|Year : 2016 | Volume
| Issue : 2 | Page : 74-77
Disseminated nocardiosis in a young male with nephrotic syndrome
Gaurav Pandey1, Hiralal2
1 Department of Pulmonary Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Radiadiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Web Publication||10-Jun-2016|
Department of Radiadiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
A 20-year-old male with 10 years history of treatment for nephrotic syndrome was admitted with 1 month history of fever with chills, productive sputum, pleuritic chest pain, exertional breathlessness, anorexia and 10 days history of vomiting off/on associated with headache. Gram staining of the sputum revealed gram-positive and acid-fast Bacilli by Ziehl–Neelsen staining which had a branching and fragmented morphology suggestive of Nocardia. Computed tomography of the thorax was suggestive of bilateral multiple nodules with cavitation and breakdown and minimal pleural effusion on the right, pleural fluid was turned exudative in nature, and cultures were negative for bacterial and mycobacterial. Contrast magnetic resonance imaging brain revealed multiple nodular lesions in cerebellum and cerebalar hemisphere, the majority of the lesions are showing ring enhancement. Cerebrospinal fluid did not show any abnormality. A provisional diagnosis of disseminated nocardiosis was made. The patient has started a treatment with oral trimethoprim/sulphamethoxazole, injectable ceftriaxone and imipenem for 1 month, and on regular follow–up, he had a marked clinical and radiological improvement.
Keywords: Corticosteroid, immunocompromised, nocardiosis
|How to cite this article:|
Pandey G, Hiralal. Disseminated nocardiosis in a young male with nephrotic syndrome. J Assoc Chest Physicians 2016;4:74-7
| Introduction|| |
Nocardia species are increasingly being isolated from clinical specimens, especially in patients who are immunocompromised. Nocardiosis most commonly presents as pulmonary disease though other manifestations such as cutaneous, subcutaneous, and systemic are also seen.
Nocardia asteroides complex is an important opportunistic agent in immunosuppressed patients. Nocardia are classically aerobic, gram-positive, filamentous, weakly acid-fast Bacilli, ubiquitous soil saprophytes that cause opportunistic exogenous infection, usually primary pulmonary infection occurs followed by dissemination.
Our case report lays importance that the patients with the risk factors such as chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, and any other immunocompromised state, with nonresponsive pneumonia, must be evaluated for rare infections like Nocardia.
| Case Report|| |
A 20-year-old male with 10 years history of treatment for nephrotic syndrome was admitted with 1 month history of fever with chills, productive sputum, pleuritic chest pain, exertional breathlessness, anorexia and 10 days history of vomiting off/on associated with headache.
Fever was high grade, intermittent in nature and was associated with cough and expectoration. He also complaint of headache which was associated with vomiting off/on, there was no episodes of altered sensorium, loss of consciousness, or seizure.
He was on immunosuppressant drugs off/on for nephrotic syndrome for the past 10 years. His recent treatment regimen was prednisolone 50 mg daily for the past 3 months before attending to our hospital.
Examination revealed a febrile, emaciated pale person of lean and thin build without lymphadenopathy, clubbing, cyanosis, edema, or icterus. Blood pressure was 120/70 mmHg, pulse 100/min regular, temperature 100° F, and a respiratory rate of 24/min. Chest examination revealed decreased movements on the right side, a stony dull percussion note in the right infra-scapular area associated with loss of breath sounds in the right infra-scapular and infra-mammary area. Central nervous system examination revealed a confused, disoriented person with no meningeal signs, cranial nerve palsies, or motor weakness. Other system examination was normal. Investigations revealed hemoglobin – 7.7 g, white cell count of 20,500 cells/mm 3, with 75% segmented neutrophils, 20% band forms, 3% basophils and 2% eosinophils, erythrocyte sedimentation rate was elevated to 125 mm/h, platelets – 1.5 lac/cu mm, Peripheral blood film (PBF) - hypochromic microcytic and reticulocyte count – 1.5%. His kidney function and liver function test were normal, viral serologies for human immunodeficiency virus (HIV) and hepatitis C virus were negative. Urine examination was normal. Sputum [Figure 1] revealed Gram-positive branching, fragmented acid-fast Bacilli by Ziehl-Neelsen staining was suggestive of Nocardia.
