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Pulmonary nocardiosis (PN) is a rare but severe disease caused by Nocardia spp. Despite the traditional description as opportunistic infection, case reports and case series of pulmonary nocardiosis have recently been reported in immunocompetent patients too, in particular among people with chronic pulmonary diseases such as advanced Chronic Obstruc...
Citations
... That same year, Eppinger reported the first case of natural human infection. 6 The latest research has confirmed 54 different species of Nocardia associated with human infections, placing them prominently among the known 119 species 7,8 Among these, the four main pathogenic species to humans are: Nocardia asteroides, Nocardia farcinica, Nocardia brasiliensis, and Nocardia otitidiscaviarum. 9 Nocardia farcinica is a bacterial pathogen characterized by a clinically insidious onset, intense tissue damage, and a tendency for recurrence. ...
Background
Nocardiosis is primarily an opportunistic infection affecting immunocompromised individuals, with a predilection for the lungs, brain, or skin in those with compromised immune function. Granulomatous hepatitis caused by Nocardia is a rare clinical manifestation. This study aims to provide a systematic overview of the clinical features of Nocardiosis caused by Nocardia farcinica, enhancing our understanding of this disease.
Methods
We report a case of a 75-year-old male with no underlying diseases presenting with a history of “recurrent fever for more than 4 months”, along with fatigue, poor appetite, and pleural and abdominal effusion. Despite treatment at multiple hospitals, the patient showed little improvement. Chest CT revealed chronic inflammation, small nodules, bilateral pleural effusion, and pleural thickening. Abdominal CT indicated multiple low-density lesions in the liver, multiple small calcifications, and abdominal effusion.
Results
Liver biopsy suggested inflammatory changes, with focal granuloma formation. Metagenomic next-generation sequencing (mNGS) of liver tissue indicated Nocardia farcinica, leading to the final diagnosis of disseminated Nocardia farcinica granulomatous hepatitis.
Conclusion
Nocardia infection is a rare disease primarily observed in immunocompromised patients but can also occur in those with normal immune function. The clinical and radiological features lack specificity; however, the utilization of mNGS technology enables rapid identification of the pathogenic microorganism. Nocardia farcinica is generally susceptible to sulfonamide drugs and amikacin, offering viable treatment options.
... In Pakistan, a 10-year retrospective review of pulmonary nocardiosis showed that COPD (n = 13; 23.6%) and tuberculosis (n = 12; 21.8%) were the most common respiratory diseases (36). COPD was also reported as an isolated risk factor for pulmonary nocardiosis in Italy (37). All data suggest that COPD is the most common predisposing factor of pulmonary nocardiosis. ...
The aim of this study was to investigate the clinical features, distribution and antimicrobial susceptibility of Nocardia species isolated from pulmonary nocardiosis cases in tertiary hospital in China. The species were collected from January 1, 2018 to May 31, 2019 and identified using MALDI-TOF MS or PCR. Antimicrobial susceptibility testing was performed using the broth microdilution method. Within the 44 Nocardia species, N. farcinica was the most frequently identified species (n = 36), followed by N. nova (n = 5), N. otitidiscaviarum (n = 1), N. cyriacigeorgica (n = 1), and N. transvalensis (n = 1). The top three predisposing factors of pulmonary nocardiosis were chronic obstructive pulmonary disease (45.5%), hypertension (34.1%), and tuberculosis (31.8%). All 44 Nocardia strains were susceptible to amikacin, trimethoprim / sulfamethoxazole, and linezolid. The resistance rates of Nocardia to amoxicillin-clavulanic acid, ciprofloxacin, clarithromycin, ceftriaxone, tobramycin, and imipenem were 4.5%, 9.1%, 79.5%, 72.7%, 63.6%, and 38.6%, respectively. Two Nocardia strains had decreased sensitivity to trimethoprim / sulfamethoxazole. In conclusion, N. farcinica was the most frequently isolated Nocardia species in the First Hospital of Changsha. All isolated clinical Nocardia strains showed susceptible to amikacin, trimethoprim / sulfamethoxazole, and linezolid, suggesting that these drugs can be primary therapeutic choices for treating Nocardia infections.
