Nocardiosis pulmonar y del sistema nervioso central: el alcoholismo como factor de inmunocompromiso / Pulmonary and central nervous system nocardiosis: Alcoholism as an immunocompromising factor

La nocardiosis es una enfermedad de distribución mundial; de forma habitual se encuentra en zonas tropicales y afecta principalmente a pacientes inmunocomprometidos, sin embargo, también existen casos reportados de infección en personas inmunocompetentes. Esta infección es causada por actinomicetos del género Nocardia spp. que son bacterias Gram positivas, saprófitos ambientales. Aunque la exposición a Nocardia spp. es casi universal, solo una pequeña fracción de las personas expuestas desarrollan la enfermedad. Se presenta el caso de un hombre de 47 años, sin dato de inmunosupresión, procedente de un área rural de Boyacá, que consultó por un cuadro clínico de cefalea intensa e intermitente, con parestesias y, finalmente, alteración del estado de conciencia. Se practicó una resonancia magnética cerebral, en la que se evidenció una lesión que ocupaba espacio de localización córtico-subcortical en la región fronto-témporo-parietal izquierda, con efecto compresivo y desplazamiento de las cavidades del sistema ventricular. Se sospechó, inicialmente, una lesión neoplásica o un absceso cerebral. El paciente fue sometido a una resección quirúrgica, y el cultivo de la lesión documentó Nocardia africana/nova; en estudios posteriores, se evidenció un posible foco pulmonar primario. Como único factor de riesgo en el paciente, se documentó alcoholismo. Completó seis semanas de tratamiento antibiótico intrahospitalario con evolución clínica y radiológica, y egresó con plan de un año de terapia antibiótica ambulatoria. Aunque la enfermedad por Nocardia spp. afecta principalmente a pacientes inmunocomprometidos, la "evidencia" clínica demuestra que este microorganismo también puede ser una amenaza para individuos sin los factores de riesgo tradicionales para inmunosupresión.

Nocardiosis is a disease with worldwide distribution. It is usually found in tropical areas and mainly affects immunocompromised patients, however, there are also cases where its infection has been reported in immunocompetent patients. This pathology is caused by bacteria known as Nocardia spp., which are gram-positive microorganisms and environmental saprophytes, and although exposure to Nocardia spp. is almost universal, only a small fraction of exposed people develops the disease. We present the case of a 47-year-old man, with no evidence of immunosuppression, from a rural area of Boyacá, who was admitted due to intense and intermittent headache accompanied by paresthesia and, finally, a decrease in consciousness. A brain magnetic resonance was performed and evidenced a fronto-temporo- occipital space-occupying lesion in the cortico-subcortical region with a compressive effect and displacement of the ventricular system cavities. It was suspected at first a neoplastic lesion or a brain abscess. The lesion was surgically resected, and its culture showed Nocardia africana/nova. In later studies a possible primary pulmonary focus was evidenced. Alcoholism was the only risk factor documented. The patient completed 6 weeks of hospital antibiotic treatment with favorable clinical and radiological evolution and was discharged with a 1-year plan of outpatient antibiotic therapy. Although Nocardia spp. mainly affects immunocompromised patients, evidence shows that this microorganism can also be a threat to individuals without traditional immunosuppression risk factors.

Membranous nephropathy complicated by Nocardia infection: 1 case report and literature review / 中国医师杂志

