Absceso cerebral por nocardia SP en paciente con anemia hemolítica reporte de un caso / Cerebral abscess due to nocardia SPP in a patient with hemolytic anemia report of a case

Las infecciones por Nocardia no son comunes para humanos inmunocompetentes la mayoría de casos es reportada en pacientes inmunosupresos, usualmente la mayoría de estos casos se reportan a nivel pulmonar y tejidos blandos. Los abscesos por Nocardia son usualmente poco comunes reportando aproximadamente el 1 a 2% del total de abscesos cerebrales. A continuación, se describe el caso de una paciente con antecedente de Anemia Hemolítica a quien se diagnosticó absceso cerebral por Nocardia...(AU)

Clinical significance, antimicrobial susceptibility and molecular identification of Nocardia species isolated from children with cystic fibrosis

ABSTRACT Nocardia is an opportunistic pathogen that causes respiratory infections in immunocompromised patients. The aim of this study was to analyze the epidemiology, clinical significance and antimicrobial susceptibility of Nocardia species isolated from eight children with cystic fibrosis. The isolated species were identified as Nocardia farcinica, Nocardia transvalensis, Nocardia pneumoniae, Nocardia veterana and Nocardia wallacei. N. farcinica was isolated in three patients and all of them presented lung affectation with a chronic colonization and pneumonia. N. farcinica showed resistance against gentamicin, tobramycin, cefotaxime, but was susceptible to trimethoprim-sulfamethoxazole and amikacin. N. transvalensis, which was isolated from two patients, showed an association with chronic colonization. N. transvalensis was resistant to tobramycin and amikacin, but susceptible to ciprofloxacin, trimethoprim-sulfamethoxazole and cefotaxime. N. veterana, N. pneumoniae and N. wallacei were isolated from three different patients and appeared in transitory lung colonization. N. veterana and N. pneumoniae were susceptible to imipenem, trimethoprim-sulfamethoxazole, amikacin, tobramycin, and cefotaxime. N. wallacei was resistant to amikacin, tobramycin, imipenem, and trimethoprim-sulfamethoxazole and susceptible to ciprofloxacin and cefotaxime. All the isolates were identified up to species level by 16S rRNA gene sequencing. The presence of Nocardia in the sputum of patients with cystic fibrosis is not always an indication of an active infection; therefore, the need for a treatment should be evaluated on an individual basis. The detection of multidrug-resistant species needs molecular identification and susceptibility testing, and should be performed for all Nocardia infections.

MOLECULAR IDENTIFICATION AND ANTIMICROBIAL RESISTANCE PATTERN OF SEVEN CLINICAL ISOLATES OF Nocardia spp. IN BRAZIL / Identificação molecular e perfil de sensibilidade a antimicrobianos de sete isolados clínicos de Nocardia spp. no Brasil

Nocardia is a ubiquitous microorganism related to pyogranulomatous infection, which is difficult to treat in humans and animals. The occurrence of the disease is on the rise in many countries due to an increase in immunosuppressive diseases and treatments. This report of cases from Brazil presents the genotypic characterization and the antimicrobial susceptibility pattern using the disk-diffusion method and inhibitory minimal concentration with E-test® strips. In summary, this report focuses on infections in young adult men, of which three cases were cutaneous, two pulmonary, one neurological and one systemic. The pulmonary, neurological and systemic cases were attributed to immunosuppressive diseases or treatments. Sequencing analysis of the 16S rRNA segments (1491 bp) identified four isolates of Nocardia farcinica, two isolates of Nocardia nova and one isolate of Nocardia asiatica. N. farcinica was involved in two cutaneous, one systemic and other pulmonary cases; N. nova was involved in one neurological and one pulmonary case; and Nocardia asiatica in one cutaneous case. The disk-diffusion antimicrobial susceptibility test showed that the most effective antimicrobials were amikacin (100%), amoxicillin/clavulanate (100%), cephalexin (100%) and ceftiofur (100%), while isolates had presented most resistance to gentamicin (43%), sulfamethoxazole/trimethoprim (43%) and ampicillin (29%). However, on the inhibitory minimal concentration test (MIC test), only one of the four isolates of Nocardia farcinica was resistant to sulfamethoxazole/trimethoprim.