|Figure 1: Gram-positive branching, fragmented acid-fast Bacilli by Ziehl–Neelsen staining was suggestive of Nocardia|
Click here to view
His chest radiograph showed bilateral lower zone nonhomogenous opacities with obliteration of right costo-phrenic angle and a nodular opacity over left lower zone [Figure 2]. Analysis of pleural fluid revealed a straw color exudative fluid with cell counts – 5000, (neutrophils – 70%, lymphocyte – 30%), protein – 4 g/dl, sugar – 30 mg/dl, and adenosine deaminase – 30 IU/l was negative for malignant cells. Gram's and acid-fast Bacilli staining of pleural fluid did not reveal any organisms. Cultures of pleural fluid, blood, urine, and sputum were sterile. His thorax computed tomography [Figure 3] revealed bilateral multiple nodules with cavitation and breakdown and minimal pleural effusion on right. Contrast magnetic resonance imaging [Figure 4] brain revealed multiple nodular lesions in cerebellum and cerebellar hemisphere, majority showing ring enhancement.
|Figure 2: Bilateral lower zone nonhomogenous opacities with obliteration of right costo-phrenic angle and a nodular opacity over left lower zone|
Click here to view
|Figure 3: Thorax computed tomography revealed bilateral multiple nodules with cavitation and breakdown and minimal pleural effusion on right|
Click here to view
|Figure 4: Contrast magnetic resonance imaging brain revealed multiple nodular lesion in cerebellum and cerebalar hemisphere, majority showing ring enhancement|
Click here to view
On the basis of clinical history, examination, and investigations, the provisional diagnosis of disseminated nocardiosis was made and he was started with oral cotrimoxazole with injectable ceftriaxone and imipenem. Patient started improving after 3 weeks of parentral and oral antibiotics and his repeat chest [Figure 5] radiograph showed complete resolution of bilateral lower zone nonhomogenous opacities and a nodular opacity over left lower zone after 1 month of treatment, his neurological symptoms were also relieved and he was discharged in a stable condition with advice to continue oral cotrimoxazole twice daily for 6 months with regular follow-up.
|Figure 5: Chest radiograph showed complete resolution of bilateral lower zone nonhomogenous opacities and a nodular opacity over left lower zone after 1 month of treatment|
Click here to view
| Discussion|| |
The most common predisposing factors (conditions) leading to Nocardia infection is organ transplantation and diabetes. Disseminated nocardiosis can occur in various rheumatologic diseases including systemic lupus, temporal arteritis, polyarteritis nodosa, intermittent hydarthrosis, vasculitis, uveitis, and pulmonary alveolar protinosis.,
The clinical symptoms and chest X-ray findings of pulmonary nocardiosis are nonspecific, similar to those caused by other bacteria. The illness tends to have a protracted course and the diagnosis is often delayed. To reduce the delay in diagnosis and treatment, testing for Nocardia spp. should be performed in patients with risk factors for pulmonary nocardiosis and pneumonia which have not responded to treatment. Microbiological studies of respiratory tract specimens obtained by noninvasive methods are effective. As seen in our case, lungs are the most frequent primary site of systemic nocardiosis (60–80% of cases) with a variety of clinical presentations including cough, dyspnea, fever, night sweats, weight loss, and pleuritic chest pain. Roentgenographic studies are nonspecific with multifocal airspace opacities, lobar consolidation, nodules with or without cavitation, reticulonodular interstitial lung disease, pleural effusion, or empyema. Granulomas mimicking tuberculosis though rare have also been reported. Similar findings were seen in the patient who presented to us.
