A case of atypical nocardia asteroides sclerouveitis resistant to fourth-generation fluoroquinolones / Um caso atípico de esclero-uveíte por Nocardia Asteroides resistente a fluorquinolona de quarta-geração

ABSTRACT We describe an unusual case of Nocardia spp scleritis in a health girl resistant to topical fourth-generation fluoroquinolones. Clinically, there was only partial response of the scleritis to initial therapy. Treatment was changed to meropenem intravenously and topical amikacin. Following several weeks of antibiotic treatment, the patient's infection resolved but her vision was reduced to no light perception. Nocardia asteroides must be considered as a possible agent in cases of necrotizing scleritis in patients without a clear source. Antibiotic sensitivity testing has a definitive role in view of the resistance to these new medications.

RESUMO Nós descrevemos um raro caso de esclerite por Nocardia spp em uma criança sadia resistente a utilização tópica de fluorquinolona de quarta-geração. Clinicamente, a paciente apresentou apenas uma resposta parcial do quadro de esclerite a terapêutica inicial. O tratamento foi então modificado para meropenem intravenoso e amicacina tópica. Após várias semanas de tratamento com antibiótico, o quadro infeccioso regrediu porém a visao da pacientes evoluiu para perda da percepção luminosa. Em casos de esclerite necrotizante em pacientes sem fatores de risco aparente é necessário considerer a Nocardia Asteroides como possível agente causador. Os testes de sensibilidade medicamentosa apresentam importância significativa em virtude do aparecimento de resistência aos novos medicamentos.

Contact Lens-associated Nocardial Necrotizing Scleritis

A 52 year-old, contact lens-wearing man presented with progressive right eye pain and redness for one month. He had been evaluated and treated for necrotizing scleritis by multiple eye care specialists prior to presentation. He underwent a complete systemic work-up for both autoimmune and infectious causes of scleritis, including a culture. The culture revealed heavy growth of Nocardia asteroides complexes. The patient was treated with topical amikacin and oral Bactrim. Following several weeks of antibiotic treatment, the patient's infection resolved completely, and his visual acuity returned to baseline status. Nocardia is a rare but potentially devastating cause of necrotizing scleritis that may affect contact lens wearers without an associated keratitis. Prompt recognition and early treatment with appropriate antimicrobial agents are critical to achieve a favorable outcome.

A case of endophthalmitis associated with limbal relaxing incision.

Limbal relaxing incisions (LRIs) are considered a relatively safe procedure with rapid stabilization and absence of infectious complications. Do we need to readdress this last impression? We report a case of nocardia endophthalmitis associated with an exudate at the site of an LRI in a patient who underwent routine cataract surgery. This case, to the best of our knowledge, is the first report of its kind, stressing the need for a cautious approach to the adoption of this method of astigmatic correction.

Rare zoonosis (hemotrophic mycoplasma infection) in a newly diagnosed systemic lupus erythematosus patient followed by a Nocardia asteroides pneumonia

Systemic lupus erythematosus (SLE) is per se a disease characterized by suppressed immune response and thus susceptibility to various opportunistic infections. We describe the case of a 21-yearold woman who developed a rare zoonosis - hemotrophic mycoplasma infection in the initial stage of SLE, complicated with Nocardia asteroides pneumonia afterwards. Nocardia infection coincided with initiation of glucocorticoids and cyclophosphamide therapy for SLE. After the treatment she recovered completely. To our knowledge the only case of human hemoplasmosis (then referred to as eperythrozoonosis) in medical literature was the one described by a group of Croatian authors 22 years ago. No cases of a hemotrophic mycoplasma infection in a SLE patient have been published up to now.

Disseminated orbital actinomycetoma: A case report.

Mycetoma is a chronic granulomatous infection. Lower extremities are commonly involved. A 20-year-old male came with complaints of multiple sinuses on scalp, left eyelid swelling with a sinus and dystopia, since one year. On examination there was relative proptosis in left eye of 2 mm. Computed tomography scan showed soft tissue swelling of the pre-septal area of the left upper eyelid with orbital involvement. Magnetic resonance imaging showed increased left orbital volume and evident dystopia. Microbiology testing of the erosive scalp and lid lesions showed genus Nocardia, suggestive of actinomycetoma. This case is presented as it shows an unusual involvement of the orbit.

Sporotrichoid pattern of cutaneous nocardiasis due to Nocardia asteroids.