Nocardia é um microorganismo ubiquitário relacionado a infecções piogranulomatosas, com difícil resolução tecidual em humanos e animais. A doença é mundialmente emergente devido ao aumento de doenças e tratamentos imunossupressores. Este relato de casos ocorridos no Brasil visa apresentar a identificação molecular dos isolados e o padrão de sensibilidade a antimicrobianos por disco-difusão e concentração inibitória mínima (CIM) através de fitas E-test®. Os casos ocorreram em homens, em idade adulta. Três quadros foram cutâneos, dois pulmonares, um neurológico e um sistêmico. O quadro respiratório, o neurológico e um sistêmico estavam associados à doença ou terapia imunossupressoras. O sequenciamento do gene 16S rRNA (1491pb) possibilitou a identificação de quatro isolados de Nocardia farcinica, dois de Nocardia nova e um de Nocardia asiatica. N. farcinica foi observada em dois casos dermatológicos, um pulmonar e um quadro sistêmico, N. nova foi isolada de um caso neurológico e outro pulmonar; e N. asiatica em um caso dermatológico. O teste de disco-difusão mostrou que amicacina (100%), amoxicilina/clavulanato (100%), cefalexina (100%) e ceftiofur (100%) foram mais efetivos; enquanto gentamicina (43%), sulfametoxazol/trimetoprim (43%) e ampicilina (29%) foram menos efetivos. No entanto, no teste de concentração inibitória mínima (CIM), apenas um dos quatro isolados da espécie Nocardia farcinica mostrou-se resistente a sulfametoxazole-trimetropina.

Nocardia veterana: disseminated infection with urinary tract infection

Nocardia spp. are a group of aerobic actinomycetes widely distributed in soil, and associated with severe opportunistic infections, essentially pulmonary infections. We report the first case of disseminated infection associated with urinary tract infection caused by Nocardia veterana. The diagnosis was difficult; despite the presence of pulmonary nodules, the lung biopsies remained negative while only one aerobic blood culture and the urine culture were positive for N. veterana, identified after a 16S rDNA gene sequence analysis. Few cases of clinical importance due to N. veterana have been published since its characterization. The bacteriological diagnosis of nocardiosis can be difficult to establish because of the delayed growth and the specific techniques that are required. This case illustrates the necessity of performing specific investigations in immunocompromised patients who present with infectious disease because the severity of this infection requires early diagnosis and quick initiation of appropriate antibiotic therapy.

DIFFERENTIATION BETWEEN Nocardia spp. AND Mycobacterium spp.: CRITICAL ASPECTS FOR BACTERIOLOGICAL DIAGNOSIS / Diferenciação de Nocardia spp. e Mycobacterium spp.: aspectos críticos para o diagnóstico bacteriológico

New methodologies were developed for the identification of Nocardia but the initial diagnosis still requires a fast and accurate method, mainly due to the similarity to Mycobacterium, both clinical and bacteriologically. Growth on Löwenstein-Jensen (LJ) medium, presence of acid-fast bacilli through Ziehl-Neelsen staining, and colony morphology can be confusing aspects between Nocardia and Mycobacterium. This study describes the occurrence of Nocardia spp. in a mycobacterial-reference laboratory, observing the main difficulties in differentiating Nocardia spp. from Mycobacterium spp., and correlating isolates with nocardiosis cases. Laboratory records for the period between 2008 and 2012 were analyzed, and the isolates identified as Nocardia sp. or as non-acid-fast filamentous bacilli were selected. Epidemiological and bacteriological data were analyzed as well. Thirty-three isolates identified as Nocardia sp. and 22 as non-acid-fast bacilli were selected for this study, and represented 0.12% of isolates during the study period. The presumptive identification was based on macroscopic and microscopic morphology, resistance to lysozyme and restriction profiles using the PRA-hsp65 method. Nocardia spp. can grow on media for mycobacteria isolation (LJ and BBL MGIT™) and microscopy and colony morphology are very similar to some mycobacteria species. Seventeen patients (54.8%) were reported and treated for tuberculosis, but presented signs and symptoms of nocardiosis. It was concluded that the occurrence of Nocardia sp. during the study period was 0.12%. Isolates with characteristics of filamentous bacilli, forming aerial hyphae, with colonies that may be pigmented, rough and without the BstEII digestion pattern in PRA-hsp65 method are suggestive of Nocardia spp. For a mycobacterial routine laboratory, a flow for the presumptive identification of Nocardia is essential, allowing the use of more accurate techniques for the correct identification, proper treatment and better quality of life for patients.