Microscopy and culture are not difficult; however, because of the slow growth of the organisms, cultures should be kept for at least 30 days. The microbiology laboratory should be informed that Nocardia spp. is suspected as the bacteria require specific media, a long culture period and modified Ziehl–Neelsen staining for direct demonstration.,
A prevalence of 1.4% for pulmonary nocardiosis was reported in a tuberculosis and chest diseases hospital in Amritsar by Singh et al. Although, Pintado et al. indicated that the overall incidence of nocardiosis among HIV-infected patients is between 0.1 and 0.4%, and is associated with high morbidity and mortality rates. Concurrent infection of pulmonary nocardiosis with other microorganisms is not rare. Concurrent pulmonary aspergillosis and nocardiosis were reported in an immunocompromised patient following long-term steroid therapy. Similarly, our patient was also immunocompromised as on long-term steroid therapy.
Pulmonary nocardiosis in HIV-infected patients with suspected pulmonary tuberculosis was reported to be 3% by Ekrami et al.; they reported an average of 3–4% for this infection.
Most cases of disseminated nocardiosis have fatal outcome. Therapy is initiated with parenteral treatment with trimethoprim/sulphamethoxazole (TMP/SMZ) and continued with oral therapy using one double strength tablet twice a day in adults. Amikacin, imipenem, and ceftriaxone  are other alternative parenteral drugs used in patients who are resistant or allergic to TMP/SMZ. Treatment may be given from 6 months to 1 year depending on the response of the patient as evidenced by clinical improvement and radiological clearing of the lesions.
In our patient, due to high suspicion of nocardiosis, we immediately started the empirical therapy and patient's improvement was remarkable within 3 weeks of starting treatment.
| Conclusion|| |
Pulmonary infection may be difficult to diagnose only on the basis of clinical and radiological findings as they are nonspecific. Close collaboration between clinicians and microbiologists and radiologists is required to include specific stains and cultures for early diagnosis of such infection and rapid institution of specific and effective therapy, especially in immunocompromised patients and to evaluate all the possible causes of pulmonary involvement for a better patient outcome.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zaatreh M, Alabulkarim W. Images in clinical medicine. Disseminated central nervous system nocardiosis. N Engl J Med 2006;354:2802.
Pintado V, Gómez-Mampaso E, Cobo J, Quereda C, Meseguer MA, Fortún J, et al.
Nocardial infection in patients infected with the human immunodeficiency virus. Clin Microbiol Infect 2003;9:716-20.
Ekrami A, Khosravi AD, Samarbaf Zadeh AR, Hashemzadeh M. Nocardia
co-infection in patients with pulmonary tuberculosis. Jundishapur J Microbiol 2014;7:e12495.
Mohan A, Sharma SK, Arora VK, Sharma S, Prakash J. Concurrent pulmonary aspergillosis and nocardiosis in an old tubercular cavity masquerading as malignancy in an immunocompetent individual. Respir Med2008;1:231-4.
Wu BQ, Zhang TT, Zhu JX, Liu H, Huang J, Zhang WX. Pulmonary nocardiosis in immunocompromised host: Report of 2 cases and review of the literature. Zhonghua Jie He He Hu Xi Za Zhi 2009;32:593-7.
Minero MV, Marín M, Cercenado E, Rabadán PM, Bouza E, Muñoz P. Nocardiosis at the turn of the century. Medicine (Baltimore) 2009;88:250-61.
Lederman ER, Crum NF. A case series and focused review of nocardiosis: Clinical and microbiologic aspects. Medicine (Baltimore) 2004;83:300-13.
Singh M, Sandhu RS, Randhawa HS, Kallan BM. Prevalence of pulmonary nocardiosis in a tuberculosis hospital in Amritsar, Punjab. Indian J Chest Dis Allied Sci 2000;42:325-39.
Ambrosioni J, Lew D, Garbino J. Nocardiosis: Updated clinical review and experience at a tertiary center. Infection 2010;38:89-97.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]