Nocardia otitidiscaviarum as Possible Etiologic Agent of Non-resolving Pneumonia

Nocardia otitidiscaviarum is an infrequent cause of nocardial pneumonia and rarely affects non-immunocompromised individuals. Pneumonia may not resolve if the causative organism is not susceptible to the empirically given antimicrobial drug. Amoxicillin朿lavulanic acid is a commonly used initial empiric antibiotic for suspected community-acquired bacterial pneumonia on outpatient basis. We report an unusual case of N. otitidiscaviarum as a possible etiologic agent of non-resolving pneumonia due to amoxicillin-clavulanic acid resistance in a previously healthy adult male.

Neck swelling after sneezing.

A 29-year-old, non-smoker male presented with a painless neck swelling with a sudden onset after a bout of violent sneezing two days ago. He had no other remarkable medical history except for seasonal allergic rhinitis for the past three years. He was referred for evaluation after being advised an antihistaminic drug for the relief of nasal symptoms. Bilateral crepitant swelling was found in the neck on physical examination.

Fatal re-expansion pulmonary oedema in a mechanically ventilated patient.

Fatal course of re-expansion pulmonary oedema (REPO) is infrequent and very rarely documented in mechanically ventilated patients. We report a case of fatal REPO following tube thoracostomy for a right-sided pneumothorax in an elderly patient of chronic obstructive pulmonary disease (COPD) with respiratory failure on mechanical ventilation.

Unusual complication of cervical tuberculous lymphadenopathy.

Lymphadenopathy is the most common form of extrapulmonary tuberculosis; cervical region being the most frequent site. Yet, tuberculous cervical lymphadenopathy is rarely associated with Internal Jugular Vein (IJV) thrombosis. We report right IJV thrombosis with isolated cervical tuberculous lymphadenopathy in a 22-year-old woman. Anti-tuberculous treatment resulted in complete regression of lymphadenopathy but anticoagulation treatment failed to restore the caliber of thrombosed IJV to normal. Thrombosis of adjacent IJV is a potential complication of delay in diagnosis and treatment of cervical lymphnode tuberculosis.

Pulmonary nocardiosis due to nocardia farcinica in a renal transplant recipient.

Nocardia farcinica is an infrequent cause of nocardiosis among the renal transplant recipients and it has not been reported so far from India. We report a case of pulmonary nocardiosis due to N. farcinica in a 32-year-old woman with hypothyroidism and post-renal transplant status, currently on immunosuppressive therapy (prednisolone, azathioprine and tacrolimus). The N. farcinica isolate was susceptible to trimethoprim-sulfamethoxazole (TMP-SMZ), linezolid, imipenem, gentamicin but resistant to ceftriaxone, ciprofloxacin, tobramycin, erythromycin, amoxycillin-clavulanic acid and tetracycline. Treatment with TMP-SMZ and linezolid resulted in marked clinico-radiological improvement but after two weeks both of the drugs had to be stopped due to severe pancytopenia as adverse effect of their use. Currently, the patient is on imipenem and remains stable after four weeks of treatment. In N. farcinica infections, multi antibiotic resistance and toxicity of some specific drugs enhances the risk of therapeutic failure in renal transplant recipients.

Pleural nocardiosis.

Pleural involvement in nocardiosis is rarely documented in India. We report two cases of pleural nocardiosis. In both the cases, the aetiologic agent was isolated from pleural fluid and was later identified as Nocardia asteroides in one case and as Nocardia brasiliensis in the second case. The former case of pyopneumothorax died before the diagnosis was made and the latter with pleural effusion showed excellent response to six months of therapy with trimethoprim-sulfamethoxazole.

Chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension (CTEPH) is an uncommon consequence of acute pulmonary embolism. We report CTEPH in a 58-year-old male who had pleurisy with a small haemorrhagic pleural effusion three months ago. The six-month course of anti-coagulation therapy failed to resolve thromboemboli completely or improve pulmonary hypertension. Computed tomographic pulmonary angiography (CTPA) is useful for the diagnosis as well as for the followup of chronic pulmonary thromboembolism.

Successful outcome of medical therapy in a case of acute massive pulmonary thromboembolism presenting with saddle thromboembolus.

Antemortem diagnosis of acute massive pulmonary thromboembolism (PTE) with a large thromboembolus at the bifurcation of the pulmonary trunk (saddle thromboembolus) is difficult, as most patients either die or are too ill for any diagnostic imaging. We report a case of massive PTE where constrast enhanced computed tomographic (CECT) scan of chest detected a saddle thromboembolus and showed its resolution with anticoagulant treatment. In our case, the presenting feature was unusual massive PTE as there was no haemodynamic instability or hypoxaemia.

Anaphylactic reaction due to paracetamol.

A 58-year old woman had anaphylactic reaction two hours after oral administration of paracetamol. She was treated conservatively and responded favourably. This incident is being reported as anaphylaxis to paracetamol which is rare. Whenever there is history of allergy to other non-narcotic analgesic drugs, paracetamol sensitivity should be tested under medical supervision.

Nocardial hydropneumothorax.

Pleural involvement in nocardiosis is rarely reported from India. A case of hydropneumothorax due to Nocardia asteroides in a patient with diabetes mellitus is reported. Tube thoracostomy drainage and therapy with trimethoprim-sulphamethoxazole for seven months prevented reaccumulation of pleural fluid and improved the general condition but failed to expand the lung. Bronchoscopy may be useful if multiple sputum examinations are negative in diagnosing pulmonary nocardiosis.

Re-expansion pulmonary oedema: revisited.

A case of re-expansion pulmonary oedema (RPO) following chest tube insertion for left spontaneous pneumothorax is reported. There were no severe symptoms and routine chest radiograph done four hours after tube thoracostomy showed features of pulmonary oedema in the re-expanded left lung. RPO is an uncommon complication of rapid pleural drainage of air or fluid with potentially serious cardiopulmonary manifestations but appears to run a benign course if there is no prior systemic hypoxaemia and if pneumothorax is drained without suction. Chest radiograph should be done routinely within four hours after chest tube insertion for early detection of RPO.

Pleural effusion due to lymphatic filariasis.

A case of pleural effusion is reported. Pleural biopsy showed microfilariae on histopathological examination. Treatment with diethyl carbamazine yielded excellent results. Filarial aetiology should be included in the differential diagnosis of idiopathic pleural effusions, especially in endemic areas.

Pleural involvement in HIV infection: clinico-radiological profile and prognostic significance.

The clinico-radiological profile of seven patients with pleural involvement and HIV infection is presented. Five out of seven subjects had a right-sided effusion. The aetiology in three cases; two tubercular and one invasive candidiasis was established by pleural biopsy. The mortality was high (5/7) indicating a poor prognosis in patients of HIV with pleural involvement.

Lung and HIV infection with special reference to tuberculosis: preliminary report on 20 HIV-1 seropositive cases.

The clinico-radiological profile of 20 patients with tuberculosis and other respiratory diseases infected with HIV-1 is presented in this preliminary communication. Twelve patients had proven and 4 had suspected tuberculosis. Two patients were diagnosed as having interstitial pneumonitis on limited autopsy. Five patients fulfilled the CDC's new AIDS definition criteria. Though our experience is limited, yet, in the present series, the patients with tuberculosis showed typical extensive upper zone infiltrative lesions. Patients with tuberculosis (pulmonary and extrapulmonary, excluding disseminated disease) showed improvement on short course regimens of anti-tuberculosis chemotherapy, without any toxic effects.