Novas metodologias têm sido desenvolvidas para a identificação de Nocardia spp. mas o diagnóstico inicial ainda necessita de método rápido e preciso, principalmente devido à similaridade com o gênero Mycobacterium, clínica e bacteriologicamente. O crescimento em meio de Löwenstein Jensen (LJ), a presença de bacilos corados pela coloração de Ziehl Neelsen e colônias com características diferentes podem ser fatores de confusão entre nocardias e micobactérias. Este estudo descreve a ocorrência de Nocardia spp. em laboratório de referência em micobacteriologia, observando-se as principais dificuldades em diferenciar Nocardia spp. e Mycobacterium spp., correlacionando isolados com casos de nocardiose. Os registros laboratoriais dos anos 2008 a 2012 foram analisados e os isolados identificados como Nocardia sp. ou como bacilos não álcool - ácido resistentes (NBAAR) foram selecionados. Os dados epidemiológicos e bacteriológicos foram analisados. Trinta e três isolados identificados como Nocardia sp. e 22 como NBAAR foram selecionados para este estudo, perfazendo 0,12% do total de isolados identificados no período estudado. A identificação presuntiva foi baseada na morfologia macroscópica e microscópica, resistência à lisozima e perfis de restrição pelo método PRA-hsp65. Nocardia spp. pode crescer em meios de isolamento para micobactérias (LJ e BBL MGIT™) e microscopia de morfologia e as colônias são muito semelhantes a algumas espécies de micobactérias. Dezessete pacientes (54,8%) foram notificados e tratados para tuberculose, mas apresentaram sinais e sintomas para nocardiose. Concluimos que a ocorrência de Nocardia sp. no período estudado foi de 0,12%. Os isolados com características de bacilos filamentosos, formadores de hifas aéreas, com colônias que podem ter pigmento, rugosas e que não possuem padrão de digestão para BstEII no método PRA-hsp65 são sugestivos de Nocardia spp. Para um laboratório de rotina de Micobactérias, um fluxo de identificação presuntiva para Nocardia spp. é essencial para permitir que esses isolados sejam identificados com técnicas mais precisas, para que seja oferecido o tratamento adequado e qualidade de vida aos pacientes.

Pulmão dos criadores de aves complicado por nocardiose pulmonar / Bird fancier's lung complicated by pulmonary nocardiosis

Relatamos o caso de um paciente de 84 anos que foi hospitalizado devido a tosse persistente e dispneia. A radiografia de tórax inicial revelou infiltrados pulmonares. Nocardia asteroides foi detectada no escarro, e o paciente foi tratado com antibióticos; entretanto, seus sintomas não melhoraram por completo. O paciente foi hospitalizado várias vezes, e os sintomas reapareceram após cada alta. Houve a suspeita de pneumonite de hipersensibilidade, sendo o paciente diagnosticado com pulmão dos criadores de aves. É provável que a nocardiose pulmonar se desenvolva em pacientes com doenças pulmonares crônicas, como DPOC, e em hospedeiros imunossuprimidos. Até onde sabemos, este é o primeiro relato de um caso de pulmão dos criadores de aves complicado por nocardiose pulmonar.

We report the case of an 84-year-old male who was admitted to the hospital with persistent cough and dyspnea. An initial chest X-ray revealed pulmonary infiltrates. Nocardia asteroides was detected in sputum, and the patient was treated with antibiotics. However, his symptoms did not completely resolve. He was admitted multiple times, and his symptoms relapsed after every discharge. He was finally suspected of having hypersensitivity pneumonitis and was diagnosed with bird fancier's lung. Pulmonary nocardiosis is likely to develop in patients with chronic pulmonary disorders, such as COPD, as well as in immunosuppressed hosts. To our knowledge, this is the first report of a case of bird fancier's lung complicated by pulmonary nocardiosis.

Nocardia brasiliensis primary pulmonary nocardiosis with subcutaneous involvement in an immunocompetent patient.