... Among respiratory diseases, COPD is a major risk factor. ese patients are most often treated with corticosteroid therapy, and along with their impaired local defences, they become prone to nocardiosis infection more than any other respiratory condition [8,9]. In our study, diabetes was found to be the most common risk factor for nocardiosis and consisted of 50% of cases followed by COPD and lung malignancy. ...
Nocardiosis is a rare bacterial infection that may lead to a severe disease. These infections are rare among normal population and are showing an increasing trend worldwide attributable to the increase in the immunosuppressed population. Most of these patients present with nonspecific clinical features such as fever, productive cough, and exertional dyspnoea as seen in our series of patients which makes it difficult to be diagnosed. Pulmonary nocardiosis is rarely clinically suspected and often diagnosed very late in the course of disease resulting in high mortality. A similar observation was made in one of our cases where the patient was being treated on the lines of pneumonia, and in the end she was diagnosed with pulmonary nocardiosis. In view of the limited literature available, we report here a case series of pulmonary nocardiosis in immunosuppressed patients diagnosed incidentally by fungal KOH mount. The most common conditions causing immunosuppression were type II DM, case, and pulmonary tuberculosis.
... Among respiratory tract diseases, COPD was the most common. Studies have reported that COPD is the disease most often treated with corticosteroid therapy and therefore leaves the patient prone to Nocardiosis infection more than any other respiratory condition; even without steroid therapy COPD remains a critical risk factor behind nocardiosis [8][9]. Munoz et al. in their series of 27 Nocardia cases identified 70% of their patients to have COPD [10]. ...
Introduction
Nocardiosis is a rare opportunistic bacterial infection usually seen in immunosuppressed patients. It is caused by gram-positive, aerobic actinomycetes of the Nocardia genus. The most common site of infection is lungs; but it may affect other organs or even disseminate into blood.
Methods
In this a 10-year retrospective review, all diagnosed cases of Pulmonary Nocardiosis in a tertiary care hospital were included. The clinical and radiological characteristics, course of complications and lifesaving interventions, and disease outcome were evaluated.
Results
Among the 55 identified cases, most common risk factor was chronic steroid therapy (n=38; 69.1%). Among respiratory diseases, chronic obstructive pulmonary disease (n=13; 23.6%) and tuberculosis (n=12; 21.8%) were the most common. On chest radiograph, pleural effusion (n=23; 41.8%) and consolidation (n=22; 40.0%) were the common findings. Complications were observed in 32 (58.2%) patients with septicemia and respiratory failure being the most common (n=15; 46.8% in each). Dissemination occurred in 10 (31.2%) patients. The mortality rate of Nocardia is 34.5% (n=19).
Conclusion
The disease burden of Nocardia is underestimated by clinicians and researchers. Pulmonary Nocardia should always be a differential diagnosis of signs of lower respiratory tract infection and must be excluded in patients not responding to treatment of chronic obstructive pulmonary disease (COPD) and pulmonary tuberculosis. Early recognition and individualized management plan can ensure successful recovery.
... The characterization of TB lesions is pronounced by the predominant migration of monocytes/macrophages to the infection site. Meanwhile, the earliest response is mainly the polymorphonuclear neutrophils (PMN) Influx [2]. This early response results from the function of chemotactic factors, through capillaries to the interstitium and ultimately to the alveolar air spaces [3]. ...
Mycobacterium tuberculosis (M.TB) can cause serious complications to human body in which the immune response plays an essential part. This study designed to evaluate serum levels of cytokine interleukin-18 (IL-18), interferon-gamma (IFN-γ) and soluble apoptosis-stimulating fragment (sFas) in pulmonary tuberculosis (TB) cases with confirmed M.TB infection. The study comprised of 50 patients (male & Female) with M.TB, 13 complicated and 37 uncomplicated cases. Serum IL-18, IFN-γ and sFas levels were measured using enzyme-linked immunosorbent assay (ELISA). Serum Markers (IL-18, IFN-γ and sFas) levels were elevated significantly in complicated pulmonary TB group when compared with control and uncomplicated groups. Furthermore, sFas was found to correlate positively with IL-18 (r 2 =0.634, p<0.001) and IFN-γ (r 2 =0.623, p<0.001) in TB patient. Additionally, a positive and significant correlation was observed between serum levels of IL-18 and IFN-γ (r 2 =0.612, p<0.001) in the complicated group. Therefore and from these findings, the elevated IFN-γ levels after successful M.TB treatment, suggest that Fas expression might stimulate the infected macrophages. This showed an increased Fas ligand-induced (FasL) apoptosis. Modulation of FasL framework by M.TB may consider as an escape scheme to avoid the impact of apoptosis. Moreover, higher serum levels of IL-18, IFN-γ and sFas might be considered pathognomonic markers for pulmonary TB, especially in complicated cases.
