an unusual disease affecting patients with immunodeficiency or chronic obstructive lung disease. The first case of pulmonary epithelioid haemangioendothelioma (PEH) associated with pulmonary nocardiosis, in a 36-year-old woman presenting with progressive dyspnoea and fever, is described. The neoplasm was diagnosed by thoracoscopic lung biopsy and the histological diagnosis was confirmed by immunohistochemistry and electron microscopy. Pulmonary nocardiosis was confirmed by lung tissue culture. Following treatment with antibiotics, the patient's respiratory symptoms subsided. Two years after diagnosis she was asymptomatic and chest CT scans showed stable neoplastic disease.

Nocardia nova Aortitis After Coronary Artery Bypass Surgery

Cardiac nocardiosis is a rare disease that is nearly always associated with cardiac operation. We report the case of a patient with a 10-month history of intermittent fevers after coronary artery bypass operation who presented with progressive shortness of breath and fever. He was found to have a large aortic aneurysm secondary to Nocardia nova infection likely transmitted during his original bypass operation. This is the first reported case of Nocardia aortitis after coronary bypass operation and serves to alert physicians of this rare but serious postoperative complication.

Nokardiose als Differenzialdiagnose eines PET-positiven Lungenherdes

We describe the case of a 76-year-old immunocompetent man suspected to have lung cancer in the right upper lobe on the basis of radiographic and clinical findings. The tumour could not be confirmed histologically by transbronchial biopsy. In the fluorodeoxyglucose positron emission tomography (FDG-PET) we found a significantly elevated standard uptake value (SUV) of 13.4. The patient underwent thoracotomy with excision of the tumour, the histological diagnosis was chronic pneumonia. Tissue culture revealed Nocardia spp. Using 16-rDNA-gene sequence analysis the species was identified as Nocardia abscessus. The patient was treated with trimethoprim-sulfamethoxazol regarding the susceptibility profile and improved remarkably both clinically and radiographically.

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.

[Pulmonary nocardiosis due to reagudizations in a COPD patient]

Pulmonary infection due to Nocardia sp. is an infrequent disease that affects principally to immunodefficient patients although it can be also seen in patients with normal immunity. Diagnosis is based in isolation of micro-organism in respiratory samples while clinical presentation and radiology are non specific. Treatment is made with trimethropim-sulfametoxazole (TMP/SMX), though resistance has developed in some patients. The recommended length of treatment is 6 weeks to 12 months depending on the immunitaly status. We present the case of a male patient of 81 years old affected with COPD and treated with glucocorticoids in a chronic basis, who was admitted because relapsing fever episodes during 3 months before, weight loss and new hard pulmonary infiltrates with Nocardia sp. cultured sputum, and evolution to clinical, radiological and microbiologic resolution with TMP/SMX treatment.

[Pulmonary nocardiosis in an immunocompetent patient with bronchiectasis]

We present a case of pulmonary nocardiosis in an immunocompetent patient with bronchiectasis in the middle lobe and lingula. The radiologic findings were pulmonary nodules, areas of consolidation, and multiple bronchiolar impactions. The patient died and the definitive diagnosis was confirmed at autopsy. Nocardiosis should be taken into account in patients with exacerbation of bronchiectasis.

[Radiological findings in initial pulmonary alveolar proteinosis detected in the post-treatment course of nocardiosis]

Chest CT detected a small localized ground glass opacity in the right upper lung in a 52-year-old woman being treated for nocardiosis. A PAS-stain positive material and elevated surfactant level were confirmed in bronchoalveolar lavage fluid, then a diagnosis of pulmonary alveolar proteinosis was established. In early pulmonary alveolar proteinosis with focal opacity, HRCT can demonstrate the substantial findings of alveolar proteinosis such as a crazy-paving appearance or geographic distribution. We should note that alveolar proteinosis in the early stage is easily overlooked and, in addition, nocardiosis might overlap with alveolar proteinosis.

Pulmonary nocardiosis: an unusual cause of a solitary pulmonary nodule

Nocardiosis is an infection caused by a soil-borne aerobic micro-organism. The pathogen is most commonly introduced in humans by inhalation into the respiratory tract. This infection may be transient and subclinical or may result in an acute or chronic bronchopulmonary process. Although an unusual cause of pulmonary infection in immunocompentent individuals, human nocardiosis is now documented more often in patients whose cell-mediated immunity is compromised by immunosuppression from comorbid disease or as a result of modern medical intervention. The diagnosis is often elusive unless a high index of suspicion is maintained. We present a patient with localized pulmonary nocardiosis who was immunosuppressed by virtue of a myeloproliferative disorder.

A chronic nocardial infection following conservative treatment of a high pressure injection injury of air

We present a case of recurrent cutaneous nocardiosis following a high pressure air injection injury which was treated conservatively. The patient subsequently developed multiple chronic granulomatous nodules in the palm and dorsum of the hand requiring repeated surgical debridements and long term antibiotics for complete resolution. Some reports suggest that high pressure injection injuries of air or water run a benign course and may be treated conservatively. However, inoculation by high pressure injection injury of air or water may result in chronic infections, which cause significant morbidity and are a therapeutic challenge. Although uncommon, they may be avoided by adherence to established treatment principles which include prompt recognition, realisation of its severity and aggressive treatment by open wound management, even for seemingly innocuous trauma or inoculum.