This is a report of an unusual case of Nocardia brasiliensis causing primary pulmonary nocardiosis with disseminated subcutaneous lesions in an immunocompetent patient. This case highlights the importance of considering nocardiosis as a differential diagnosis in patients with pulmonary and cutaneous lesions and the need for vigorous management for complete cure.

A rare case of pulmonary nocardiasis in an AIDS patient.

Nocardia infections are rare among normal individuals. Mostly they occur in immuno-compromised individuals. Here, we report a case of pulmonary nocardiosis in a person who was diagnosed as having pulmonary tuberculosis and was treated with anti-tuberculous treatment for 6 months. But the sputum smear was positive even after a complete course of treatment. The patient was seropositive to HIV-1 antibodies.

Primary sternal osteomyelitis caused by Nocardia nova: case report and literature review

A 51 year old woman without significant past medical history or risk factors for Nocardia infection developed primary Nocardia nova sternal osteomyelitis with mediastinal abscess, diagnosed with open biopsy. She required prolonged antibiotic therapy and had a favorable outcome. Primary sternal osteomyelitis develops in the absence of a contiguous focus of infection, as opposed to secondary sternal osteomyelitis, which is usually a complication of sternotomy. Staphylococcus aureus probably still is the most common cause of both forms of sternal osteomyelitis. Nocardia species invade humans usually through the respiratory tract and can cause a variety of localized infections through the hematogenous route. Pulmonary involvement may or may not coexist. Immunosuppressed patients are more prone to infection by Nocardia species, although cases involving seemingly immunocompetent patients are not rare. This is the first reported case in the English literature of primary sternal osteomyelitis due to Nocardia nova or any other Nocardia species.

Nocardiosis: an overview and additional report of 28 cases in cattle and dogs / Nocardiose: visão geral e relato de 28 casos em vacas e cães

Phenotypic characteristics, antimicrobial susceptibility profile, and clinical-epidemiological features of 28 Nocardia strains isolated from 19 cases of bovine mastitis, eight cutaneous-subcutaneous lesions and one case of pneumonia in dogs were evaluated. Microbiological, biochemical, cytological and scanning electron microscopy methods were used in diagnosis. Nocardia asteroides type IV, Nocardia otitidiscaviarum,Nocardia nova (type III) and Nocardia farcinica (type V) were isolated from bovine milk, bronchial lavage and/or cutaneous-subcutaneous abscesses in dogs. Nocardial bovine mastitis was diagnosed predominantly in clinical cases, in dairy herds with poor environmental hygienic conditions between milking and inappropriate intramammary therapy. Canine nocardiosis was observed commonly in animals co-infected with distemper virus. Sulphamethoxazole-trimethoprim (92.8 percent), amikacin (92.8 percent) and ceftiofur (92.8 percent) were the most effective drugs in 28 isolates. Multiple drug resistance to three or more and five or more antimicrobials was observed in ten (35.7 percent) and three (10.7 percent) strains, respectively, predominantly with use of cloxaxillin, cefoperazone and ampicillin. The species (type) classification, clinical-epidemiological characteristics, diagnosis, multiple-drug resistance and public health considerations in Nocardia strains isolated from cattle and dogs in Brazil are discussed, with special reference to report of bovine mastitis by N. otitidiscaviarum by first time in Brazil and the similarity between Nocardia species isolated from human and animal origin.

A caracterização fenotípica, perfil de sensibilidade aos antimicrobianos e aspectos clínico-epidemiológicos foram avaliados em 28 linhagens de Nocardia isoladas de 19 casos de mastite, oito lesões tegumentares e um caso de pneumonia em cão. Foram utilizados no diagnóstico métodos microbiológicos, bioquímicos, citológicos e microscopia eletrônica de varredura. Nocardia asteroides tipo IV, N. otitidiscaviarum,N. nova (tipo III) e N. farcinica (tipo V) foram isoladas do leite de vacas com mastite, de material de lavado transtraqueal e de lesões cutâneas de cães. Nocardiose mamária bovina foi diagnosticada predominantemente sob a forma clínica, em propriedades com precárias condições de higiene na pré e pós-ordenha, e inadequado procedimento de terapia intramamária. Nocardiose canina foi diagnosticada comumente em animais co-infectados com o vírus da cinomose. Sulfametoxazole/trimetoprim (92,8 por cento), amicacina (92,8 por cento) e ceftiofur (92,8 por cento) foram os antimicrobianos mais efetivos frente às linhagens de Nocardia. Resistência múltipla a três ou mais e cinco ou mais antimicrobianos foram observadas, respectivamente, em dez (35,7 por cento) e três (10,7 por cento) linhagens, notadamente frente à cloxacilina, cefoperazona e ampicilina. A caracterização de espécies (tipo), aspectos clínico-epidemiológicos, diagnóstico, resistência múltipla aos antimicrobianos e reflexos em saúde pública de linhagens de Nocardia isoladas de bovinos e cães no Brasil foram discutidos. Foi destacada a similaridade entre as espécies de Nocardia isoladas de animais e do homem, e a primeira descrição no Brasil de N. otitidiscaviarum na etiologia da mastite bovina.

