Pulmonary Nocardiosis Due to Nocardia exalbida Infection Following Living-donor Liver Transplantation.

Nocardia exalbida, an uncommon Nocardia, was first identified in 2006. We herein report a 70-year-old man with pulmonary nocardiosis caused by N. exalbida after living-donor liver transplantation. We also review 11 previously reported cases of N. exalbida infections. To our knowledge, there are no case reports available on nocardiosis consequent to N. exalbida infection following transplantation, thus highlighting the importance of identifying bacterial species for the successful management of infection.

[Cholestasis, delirium and pulmonary nocardiosis in a man with systemic lupus erythematosus of late onset]. / Colestasis, delirium y nocardiosis pulmonar en un varón con lupus eritematoso sistémico de inicio tardío.

A case is presented of a 64-year-old male patient who was admitted because of delirium, jaundice, a pattern of cholestasis in the liver profile and a right lung mass in the context of a constitutional syndrome and weight loss in the last eight months. The lung mass was punctured and the culture of the obtained material developed white colonies, identified by mass spectrometry (MALDI-TOF) as Nocardia cyriacigeorgica. Regarding the clinical diagnosis, it was considered as systemic lupus erythematosus (SLE), on the basis of fulfilling 8 criteria according to SLICC 2012 group, and 24 points according to EULAR/ACR 2019. The liver biopsy showed a mixt cellular infiltrate in portal spaces, with absence of interphase hepatitis and presence of peripheral ductular reaction. These findings were interpreted as liver compromise relate to SLE. Delirium was also considered as a neurological manifestation related to SLE on the basis of ruling out other causes. After being treated with antibiotics and documenting a reduction in the size of the lung mass he received cyclophosphamide in intravenous pulses, achieving normalization of his liver profile and his state of consciousness, and a progressively weight recovering. A year after he was in good health. The report of this case is justified because of the rare presenting form of late onset SLE, as well as the concomitant pulmonary nocardiosis in the absence of previous immunosuppressant treatment.

Se presenta el caso de un varón de 64 años que fue internado por delirium asociado a ictericia con patrón de colestasis en el hepatograma, y una masa en el pulmón derecho en el contexto de pérdida de peso y síndrome constitucional de 8 meses de evolución. Se realizó punción de la masa pulmonar cuyo cultivo desarrolló colonias blanquecinas identificadas como Nocardia cyriacigeorgica por espectrometría de masas (MALDI-TOF MS). Se llegó al diagnóstico de lupus eritematosos sistémico (LES) por presentar 8 de los criterios de acuerdo con el grupo SLICC 2012 y 24 puntos de acuerdo a los criterios EULAR/ACR 2019. La biopsia hepática mostró leve y variable infiltrado inflamatorio mixto en espacios porta, con ausencia de hepatitis de interfase y presencia de reacción ductular periférica. Se interpretaron estos hallazgos como vinculados a hepatopatía por LES. El delirium fue interpretado como afectación neurológica por LES en base al descarte de otras enfermedades. Recibió tratamiento antibiótico y tras constatarse reducción del tamaño de la masa pulmonar se administraron pulsos de ciclofosfamida intravenosa. Evolucionó favorablemente, con normalización del hepatograma y el estado de conciencia, y recuperación del peso en forma progresiva. Al año se lo encontró en buen estado de salud. Justifica el reporte del caso la rara forma de presentación del LES de comienzo tardío, así como la nocardiosis pulmonar concomitante sin tratamiento inmunosupresor previo.

Unusual Presentation of Nocardiosis With Pleural Effusion in an Immunocompetent Host.

Nocardiosis is a disease caused by gram-positive, catalase-positive, rod-shaped bacteria that stain weakly on a Gram stain. It usually affects the lungs and skin but can cause disseminated infections. Nocardia has 85 species, ranging from nonpathogenic to pathogenic. Nocardia is an opportunistic organism that causes infections in the immunocompromised; however, 7% of the immunocompetent population has suffered from Nocardia infection. This case report highlights an unusual occurrence of pulmonary nocardiosis in a 31-year-old woman with a normal immune system. She was initially treated as an outpatient for what appeared to be community-acquired pneumonia. However, her condition deteriorated, ultimately revealing a substantial right pleural effusion with loculation and adjacent compressive atelectasis affecting a significant portion of her right middle and lower lung lobes, as detected by a CT scan followed by pleural fluid analysis which confirmed the infection. By sharing this experience, we aim to contribute to the collective knowledge of medical professionals and improve the accuracy of diagnosis and treatment.

The first reported pulmonary nocardiosis caused by Nocardia gipuzkoensis resisted to trimethoprim/sulfamethoxazol (TMP-SMZ) in an immunocompetent patient.