... A C C E P T E D ACCEPTED MANUSCRIPT infections in humans, especially in patients with underlying immune-compromised disease [2] . Pulmonary is the major site of Nocardia infection [3] , and Nocardia can also be disseminated to skin, subcutaneous, muscle and central nervous system [4] . ...
Purpose: To retrospectively analyze the radiological features of nocardiosis.
Methods: We identified patients with Nocardia infection in our hospital from January 2011 to May 2016. Both the clinical and radiological data of the patients were collected for analysis. We also performed a literature review of previous reports on nocardiosis.
Results: Totally 5 patients with nocardiosis was recruited as the subjects of our study with a median age of 46 years old (range, 41–52 years old). All the patients had underlying disease that could compromise the immune system. Among them, we identified 4 patients with pulmonary nocardiosis, 2 patients with brain nocardiosis and 2 patients with leg nocardiosis. Our study demonstrated that common computed tomography findings of pulmonary nocardiosis included nodule, mass, consolidation and cavitation. Multifocal and ring-enhancing lesions on T1-weighted contrast-enhanced image of magnetic resonance imaging were the common features of brain and leg nocardiosis.
Conclusions: The clinical and radiological characteristic of nocardiosis is non-specific, but the awareness of this disease is critical for the diagnosis and early treatment of the patients. Nodule, mass, consolidation and cavitation are the common findings of pulmonary nocardiosis. Multifocal ring-enhancing lesions are the dominant features of brain and muscle nocardiosis.
Nocardiosis is a rare opportunistic infection mostly affecting the lungs, brain, or skin of immunocompromised individuals. Most pulmonary nocardiosis patients present with nonspecific clinical features such as productive cough, exertional dyspnea, and fever. The disease is uncommonly suspected, especially in tuberculosis-endemic regions, and clinical diagnosis is often delayed, resulting in high mortality. Pulmonary nocardiosis in apparently immunocompetent individuals is uncommon. Here, we present the case of an elderly gentleman with a background history of poorly controlled diabetes but no history of systemic steroid use who presented with worsening symptoms of chronic obstructive pulmonary disease in the form of productive cough and dyspnea. The patient had diffuse crepitations in bilateral lung fields and an arterial oxygen saturation of 86% at admission. Sputum microscopy revealed gram-positive filamentous bacteria that could be successfully cultured and identified as Nocardia amamiensis on 16S ribosomal RNA sequencing. Contrast-enhanced computed tomography of the lungs revealed cavitary nodules and consolidation. The patient responded well to treatment with specific antibiotics based on sensitivity patterns. Because of the nonspecific clinical and radiological findings in pulmonary nocardiosis, a high index of suspicion is required, especially in tuberculosis-endemic regions.
An 86-year-old woman with a 6-year history of bronchiectasis and recurrent pneumonia in the right lung presented to our hospital with a several weeks' history of bloody sputum. Imaging studies showed ground-glass and infiltrative opacities in the right lung, and Nocardia species were repeatedly isolated on sputum culture testing. Genetic testing identified Nocardia wallacei, which was resistant to sulfamethoxazole/trimethoprim. Therefore, the patient was treated with clavulanic acid/amoxicillin (CVA/AMPC) for a total of 6 months, and the symptoms, including the bloody sputum and cough, as well as the imaging findings, improved. Pulmonary nocardiosis can occur in patients with chronic lung disorders such as bronchiectasis, even in the absence of immunodeficiencies. Trimethoprim-sulfamethoxazole is the drug of first choice for nocardiosis, but identification of the Nocardia species and susceptibility testing are recommended for treatment, because the susceptibility varies with the species.