Nocardial infections: report of 22 cases

Twenty-two cases of nocardial infections were diagnosed in our city between 1977- 1998. All patients whose clinical specimens showed Nocardia spp. at Gram stain, which were further confirmed by culture, were selected to be included in the study. Data from patients who were cured were compared with those from patients who died by statistical tests using EPIINFO version 6.04 software. Six isolates were identified as Nocardia asteroides complex, one as Nocardia asteroides sensu stricto and other as Nocardia brasiliensis. We had 17 cases of lung nocardiosis, being one out of them also a systemic disease. Other four cases of systemic nocardiosis were diagnosed: nocardial brain abscesses (one); nocardiosis of the jejunum (one); multiple cutaneous abscesses (one); and a case of infective nocardial endocarditis of prosthetic aortic valve. One patient had a mycetoma by N. brasiliensis. Fifteen (68.2 percent) out of 22 patients were immunosuppressed, being most (93.3 percent) by high-doses corticotherapy. Mortality by nocardial infection was 41 percent; mortality of systemic nocardiosis was 60 percent. Nocardiosis has a bad prognosis in immunosuppressed patients and also in non-immunosuppressed patients if the diagnosis is delayed. We propose that the delay in diagnosis should be examined in larger series to document its influence in the prognosis of the disease.

São apresentados 22 casos de infecção por Nocardia species entre 1977 e 1998, apresentando-se seu quadro clínico e evolução. Todos os pacientes cujos espécimes clínicos mostraram microorganismos sugestivos de Nocardia spp. à coloração de Gram, confirmados posteriormente por cultura, foram incluídos no estudo. Os dados dos pacientes que obtiveram cura foram comparados com aqueles dos pacientes que foram a óbito pelo programa EPIINFO versão 6.04; nível de significância menor que 5 por cento foi considerado estatisticamente significativo. Foram obtidos 22 casos de infecção por Nocardia spp.: seis isolamentos identificados como Nocardia asteroides complex, um como Nocardia asteroides sensu stricto e outro como Nocardia brasiliensis, enquanto os restantes foram identificados como Nocardia spp. Tivemos 17 casos de nocardiose pulmonar (um com disseminação). Tivemos outros quatro casos de nocardiose sistêmica: múltiplos abscessos cerebrais (um); endocardite infecciosa de prótese valvular aórtica (um); nocardiose de intestino delgado (um); abscessos cutâneos múltiplos por Nocardia spp (um). Um paciente apresentou micetoma por Nocardia brasiliensis. Imunossupressão esteve presente em 15 pacientes (68,2 por cento), predominantemente por corticoterapia (93,3 por cento). Nossa mortalidade foi 41 por cento; a mortalidade dos pacientes com nocardiose sistêmica foi de 60 por cento. A nocardiose tem pior prognóstico em pacientes imunossuprimidos e em pacientes com nocardiose sistêmica.

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.