OBJECTIVES: Nocardia gipuzkoensis was first described as a novel and distinct species in 2020 by Imen Nouioui and pulmonary nocardiosis associated with N. gipuzkoensis was once reported in two bronchiectasis patients. Noteworthy, both reported N. gipuzkoensis cases showed sensitivity to trimethoprim/sulfamethoxazol (TMP-SMZ), which are usually recommended for empirical therapy. METHODS: We reported the third case of N. gipuzkoensis infection in a 16-year-old girl with chief complaints of cough and persistent chest and back pain. No underlying immuno-suppressive conditions and glucocorticoid use was revealed. Patchy lesions next to the spine and located in the posterior basal segment of the lower lobes of the left lung were seen in thorax computed tomography (CT), but no pathogenic bacteria were detected according to routine laboratory testings. RESULTS: Metagenomic next-generation sequencing (mNGS) combined with whole-genome sequencing (WGS) was used to classified our isolate from bronchoalveolar lavage fluid (BALF) as N. gipuzkoensis. It is worth mentioning that drug susceptibility testing of our isolate showed resistance to TMP-SMZ, which was never reported before. The patient improved remarkably both clinically and radiographically according to the treatment with imipenem-cilastatin infusion alone. CONCLUSION: mNGS and WGS showed excellent performance in identifying the Nocardia genus to the species level and improving the detection rate of N. gipuzkoensis ignored by traditional culture. Different from previously reported cases, the N. gipuzkoensis infection case showed resistance to TMP-SMZ, which is an unprecedented finding and a crucial addition to our understanding of the antibacterial spectrum of N. gipuzkoensis. The successful treatment with imipenem-cilastatin infusion alone in this case is a testament to the importance of precise identification and tailored antibiotic therapy.

Unremitting Asthma as a Presentation of Pulmonary Nocardiosis: A Case Report.

Severe, refractory asthma requires a combination of multiple maintenance inhalers and medications including high-dose inhaled corticosteroids and immunomodulators to achieve control of symptoms. The use of inhaled corticosteroids, however, increases the susceptibility of opportunistic bacterial infections, such as Nocardia, resulting in pulmonary nocardiosis. This case describes a 46-year-old patient with a history of severe, refractory asthma who presented with progressively worsening asthma exacerbation symptoms. She was treated with immunomodulators, high-dose inhaled corticosteroids and oral steroids, and several courses of antibiotics. CT imaging revealed bibasilar peri-bronchial thickening and tree-in-bud nodularity in the right lower lobe. Pulmonary cultures collected from bronchoscopy grew Nocardia nova complex. This was a rare case of persistent asthma exacerbation by N. nova complex bronchopulmonary infection. Broad differentials should be considered in patients with severe, refractory asthma who were previously controlled and were found to fail treatment therapies. Immunocompromised patients with chronic lung disease are at higher risk of severe infection with disseminated nocardiosis. These patients have a higher mortality and morbidity risk if early diagnosis of pulmonary nocardiosis does not occur.

Comparative Analysis of CT Findings and Clinical Outcomes in Adult Patients With Disseminated and Localized Pulmonary Nocardiosis.

BACKGROUND: Pulmonary nocardiosis is a rare opportunistic infection with occasional systemic dissemination. This study aimed to investigate the computed tomography (CT) findings and prognosis of pulmonary nocardiosis associated with dissemination. METHODS: We conducted a retrospective analysis of patients diagnosed with pulmonary nocardiosis between March 2001 and September 2023. We reviewed the chest CT findings and categorized them based on the dominant CT findings as consolidation, nodules and/or masses, consolidation with multiple nodules, and nodular bronchiectasis. We compared chest CT findings between localized and disseminated pulmonary nocardiosis and identified significant prognostic factors associated with 12-month mortality using multivariate Cox regression analysis. RESULTS: Pulmonary nocardiosis was diagnosed in 75 patients, of whom 14 (18.7%) had dissemination, including involvement of the brain in 9 (64.3%) cases, soft tissue in 3 (21.4%) cases and positive blood cultures in 3 (21.4%) cases. Disseminated pulmonary nocardiosis showed a higher frequency of cavitation (64.3% vs. 32.8%, P = 0.029) and pleural effusion (64.3% vs. 29.5%, P = 0.014) compared to localized infection. The 12-month mortality rate was 25.3%. The presence of dissemination was not a significant prognostic factor (hazard ratio [HR], 0.80; confidence interval [CI], 0.23-2.75; P = 0.724). Malignancy (HR, 9.73; CI, 2.32-40.72; P = 0.002), use of steroid medication (HR, 3.72; CI, 1.33-10.38; P = 0.012), and a CT pattern of consolidation with multiple nodules (HR, 4.99; CI, 1.41-17.70; P = 0.013) were associated with higher mortality rates. CONCLUSION: Pulmonary nocardiosis with dissemination showed more frequent cavitation and pleural effusion compared to cases without dissemination, but dissemination alone did not affect the mortality rate of pulmonary nocardiosis.