Objective:To investigate the clinical features, diagnosis and treatment of membranous nephropathy complicated with Nocardia infection, and to improve the understanding of Nocardia infection.Methods:The clinical data of a patient with membranous nephropathy complicated by Nocardia infection who were hospitalized in the department of respiratory medicine, Xiangya Hospital of Central South University were retrospectively analyzed. Using " Nocardiosis" and " membranous nephropathy" on China National Knowledge Internet (CNKI) and Wanfang databases, and using " Nocardiosis" and " menbranous nephropathy" as keywords to search the pubmed database to summarize the clinical characteristics and diagnosis and treatment points of patients with membranous nephropathy complicated by Nocardia infection.Results:This patient is a 47-year-old middle-aged male. He was admitted to the respiratory medicine department in Xiangya Hospital of Central South University due to " coughing and expectoration of sputum for 2 months, and a mass in the left lower extremity was found for 20 days" . Lung computed tomography (CT) showed that multiple nodules and changes in pleural effusion were seen in the right pleura. The sputum smear showed Gram-positive bacilli, and the smear of the mass puncture fluid of the left lower extremity showed Gram-positive bacilli (branched). After treatment with compound sulfamethoxazole, meropenem and levofloxacin successively, the phlegm was obviously improved, and the mass in the left lower extremity was basically absorbed. After 2 months of follow-up, the pleural effusion and the mass in the left lower extremity were completely absorbed. A total of 4 literatures were collected in the literature search, including 6 cases of this case, including 3 cases (50%) of Nocardia anthracis, 1 case (16.7%) of Nocardia otitis in guinea pigs, and 1 case of Nocardia stellariformis (16.7%). 1 case (16.7%) was not classified.Conclusions:Although Nocardia anthracis is rare in patients with membranous nephropathy, it can easily cause systemic disseminated infection. Therefore, in immunocompromised patients, attention should be paid to the occurrence of Nocardia infection. Co-sulfamethoxazole should be used empirically before Nocardia infection is confirmed. For sulfonamide-resistant strains, linezolid and other drugs can be used for anti-infective treatment.

Abscesos cerebrales por Nocardia spp. en una paciente inmunocompetente / Multiple brain abscesses due to Nocardia spp. in an immunocompetent patient

La infección por Nocardia spp. no es común en pacientes inmunocompetentes. El tratamiento antimicrobiano empírico dirigido según las regiones anatómicas, no contempla las particularidades del germen y el análisis microbiológico se hace necesario para el tratamiento específico. A continuación, se presenta el caso de una paciente previamente sana, inmunocompetente y sin factores de riesgo conocidos para la infección por Nocardia spp., con evidencia de compromiso en el parénquima pulmonar y la piel, que posteriormente desarrolló varios abscesos cerebrales.

The infection by Nocardia spp is not common in immunocompetent patients. The empirical antimicrobial treatment directed by anatomical regions does not contemplate the particularities of the germ and the microbiological analysis is necessary for the specific treatment. We present the case of a previously healthy and immunocompetent patient, without known risk factors for Nocardia spp. infection, with evidence of involvement of the pulmonary parenchyma and the skin and subsequent development of multiple brain abscesses.

Nocardiosis linfocutánea en una niña sana, a propósito de un caso clínico / A clinical case of lymphocutaneous nocardiosis in a healthy infant / Um caso clínico de neocardiose linfocutânea numa menina saudável

Resumen: Las nocardiosis son infecciones poco frecuentes producidas por distintas especies del género Nocardia. Las dos especies más prevalentes son N. asteroides y N. brasiliensis. Presentan un amplio espectro de enfermedad, con formas locales o diseminadas, de evolución aguda, subaguda y/o crónica. Pueden causar enfermedad severa sobre todo en pacientes inmunodeprimidos. La infección de piel y partes blandas puede presentarse en personas inmunocompetentes y ocasionalmente en niños sanos. Se presenta el caso de una preescolar de 18 meses que presentó absceso de pie con adenoflemón inguinal derecho. El estudio microbiológico del material obtenido del drenaje de la lesión observó bacterias grampositivas de aspecto filamentoso, por lo que se planteó el diagnóstico preliminar de nocardiosis. Dicho diagnóstico se confirmó posteriormente con el cultivo bacteriológico. Recibió tratamiento con clotrimoxazol durante seis semanas por vía oral, con buena evolución, sin otras complicaciones. La valoración inmunológica inicial no mostró alteraciones. El seguimiento evolutivo de la paciente no evidencia alteraciones sugestivas de trastornos específicos de la inmunidad.