Absceso recidivante por Nocardia asteroides en una paciente portadora de poliglobulia primaria / Recurrent brain abscess caused by Nocardia asteroides in a patient with primary polycythaemia

La nocardiosis del sistema nervioso central (SNC) es una enfermedad poco común, cuya frecuencia ha aumentado con el crecimiento de los tratamientos inmunosupresores. El hombre se infecta por inhalación, inoculación traumática cutánea directa y tras una infección periodontal ingiriendo alimentos contaminados. La localización pulmonar es la más frecuente, siendo la fuente inicial de diseminación hemática, con predominio en piel, tejido celular subcutáneo y SNC. Es conocida la predilección de Nocardia por el SNC. Estos abscesos, asociados a altos índices de mortalidad, especialmente en pacientes inmunocomprometidos, siguen constituyendo un desafío diagnóstico y terapéutico, permaneciendo no aclarado su manejo terapéutico óptimo. A pesar de la controversia en cuanto al manejo quirúrgico de estas lesiones, el diagnóstico precoz, por aspiración esterotáxica, y la iniciación de una terapia antimicrobiana son esenciales para la buena evolución del paciente. Se presenta una paciente portadora de una poliglobulia primaria, con absceso cerebral recidivante por Nocardia asteroides de posible origen dentario.

Estudio clínico y microbiológico de los micetomas observados en el Hospital de Infecciosas Francisco J. Muñiz en el período 1989-2004 / Clinical and microbiological study of mycetomas at the Muñiz Hospital of Buenos Aires between 1989 and 2004

Se presentan las características clínicas, microbiológicas y los resultados del tratamiento de 76 casos de micetomas observados en el período 1989-2004 en el Hospital Muñiz. Cuarenta y nueve fueron varones y 27 mujeres, con una edad promedio de 43,4 años. La mayor parte de los pacientes adquirió la infección en nuestro país, las provincias más afectadas fueron Santiago del Estero con 31 casos y el Chaco con 11; 8 enfermos procedían del exterior, 6 de Bolivia y 2 de Paraguay. El promedio de evolución de la enfermedad fue de 9,2 años. Las localizaciones más comunes fueron las de los miembros inferiores: pies 63, tobillos 3 y rodillas 2. Se comprobó compromiso óseo en 48 casos y adenomegalias en 5. Fueron identificados los siguientes agentes causales: Madurella grisea 29 casos, Actinomadura madurae 26, Scedosporium apiospermum 5, Nocardia brasiliensis 5, Acremoniun spp. 4 (Acremonium falciforme 2, Acremonium kiliense 1 y Acremonium recifei 1), Madurella mycetomatis 3, Fusarium solani 2, Nocardia asteroides y Streptomyces somaliensis 1 caso cada uno. Los tratamientos más frecuentemente utilizados fueron ketoconazol o itraconazol en los micetomas maduromicósicos y la asociación de cotrimoxazol con ciprofloxacina o amicacina en los micetomas actinomicéticos. La amputación del miembro afectado se realizó en 6 casos, 25 pacientes alcanzaron la remisión clínica completa y 34 presentaron mejorías importantes.

This work presents clinical, microbiological and outcome data collected from 76 patients with mycetomas at the Muñiz Hospital from 1989 to 2004. Forty-nine patients were male and 27 female; the mean age was 43.4 years. The majority of the patients acquired the infection in Argentina: the most affected provinces were Santiago del Estero with 31 cases, and Chaco with 11; 8 cases came from other countries (Bolivia 6 and Paraguay 2). The mean evolution of the disease was 9.2 years. The most frequently observed sites were: feet 63 cases, ankles 3, and knees 2. Forty-eight patients had bone lesions and 5, adenomegalies. The following etiological agents were identified: Madurella grisea 29 cases, Actinomadura madurae 26, Scedosporium apiospermum 5, Nocardia brasiliensis 5, Acremonium spp. 4 (Acremonium falciforme 2, Acremonium kiliense 1, Acremonium recifei 1), Madurella mycetomatis 3, Fusarium solani 2, Nocardia asteroides 1 and Streptomyces somaliensis 1. The main drugs used in the treatments were ketoconazole and itraconazole for maduromycotic mycetomas, and cotrimoxazole associated with ciprofloxacin or amikacin for actinomycetic mycetoma. Six patients had to undergo amputation, 25 cases achieved complete clinical remission and 34 showed remarkable improvement.

A fatal pulmonary infection by Nocardia brasiliensis.

The reported case is of primary pulmonary nocardiosis, caused by Nocardia brasiliensis, in a immunocompromised patient, which ended fatally despite appropriate treatment. The partially acid fast filamentous bacterium was predominant on direct examination of the sputum. It was cultured on blood agar, MacConkey agar and by paraffin baiting technique. The bacterium was resistant to cotrimoxazole, the drug of choice for nocardiosis.