PET Imaging of Cerebral and Pulmonary Nocardia Infection

We report the case of a 69-year-old man who was suspected to have lung cancer with a single metastasis to the brain. Initial workup for neurologic and pulmonary symptoms demonstrated a ring-enhancing lesion in his right frontal lobe on MRI and a lung mass on CT. An F-18 fluorodeoxyglucose positron emission tomography (FDG PET) scan demonstrated marked glucose hypermetabolism in the lung and brain lesions with maximal standard uptake values (SUV) in both lesions of approximately 11. Biopsy of the brain mass revealed an abscess and cultures grew Nocardia. He was treated for nocardiosis, and a repeat CT of the chest in 2 months and MRI of the brain in 5 months showed nearly complete resolution of the lesions. Currently, there are few reported cases of PET evaluation of brain abscesses, particularly Nocardia. We discuss the appearance of brain infections on FDG PET scans in immunocompetent and immunocompromised patients.

Port-A catheter-associated Nocardia bacteremia detected by gallium inflammation scan: a case report and literature review

Central venous catheter-associated Nocardia bacteremia is rarely reported. We present the case of a 48-y-old male with a history of advanced T-cell lymphoma who suffered from recurrent fever and persistent Gram-positive bacillus bacteremia. Port-A catheter-associated Nocardia bacteremia was diagnosed on the basis of the clinical response to removal of the catheter and the finding of increased gallium uptake, along with the Port-A catheter presented in the gallium inflammation scan.

Pulmonary nocardiosis with multiple cavitary nodules in a HIV-negative immunocompromised patient

The radiological manifestations of pulmonary nocardiosis are very diverse, and include non-segmental consolidation and pulmonary nodule(s). Cavitary nodules most commonly appear in AIDS patients, and are uncommon in non-AIDS patients. We report a case of pulmonary nocardiosis with bilateral multiple cavitary nodules in a HIV-negative 60-year-old man with nephrotic syndrome who was receiving corticosteroid treatment. It is suggested that pulmonary nocardiosis should be considered in the differential diagnosis of multiple cavitary nodules on chest radiographs, even in non-AIDS immunocompromised patients.

Pulmonary nocardiosis in a patient with CML relapse undergoing imatinib therapy after bone marrow transplantation

We describe a case of pulmonary nocardiosis in a female patient with graft-versus-host disease (GVHD) underwent therapy with imatinib mesylate for a relapse of chronic myeloid leukemia (CML) after allogeneic bone marrow transplantation (BMT). The patient developed chronic GVHD 8 months after the use of imatinib and was on corticosteroid therapy. Three months after the development of chronic GVHD, she acquired pulmonary nocardiosis and a computed tomography (CT) scan of the chest showed multiple nodular lesions with cavitations over both lungs. She was successfully treated with single-agent trimethoprim-sulfamethoxazole (TMP/SMX) and the infection did not recur. Our case indicated that pulmonary nocardiosis could occur in patients with GVHD undergoing imatinib and corticosteroid therapy and might be treated by single-agent TMP/SMX.

Septic arthritis caused by nocardia asteroides in a renal transplant recipient

Although articular complications are common following renal transplantation, septic arthritis is not frequent. Previous bacterial infection in an another site is a consistent finding and the knee is the most often affected joint. We present a 30-year-old female renal transplant recipient with recurrent pulmonary infiltrates preceding septic arthritis of her left knee. Cultures of the aspirated synovial fluid yielded a gram-positive, rod-shaped bacterium later identified as Nocardia asteroides. The patient was treated with oral trimethoprim-sulfamethoxazole without any side effect. Nocardia is a rare but serious cause of infection in renal transplant recipients but there is no well-known predisposing factor. Recently mycophenolate mofetil has been implicated as a factor associated with Nocardia infections. Prolonged courses of treatment with sulphonamides are recommended.

Nocardia prostatitis in a small intestine transplant recipient

A 37-year-old small bowel transplant recipient with a history of urolithiasis was admitted for dysuria after passing a urinary stone. His laboratory evaluation showed increased blood urea nitrogen and creatinine. Urinalysis showed increased white blood cells and positive leukocyte esterase. A computed tomography scan revealed signs of urinary tract obstruction and prostatic enlargement. He failed to respond initially to empiric antibiotic treatment with ciprofloxacin and ampicillin sulbactam while waiting for culture results. The pathogen recovered from both urine and blood culture was subsequently identified as Nocardia asteroides complex. The isolate was sensitive to ceftriaxone and sulfa but resistant to ciprofloxacin. The patient improved on ceftriaxone and trimethoprim-sulfamethoxazole and completed a 6-month course without any relapse. Nocardia prostatitis is an uncommon infection and must be treated with a long course of antibiotics guided by susceptibility testing.