Nocardia otitidiscaviarum causing pulmonary nocardiosis: a case report and its review of the literature.

Background: Infections caused by Nocardia spp. can occur in immunocompromised as well as immunocompetent individuals. Although nocardiosis is rare, it is being increasingly recognized owing to the rise in occurrence rate over the years. The documentation of pleural involvement in nocardiosis is rare in India. Case: We report a case of pulmonary nocardiosis in an immunocompromised individual caused by Nocardia otitidiscaviarum. Discussion: Pulmonary nocardiosis caused by Nocardia otitidiscaviarum may go unnoticed without clinical suspicion. Correct and timely identification is the key to proper patient management. Conclusion: Coordination between clinicians and microbiologists is necessary for early diagnosis and appropriate management of nocardiosis.

An unexpected case of broncholithiasis secondary to pulmonary nocardiosis.

Persistent productive cough despite appropriate treatment warrants consideration of flexible bronchoscopy to obtain bronchial specimens for culture. Endobronchial examination of airways may reveal signs of infection in the form of purulent secretions, sputum plugs or in this case, an unexpected finding of a calcified broncholithiasis secondary to Nocardia infection.

Pulmonary Nocardiosis With Endobronchial Involvement Caused by Nocardiaaraoensis.

We report a rare case of pulmonary nocardiosis with endobronchial involvement caused by Nocardia araoensis. A 79-year-old man with a history of asthma and a previous right upper lobectomy for lung cancer and organizing pneumonia presented with cough and dyspnea. He presented with right bronchial stenosis associated with various mucosal lesions, including ulcerative and exophytic lesions. N araoensis was detected in sputum samples collected via bronchoscopy. The mucosal lesions improved after a 2-week course of meropenem. After a further 6 months of oral sulfamethoxazole-trimethoprim treatment, the mucosal lesions completely disappeared. Based on bronchoscopic and pathophysiologic findings, the patient was diagnosed with pulmonary nocardiosis with endobronchial involvement. Nocardiosis should be considered in the differential diagnosis of endobronchial mucosal lesions.

Pulmonary nocardiosis following COVID-19 in a patient with idiopathic pulmonary fibrosis and lung transplantation: a case report.

Background: Nocardiosis is an opportunistic infection that primarily affects immunocompromised patients. Pulmonary nocardiosis is the most prevalent form, but can also spread to other organs. Potential causes contributing to opportunistic infection may include immunosuppression and disruption of tight junctions, both of which can result from COVID-19. Case presentation: We reported a case of a 68-year-old male patient who presented with a 10-day history of fever, cough, and productive sputum. Upon physical examination, velcro rales were detected in the right lung, while breath sounds in the left lung were clear. The patient had previously undergone left lung transplantation due to idiopathic pulmonary fibrosis four years ago. He was initially hospitalized and treated for COVID-19 but was readmitted due to worsening symptoms. Subsequently, pulmonary nocardiosis was diagnosed utilizing metagenomic next-generation sequencing of bronchoalveolar lavage fluid. The above-mentioned condition was improved following treatment with cancidas and linezolid. Now, he is under regular follow-up. Conclusion: This case highlights the complexity of COVID-19 and the occurrence of secondary opportunistic infections, which require further investigation.

Nocardia caishijiensis infection: a case report and review of the literature.

BACKGROUND: Nocardia caishijiensis is a rare soil actinomycete first described in Anhui province, China, in 2003. There has been only one reported instance of human infection caused by this species in the current literature. CASE PRESENTATION: We present a case of pulmonary nocardiosis caused by Nocardia caishijiensis in a fifty-two-year-old man with human immunodeficiency virus infection and concomitant use of high-dose dexamethasone for cervical myelopathy, treated successfully with amikacin and thrimetroprim-sulfametoxazole, antibiotic resistance pattern was obtained, although interpretation may be limited. CONCLUSION: To our knowledge, this is the first reported case of Nocardia caishijiensis infection in humans in North America and the second one in the literature, this pathogen should be recognized as a potentially rising etiology of nocardiosis, especially in solid organ transplant recipients. This has a rising importance as the survival for solid organ recipients continue to rise with advance in transplant medicine leading to increased life expectancy in this particularly susceptible group.