Cutaneous nocardiosis is a rare disease, only a few cases of which have been reported from the world as well as in India. This infection, when in the lymphocutaneous form, may clinically resemble sporotrichosis, hence causing a diagnostic dilemma. Here, we report a case of primary cutaneous, sporotrichoid pattern of cutaneous nocardiosis caused by Nocardia asteroides in immunocompetent host. The patient was a 32-year-old farmer, with no predisposing factors, who presented with cutaneous nocardiosis. The diagnosis was confirmed by culture of the biopsy, after which the patient was treated successfully with antibacterial agents.

Nocardial brain abscess in an immunocompetent host.

Nocardial infection of the central nervous system is rare and usually manifests as brain abscess. Here we describe an elderly gentleman who presented with signs and symptoms of an intracranial mass lesion localising to the frontal lobe. Clinical examination and CT scan suggested neoplasia as the probable diagnosis. A biloculated abscess was seen at surgery. Aspiration of the contents and examination of pus revealed Nocardia asteroides . Treatment included total excision and prolonged antibiotic therapy which resulted in an excellent outcome.

Disseminated nocardiosis with psoas abscess in a patient with AIDS: first reported case

Psoas muscle abscess is an uncommon infection that have been diagnosed increasingly in the last years. We present a case of a patient with advanced human immunodeficiency virus infection who developed a disseminated infection due to Nocardia asteroides sensu stricto type VI with psoas abscess. To our knowledge no other cases of Nocardia psoas abscess in the setting of HIV infection have been reported in the literature.

O abscesso do músculo psoas é uma infecção pouco comum que tem sido diagnosticada de maneira crescente nos últimos anos. Apresentamos um caso de paciente com infecção avançada pelo vírus da imunodeficiência humana (HIV) que desenvolveu uma infecção disseminada por Nocardia asteroides senso estrito tipo VI, com abscesso no psoas. Em nosso conhecimento, não foram relatados na literatura outros casos de abscesso do psoas por Nocardia, no contexto da infecção por HIV.

Disseminated nocardiosis in an elderly patient presenting with prolonged pyrexia: Diagnosis by thyroid abscess culture.

We report a case of nocardiosis in an immunosuppressed elderly patient who presented with prolonged pyrexia. Nocardia asteroides was isolated from the thyroid, with CT scan evidence of dissemination to the brain, abdomen and lungs. The patient succumbed to illness despite aggressive therapy. Autopsy could not be performed. To the best of our knowledge, this is the first reported case from India, on Nocardia asteroides affecting the thyroid tissue.

Subcutaneous nocardial abscess in a post-renal transplant patient.

A case of nocardiosis in a post-renal transplant patient is being reported for the first time from Eastern India. The patient had multiple abscesses on the right thigh and chest. Direct examination of the aspirated pus by Gram stain and modified Ziehl Neelsen stain revealed gram-positive beaded, partially acid-fast, branching filaments. Culture of the pus yielded Nocardia asteroides. The patient responded to surgical drainage and sulphamethoxazole therapy.

Necrotizing nocardial scleritis after combined penetrating keratoplasty and phacoemulsification with intraocular lens implantation: a case report and review of the literature

We report the history and clinical presentation of an 88-year-old female with Fuchs dystrophy who developed an acute anterior necrotizing scleritis in her left eye 23 months after an uncomplicated combined penetrating keratoplasty and phacoemulsification with intraocular lens implantation which progressed to slceral perforation with uveal prolapses. The patient underwent a complete systemic work-up for both autoimmune and infectious causes of scleritis. Surgical specimens of the area of scleral perforation were sent for histology and microbiologic studies. Analysis of surgical specimens revealed the presence of culture-proven Nocardia asteroides as a causative agent for the patient's scleral perforation. Results of her systemic autoimmune work-up were not conclusive. Successful treatment with tectonic scleral reinforcement with donor corneal tissue and preserved pericardium, oral and topical trimethoprim-sulfamethoxazole and topical amikacin salvaged the globe and increased vision. The patient's final best-corrected visual acuity sixteen months after her last operation remains 20/70. Prompt surgical intervention with submission of appropriate specimens for pathological diagnosis and microbiology, along with consultation with rheumatologic and infectious disease specialists, are mandatory to minimize visual loss in cases of suspected infectious necrotizing scleritis.