Summary: Nocardiosis is a rare infection. The two most prevalent species, N. asteroides and N. brasiliensis, can cause a broad spectrum of clinical diseases, which could be local or disseminated infections with an acute, subacute or chronic evolution. It can cause severe infections to immunocompromised patients, or even to healthy children, who can experience skin and soft tissue infections. This is the clinical case of a healthy 18-month-old girl with a foot abscess with right inguinal adenophlegmon. The microbiological study of the lesion drainage confirmed a diagnosis of Nocardia sp. She was treated with clotrimazole for 6 weeks and had no further complications. The initial immunoassay showed no abnormalities. The patient's evolutionary follow-up does not show alterations resulting from specific immunological disorders.

Resumo: A nocardiose é uma infeção pouco frequente produzida por diferentes espécies do gênero da Nocardia. As duas espécies mais prevalentes são N. asteroides e N. brasiliensis. Geram um amplo espectro de doenças, com formas locais ou disseminadas, de evolução aguda, subaguda e / ou crônica. Podem causar doença grave, especialmente a pacientes imunodeprimidos. A infecção da pele e dos tecidos moles pode acometer a pacientes imunocompetentes ou ocasionalmente a crianças saudáveis. Apresentamos o caso de uma paciente de 18 meses de idade que apresentou abscesso permanente com adenofleimão inguinal direito. O estudo microbiológico, obtido a partir da drenagem da lesão, mostrou bactérias gram-positivas de aspecto filamentoso compatível com o diagnóstico preliminar de nocardiose. Este diagnóstico foi posteriormente confirmado através duma cultura bacteriológica. Ela recebeu tratamento com Clotrimazol por 6 semanas por via oral, teve boa evolução, sem outras complicações. A avaliação imunológica inicial não mostrou alterações. O acompanhamento evolutivo da paciente não apresenta alterações que indiquem distúrbios específicos da imunidade.

Primary Cutaneous Nocardiosis Caused by Nocardia takedensis

Nocardia species are aerobic, gram-positive, filamentous, partially acid-fast actinomycetes which are found worldwide in soil and decaying organic plant matter. When they infect human beings, they generally enter through the respiratory tract and then disseminate systemically. Rarely has a primary infection occurred as the result of direct inoculation. Isolation of Nocardia from clinical specimens and identification of species are difficult. But, with the introduction of new genetic technologies, reports of novel species of Nocardia have increased. We describe a case of cutaneous nocardiosis caused by Nocardia takedensis in an 87-year-old woman who was diagnosed by bacterial culture and 16S ribosomal RNA sequencing. N. takedensis has been described as a new species. This report describes the first clinical isolate of N. takedensis from a skin specimen in Korea.

Systemic Nocardiosis Mimicking Disease Flare-up after Discontinuation of Gefitinib in a Patient with EGFR-Mutant Lung Cancer / 결핵및호흡기질환

Disease flare-up after discontinuing epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) has been considered as a critical issue in lung cancer patients who have experienced radiologic progression after showing initial durable response. This is a case of systemic nocardiosis that occurred after chronic steroid use for radionecrosis from stereotactic radiosurgery. It was initially thought as a disease flare-up after stopping EGFR-TKI.

Nocardia Brain Abscess in an Immunocompetent Patient / 감염과화학요법

Nocardia cerebral abscess is rare, constituting approximately 1-2% of all cerebral abscesses. Mortality for a cerebral abscess of Nocardia is three times higher than that of other bacterial cerebral abscesses, therefore, early diagnosis and therapy is important. Nocardia cerebral abscess is generally occur among immunocompromised patients, and critical infection in immunocompetent patients is extremely rare. We report on a case of a brain abscess by Nocardia farcinica in an immunocompetent patient who received treatment with surgery and antibiotics. This is the second case of a brain abscess caused by N. farcinica in an immunocompetent patient in Korea.