Rapid detection of pulmonary nocardiosis by metagenomic next generation sequencing.

We retrospectively analyzed 3 cases of pulmonary nocardiosis. Patients were identified by metagenomic next generation sequencing (mNGS) in the First Affiliated Hospital of Soochow University, from January 2019 to April 2022. All patients had underlying diseases, and were in immunocompromised state, with membranous nephropathy, acute lymphoblastic leukemia (ALL), and systemic lupus erythematosus (SLE), respectively. Symptoms common to all cases included fever, cough and expectoration. Chest computed tomography (CT) presented patchy shadows or nodules, with or without cavitation lesions, or pleural effusion. mNGS detected Nocardia spp. via bronchoalveolar lavage fluid (BALF) or blood samples from patients. All the patients were discharged with recovery after using the trimethoprim-sulfamethoxazole (TMP-SMX) and remained without evidence of disease during regular follow-ups. mNGS may be a tool for rapid and accurate detection and identification of pulmonary nocardiosis, but interpreting the mNGS results should be more cautious because the mNGS assay can also detect colonization.

Treatment of refractory localized pulmonary nocardiosis caused by Nocardia mexicana with a combination of medication and surgery.

Pulmonary nocardiosis is a rare disease that is often difficult to cure because of its tendency to recur. Here, we report a case of refractory localized pulmonary nocardiosis caused by Nocardia mexicana. A 60-year-old Japanese woman had recurring pulmonary nocardiosis four times previously and each time she was treated with antibiotics for a sufficient duration; nevertheless, the disease continued to recur, probably because of resistance to antibiotics. As a fifth treatment, we performed middle lobe resection and pre- and post-operative antimicrobial therapy for 6 months. The combination of medication and surgery was useful for treating refractory localized pulmonary nocardiosis.

Mild Pulmonary Nocardiosis Caused by Nocardia terpenica in an Immunocompetent Patient.

A 53-year-old immunocompetent man was admitted to our hospital because of paroxysmal cough with a low fever for more than 5 months. On admission, chest computed tomography showed multiple plaques and nodules, some with small central cavities, in both lungs and cystic and columnar bronchiectasis of the right middle bronchus. Treatment with various antibiotics was ineffective. Metagenomic next-generation sequencing of the bronchoalveolar lavage fluid showed Nocardia terpenica, and this organism was cultured from bronchoalveolar lavage fluid, resulting in a diagnosis of pulmonary nocardiosis. After administration of trimethoprim-sulfamethoxazole for 5 weeks, chest computed tomography showed a significant reduction in the lung lesions that had been detected on admission. Immunosuppressed patients are particularly prone to nocardiosis infection, which is usually severe. N. terpenica has rarely been detected in clinical samples, and its characteristics require further study with the accumulation of more clinical cases.

Clinical pharmaceutical practice of constructing mind map by clinical pharmacists for the consultation of pulmonary nocardiosis / 中国药房

OBJECTIVE To explore the construction of mind map by clinical pharmacists for the consultation of pulmonary nocardiosis and its application in clinical practice， and to provide reference for promoting the correct selection of nocardiosis treatment drugs in clinical practice and ensuring drug safety and efficacy. METHODS A total of 7 patients with Nocardia pulmonary infection from January 2017 to April 2022 in our hospital were collected. Based on evidence-based medicine， a consultation mind map （mainly including understanding the medical history， identifying infectious bacteria， identifying risk factors， developing treatment plans， and conducting evaluations） was constructed to address the difficulties of large differences in drug sensitivity among different strains of Nocardia and numerous adverse reactions of Compound sulfamethoxazole as a first-line drug. The treatment plan was developed for 7 patients with pulmonary nocardiosis， and whole-process pharmaceutical care was provided. RESULTS Combined with the mind map， different antibiotic combination regimens were given according to the drug sensitivity results of Nocardia， the different species of Nocardia， and the patient’s allergy history. Among them， 4 cases were treated with imipenem cilastatin， the patients receiving Compound sulfamethoxazole and linezolid for a long time were given full pharmaceutical care， and the adverse drug reactions were timely treated.CONCLUSIONS Clinical pharmacists apply the consultation mind map of pulmonary nocardiosis to the treatment of inpatients， take advantage of pharmacy， participate in clinical drug therapy， and really play a role in the clinical treatment team so as to promote rational drug use.

The Findings of Pulmonary Nocardiosis on Chest High Resolution Computed Tomography: Single centre experience and review of literature.