Relato de caso de esclerite necrosante aguda, evoluindo para perfuração escleral com prolapso uveal, 23 meses após procedimento de ceratoplastia penetrante e facoemulsificação com implante de lente intra-ocular no olho esquerdo sem intercorrências.A paciente foi submetida à avaliação completa auto-imune para esclerite. Biópsia da área de perfuração escleral foi encaminhada para avaliação patológica e microbiológica. Análise de material cirúrgico revelou presença de cultura proveniente de Nocardia asteroides como agente causal da perfuração escleral. Resultados de exames do sistema auto-imune não foram conclusivos. Tratamento foi um sucesso com reforço escleral tectônico do tecido corneano doador, utilização de pericárdio preservado, associado ao uso sistêmico e tópico de sulfametoxazol-trimetropina e amicacina colírio. Apresentou melhora visual após o tratamento e a melhor correção visual final, 16 meses após o último procedimento cirúrgico foi de 20/70. Intervenção cirúrgica precoce, análise patológica e microbiológica do material, associados a consulta a especialistas na área de doenças infecciosas e reumatologia, são primordiais para minimizar perda visual em casos de suspeitas de esclerite infecciosa necrosante.

Evaluation of indirect fluorescent antibody assay for detection of Nocardia

Nocardiosis is an acute or suppurative chronic disease caused by an aerobic, gram-positive, weakly acid-fast and soil-borne filamentous and organism. Nocardia asteroides which is the dangerous and most frequently pathogen, infects humans through the respiratory tract. The bacterium is primarily an opportunistic pathogen that causes the infection in patients with underlying immunodeficiencies. The main purpose of the study was to detect antibody titre against Nocardia in all study groups, using indirect immunofluorescent assay [IFA]. Correlation between the antibody titre against Nocardia with age, sex, occupation, and chronic pulmonary infection and corticosteroid therapy patients was also investigated. The present investigation is a Cross-Sectional study conducted on a population consisted of 300 subjects including 200 hospitalized individuals patients, nurses and healthcare workers from Imam Khomeini hospital, and 100 health adult blood donors. None of the patients had already been diagnosed to be affected by Nocardia. Our results demonstrated four patients suffering from different infections, including TB, mycetoma, chronic pulmonary and chronic obstructive pulmonary diseases were IFA positive. None of the high risk hospital personnel, who were working in close proximity to the areas infected with Nocardia, were found to be IFA positive. Meanwhile there was no positive result in a group of patients [n=34] who were under corticosteroid therapy. Finally, considering the small sample size of the IFA positive cases no significant association between the IFA results and age, sex, occupation and clinical conditions of the subjects could be established

Nocardiose pulmonar e cutânea em paciente usuário de corticosteróide / Pulmonary and cutaneous nocardiosis in a patient treated with corticosteroids

Nocardiose é a infecção localizada ou disseminada causada por bactérias gram positivas do gênero Nocardia. Acomete mais freqüentemente pulmão, pele e sistema nervoso central. Ocorre principalmente em indivíduos com deficiência de imunidade celular e deve ser investigada principalmente quando se tem associação de manifestações respiratórias, cutâneas e neurológicas nesse grupo de pacientes. Relata-se um caso de nocardiose pulmonar e cutânea em paciente usuário de corticosteróide oral para tratamento de bronquiolite obliterante com pneumonia em organização idiopática, que evoluiu com melhora clínico-radiológica após tratamento prolongado com sulfametoxazol-trimetoprim.

Nocardiosis is a localized or disseminated infection caused by gram-positive bacteria of the genus Nocardia. The infection most commonly affects the lungs, skin and central nervous system. Nocardiosis principally occurs in individuals with cellular immunodeficiency and should be considered in the differential diagnosis when such individuals present respiratory, cutaneous or neurological alterations. Herein, we report a case of pulmonary and cutaneous nocardiosis in a patient receiving oral corticosteroids to treat bronchiolitis obliterans accompanied by organizing pneumonia of unknown origin. After long-term treatment with sulfamethoxazole-trimethoprim, the clinical and radiological profile improved.

Nocardiosis in a patient with common variable immunodeficiency.

We report a case of nocardiosis in a 42, years male with common variable immunodeficiency syndrome (CVID). He presented with arthritis, subcutaneous abscess and pleural effusion. Diagnosis of CVID was made during this presentation. Serum IgG, IgA and IgM levels were markedly decreased. Nocardia asteroides was cultured from pleural fluid. He was successfully treated with intravenous immunoglobulin and cotrimoxazole.

Nocardia Asteroides keratitis: report of seven patients and literature review.