Nocardiosis pulmonar, como causa de imagen radiológica en consolidación pulmonar con área de cavitación / Pulmonary nocardiosis, as a cause of radiological imaging in lung consolidation with cavitation area

La Nocardia es una bacteria aerobia estricta grampositiva. Se adquiere generalmente a través del tracto respiratorio, Comprende varias especies, siendo N. asteroides la que más afecta al hombre (85%). Su diagnóstico se basa en el aislamiento en esputo de Nocardia sp. La nocardiosis pulmonar es una infección infrecuente y debe considerarse en pacientes con estado de inmunodepresión y con patología pulmonar subyacente, como la tuberculosis. El compromiso pulmonar por Nocardia consiste con mayor frecuencia en abscesos necrotizantes. Los hallazgos radiológicos son nódulos pulmonares múltiples de diversos tamaños y las consolidaciones pulmonares son las manifestaciones más frecuentes.(AU)

Infectious endocarditis caused by Nocardia sp.: histological morphology as a guide for the specific diagnosis

Nocardia is a rare opportunistic agent, which may affect immunocompromised individuals causing lung infections and exceptionally infective endocarditis (IE). There are few reports of IE caused by Nocardia sp., usually involving biological prostheses but rarely in natural valves. Its accurate microbiological identification may be hampered by the similarity with Rhodococcus equi and Corynebacterium spp. Here we report a case of native mitral valve IE caused by this agent in which the clinical absence of response to vancomycin and the suggestion of Nocardia sp. by histology pointed to the misdiagnosis of Corynebacterium spp. in blood cultures. The histological morphology can advise on the need for expansion of cultivation time and use of extra microbiological procedures that lead to the differential diagnosis with Corynebacterium spp. and other agents, which is essential to establish timely specific treatment, especially in immunocompromised patients.

A Case of Nocardia farcinica Brain Abscess in a Focal Segmental Glomerulosclerosis Patient after Steroid Treatment / 대한신장학회지

Nocardia is an opportunistic pathogen that can cause disseminated disease in serious immunosuppressive patients with organ transplantation, advanced HIV infection, malignancy or long-term corticosteroid use. Cerebral nocardiosis constitutes the most severe form of Nocardial infection. Early detection and treatment of cerebral abscess of Nocardia is important because the mortality is three times higher than that of other bacterial cerebral abscesses. We report a case of N. farcinica brain abscess in a focal segmental glomerulosclerosis (FSGS) patient after steroid treatment.

Linezolid for treatment of nocardiosis in systemic lupus erythematosus: a case report and literature review / 中华全科医师杂志

This report presented a case of disseminated infection with nocardia in lupus erythematosus (SLE) and reviewed the current literature. Nocardiosis was a rare, sometimes life-threatening opportunistic infection in SLE patients. The isolation and identification of pathogen was fundamental for the diagnosis of nocardiosis. Sulfonamides were traditionally the agent of choice for treatment of nocardiosis; while it must be given for several months even more than one year, particularly in patients with suppressed immune function. Issues regarding the drug resistance and the toxicity of sulfonamides in long-term therapy needed to be considered. Linezolid could be an effective agent for the treatment of nocardiosis, whether it could reduce the treatment course need to be further studied.

Nocardiose pulmonar em portador de doença pulmonar obstrutiva crônica e bronquiectasias / Pulmonary nocardiosis in a patient with chronic obstructive pulmonary disease and bronchiectasis

Relatamos o caso de um paciente com doença pulmonar obstrutiva crônica e bronquiectasias, em uso crônico de corticosteróides, que desenvolveu nocardiose pulmonar, sob a forma de múltiplos nódulos pulmonares escavados. Os sintomas principais foram a tosse produtiva com escarro purulento, febre e dispnéia A radiografia simples e a tomografia computadorizada do tórax mostravam nódulos em ambos os pulmões, alguns escavados. O exame direto de escarro e a cultura mostraram a presença de Nocardia spp. A paciente foi tratada com imipenem e cilastatina, com excelente resposta clínica.

We report the case of a patient with chronic obstructive pulmonary disease and bronchiectasis, chronically using corticosteroids, who acquired pulmonary nocardiosis, which presented as multiple cavitated nodules. The principal symptoms were fever, dyspnea and productive cough with purulent sputum. Chest X-ray and computed tomography of the chest revealed nodules, some of which were cavitated, in both lungs. Sputum smear microscopy and culture revealed the presence of Nocardia spp. The patient was treated with imipenem and cilastatin, which produced an excellent clinical response.