Nocardiosis is a clinical and diagnostic challenge. This was a retrospective study carried out on cases of pulmonary nocardiosis presenting over 15 years.
Clinical data was retrieved using the electronic patient records. Vitek MS 3.2 (MALDI TOF MS) was carried out on 22 isolates and sequencing on another 9 isolates.
Of 71 patients presenting with pulmonary nocardiosis, 58 (81.6%) were on immunosuppressant therapy, 26 (46%) had a previous lung pathology, 11 (8%) were HIV associated. Disseminated disease was seen in 6 (8.4%). There were 8 (11.26%) deaths in this cohort of patients. Of 31/71 identified to species, the most common were Nocardia cyriacigeorgica (n = 11) followed by Nocardia farcinica (n = 9).
Objective: Resistance against Mycobacterium tuberculosis (MTB) is important in the sense that it has an implication in the control of tuberculosis. The terms used to describe resistance to antituberculosis drugs are resistance among new cases (or primary resistance) and resistance among previously treated patients. The resistance among previously treated patients may be due to faulty treatment like prescription of inadequate treatment regimens, interrupted availability or poor quality of drugs, or incomplete treatment adherence while subsequent transmission of these resistant organisms to others will lead to development of disease which is resistant from the beginning called primary resistance. Pakistan is ranked eighth in terms of global estimated burden of tuberculosis cases. Multi-Drug Resistant (MDR) tuberculosis among new cases and MDR among previously treated patients is 3.2% and 35% respectively. Material and methods: - AFB smear examination and grading: - AFB smear examination was carried out by direct microscopy using the Ziehl Neelsen (ZN) method. Sputum smear result was examined and interpreted according to the AFB grading. AFB culture and drug susceptibility test: - Culture examinations were done on all diagnostic specimens of AFB smear positivity. Sputum specimens from each patient were processed with sodium hydroxide (NaOH) method-Modied Petroff 's procedure and cultured on Lowenstein-Jensen (LJ) slopes.10 All inoculated LJ drug and control media were incubated at 37ºC. All cultures were examined 48-72 hours after inoculation to detect gross contaminants. Thereafter, cultures were examined weekly, up to eight weeks on a specied day of the week. Typical colonies of M. tuberculosis were rough, crumbly, waxy, non-pigmented (buff coloured) and slow-growers, i.e., only appeared two to three weeks after inoculation. The colony was conrmed by ZN staining. Detection time for MOTT was 25 days. M. tuberculosis positive strains were culture negative when they grew on p-nitro benzoate (PNB) containing medium. Only a few colonies of non-tuberculosis Mycobacteria (NTM – often pigmented, with smooth morphology or PNB positive) were grown as visible colonies on PNB containing medium. Anti-TB drug susceptibility testing: - anti-susceptibility testing perform on pre-formed LJ media with antitubercular drugs Tuberculosis First Line Kit (Total 7 slants) Containing ve antitubercular agent (Isoniazid, Streptomycin, Ethambutol, Rifampicin and Pyrazinamide) 2 controls without any antimicrobial agent. Results: out of 119 samples antitubercular testing against rst line antitubercular drugs such as Pyrazinamide were shows 12 (10.08%) sample were resistance which accounts maximum resistance among rst line antitubercular another rst line antitubercular drugs shows resistance as follows Streptomycin (9.24%), Ethambutol (8.40%), Isoniazid (7.56%), Rifampicin (6.72%), drugs out of 119 samples in which 107 samples were susceptible to the Pyrazinamide drug in in-vitro antitubercular susceptibility testing. Antitubercular resistance against second line antitubercular drugs were shows as follows out of 119 samples antitubercular testing Ethionamide were shows 9 (8.18%) sample were resistance which accounts maximum resistance among second line antitubercular another second line antitubercular drugs shows resistance as follows Clarithromycin (6.72%), Ciprooxacin (5.88%), D- Cycloserine (5.88%), Amikacin (5.04%), Kanamycin (4.20%), P- aminosalicylic acid ( 4.20%) and Rifabutin (3.36%) drugs out of 119 samples in which 107 samples were susceptible to the Pyrazinamide drug in in-vitro antitubercular susceptibility testing. MDR-TB emerged in patients who were resistant to Rifampicin and Isoniazide was 6 in number during this study.