PURPOSE: To describe clinical features and treatment outcomes in patients with advanced Nocardia asteroides keratitis. METHODS: Retrospective review of case records of 7 patients with culture-proven Nocardia keratitis. RESULTS: Corneal infection occurred after corneal trauma in two patients, cataract surgery in three patients, penetrating keratoplasty in one patient and was associated with a silicone buckle element infection in one patient. Mean duration of infection at presentation was 33.4 days (7-75 days), and five patients had received prior treatment with corticosteroids. Six of seven patients had deep corneal suppuration at the time of presentation, clinically suggestive of mycotic keratitis. In two patients who had received prolonged corticosteroid therapy (> or = 45 days), the eyes could not be salvaged. Complete resolution of infection was achieved in all 4 eyes treated with topical fortified cefazolin eye drops (50 mg/ml).

Isolamento de Niocardia asteroides de lesäo granulomatosa em carne bovina / Isolation of Niocardia asteroides of granulomatous lesions in bovine meat

Os produtos de origem animal desempenham importante papel na alimentaçäo humana devido ao seu valor protéico, porém deve-se evitar que sirvam de vias de transmissäo de doenças aos seus consumidores. A interaçäo dinâmica entre o serviço de inspeçäo de carnes e as técnicas laboratoriais diagnósticas deve ser mantida na profilaxia das doenças veiculadas por alimentos. Relata um caso de contaminaçäo bacteriana de tecido muscular de bovino destinado ao consumo humano. Macroscopicamente observaram-se lesöes granulomatosas semelhantes àquelas associadas à tuberculose. Colheu-se 2,0g do material e, utilizando-se a técnica de descontaminaçäo de Petroff (OPS 1993), tentou-se o isolamento de Mycobacterium ssp, a partir dos meios de Lowenstein-Jensen e de Stonebrink-Lesslie a 37§C. Outro fragmento foi colhido e fixado em formol a 10 por cento para exame histopatológico. Após sete dias de cultivo observou-se no meio de Lowenstein-Jensen a presença de colônias rugosas com pigmento alaranjado. No exame bacteriológico observou-se micélios que se fragmentavam formando bacilos Gram positivos. No corte histológico, corado em Hematoxilina-Eosina, verificaram-se estruturas granulomatosas. Foi identificado Nocardia asteroides a partir das colônias isoladas. Estes microrganismos säo considerados saprófitas, telúricos capazes de causar infecçöes inicialmente pulmonares, disseminando-se posteriormente para outros órgäos, como: rins, baço, fígado, cérebro e ocasionalmente de desenvolver micetomas. Sem auxílio de profissionais integrados e capacitados para diagnosticar esta patologia, haveria maior risco para o consumidor. Conclui-se, portanto, que a crescente integraçäo entre os profissionais de saúde pública e saúde animal permite o aprimoramento das práticas diagnósticas e de prevençäo das zoonoses.

Acid fast filaments in stool samples from an aids patient

The presence of filamentous bacteria morphologically similar to Nocardia in a fresh stool sample from an AIDS patient with pulmonary nocardiosis is here reported. The material was submitted to our laboratory for a parasitologic examination and was stained by the Kinyoun method, revealing numerous delicate, irregularly stained, branching acid-fast filaments. Nocardia asteroides had been isolated from sputum samples of this patient. The patient was a 32 year-old HIV+ female admitted to our center on june 1997 because of productive cough, right-sided thoracic pain and weight loss. Chest X rays showed the presence of right superior lobe excavated pneumonia. This was the first time we had observed filamentous bacteria similar to Nocardia in a stool sample submitted to parasitologic examination. For similar cases, and when its presence was not detected in other specimens collected from the same patient, intestinal endoscopy and biopsy should be performed for eventual lesions and smear examination repeated with Kinyoun stain and cultures for Nocardia.

Nocardia asteroides en absceso pulmonar interpretado como de origen tuberculoso: caso fatal / Nocardia asteroides in a pulmonary abscess considered to be of a tuberculous origin: fatal case

Se informa el hallazgo de cultivos puros de n. asteroides a partir de la colección purulenta obtenida por drenaje quirúrgico de un absceso en base pulmonar derecha, de 6 cm de diámetro, en una niña de 13 años de edad con desnutrición de segundo grado y antecedentes de tuberculosis. Lo prolongado de la evolución diagnóstica, el cuadro infeccioso inespecífico, y el probable deterioro inmunológico pudieron haber producido cierta demora en el diagnóstico y por lo tanto para el desenlace fatal