Objectives: Pulmonary nocardiosis is a rare opportunistic infection that is often encountered in immunocompromised patients, in particular those with the HIV infection and in solid organ transplant recipients. As the number of immunocompromised patients increase, the number of patients with pulmonary nocardiosis is also expected to increase. This study aimed to analyse both the chest high resolution computed tomography (HRCT) findings of patients with confirmed pulmonary nocardiosis and review the imaging features of pulmonary nocardiosis in the literature. Methods: This retrospective study was conducted at The Royal Hospital, Muscat, Oman, to identify patients with a diagnosis of pulmonary nocardiosis between January 2006 and January 2019. Accordingly, nine patients with pulmonary nocardiosis were identified, but three patients were excluded as no chest HRCT images were available. Patient clinical presentation was recorded and chest HRCT images were retrospectively reviewed. Results: A total of six patients were enrolled in this study. All were male and with a mean age of 41 ± 11 years. Three patients were immunocompromised, two of whom had undergone a renal transplant. The main HRCT findings were cavitary nodules/masses, non-cavitary nodules/masses, septal thickening, centrilobular nodules, ground glass opacities, consolidation, pleural effusion, pleural thickening, enlarged lymph nodes and necrotic lymph nodes. Conclusion: Pulmonary nocardiosis shows various findings in a chest CT, the most common of which are pulmonary nodules and masses. Awareness of these findings can help radiologists with a diagnosis in the appropriate clinical settings.

Nocardia spp. isolation in chronic lung diseases: Are there differences between patients with pulmonary nocardiosis and Nocardia colonization?

AIMS: Chronic lung diseases are a recognized risk factor for Nocardia spp. INFECTION: Nocardia spp. isolation does not inevitably imply disease, and thus colonization must be considered. Here, we aimed to analyse the differences between pulmonary nocardiosis (PN) and Nocardia spp. colonization in patients with chronic lung diseases. METHODS AND RESULTS: A retrospective study of patients with laboratory confirmation of isolation of Nocardia spp. in at least one respiratory sample was performed. Patients with PN and Nocardia spp. colonization were compared. There were 71 patients with Nocardia spp. identification, 64.8% were male, with a mean age of 67.7 ± 11.2 years. All patients had ≥1 pre-existing chronic lung disease, and 19.7% of patients were immunocompromised. PN and Nocardia spp. colonization were considered in 26.8% and 73.2% of patients, respectively. Symptoms and chest CT findings were significantly more frequent in patients with PN (p < 0.001). During follow-up time, 12 (16.9%) patients died, 6 in PN group. Immunosuppression, constitutional symptoms, haematological malignancy and PN diagnosis were associated with significantly shorter survival times, despite only immunosuppression (HR 3.399; 95% CI 1.052-10.989) and PN diagnosis (HR 3.568; 95% CI 1.078-11.910) remained associated with a higher death risk in multivariate analysis. CONCLUSIONS: PN was associated with clinical worsening, more chest CT findings and worse clinical outcomes. SIGNIFICANCE AND IMPACT OF STUDY: Nocardia spp. isolation in chronic lung disease patients is more common than expected and the differentiation between colonization and disease is crucial.

Nocardia in an Immunocompetent Host Masquerading As Lung Cancer: A Case Report.

Nocardiosis is generally regarded as an opportunistic infection that can present as a cutaneous, pulmonary, or disseminated disease based on host immunity status. Pulmonary nocardiosis is typically seen in immunocompromised patients; however, it can rarely be present in immunocompetent patients. We present a rare case of an immunocompetent patient who was thought to have a lung malignancy but was found to have pulmonary nocardiosis upon further investigation.

A Case of Asymptomatic Pulmonary Nocardia cyriacigeorgica Infection With Mild Diabetes Mellitus.

Nocardiosis is a relatively rare opportunistic infection, ranging from localized to systemic diseases, commonly occurring in immunocompromised patients with high mortality rates. We present a case of a 61-year-old man who received medical treatment for type 2 diabetes mellitus and underwent a physical examination that showed abnormal chest shadows on radiography. Chest computed tomography revealed bronchiectasis and infiltration in the left lower lobe. Nocardia spp. was detected in the bronchial washes, and he was started on sulfamethoxazole-trimethoprim under the diagnosis of pulmonary nocardiosis. 16S ribosomal RNA gene sequencing analysis identified the species as Nocardia cyriacigeorgica. His pulmonary lesions successfully improved after treatment for six months. Pulmonary nocardiosis often presents with symptoms such as hemoptysis and blood-tinged sputum, and bronchiectasis has been identified as an underlying condition. Even in hosts without underlying immunocompromising conditions, Nocardia spp. can be a causative microorganism of pulmonary infections, and it should be considered in the differential diagnoses.