A Case Series and Focused Review of Nocardiosis

Abstract

Nocardia species are ubiquitous soil organisms that often infect patients with underlying immune compromise, pulmonary disease, or a history of surgery or trauma. We report 5 cases of nocardiosis representing various aspects of this "great imitator": 1) pneumonia in the setting of underlying malignancy, 2) chronic pneumonia with drug-resistant organism, 3) bacteremia and empyema with chronic hematologic malignancy, 4) primary cutaneous disease, and 5) sternal wound infection. We present a summary of the English literature from 1966 to 2003 with a focus on the teaching points of each of our 5 cases as well as the background epidemiology and microbiology of the Nocardia genus. Isolation of the organism may be achieved with routine media but longer incubation times may be necessary, delaying diagnosis and appropriate therapy. Treatment with a sulfa-containing regimen is standard of care, but resistance testing is warranted given emerging drug resistance, high rates of discontinuation due to adverse reactions, and the potential for nephrotoxicity in transplant recipients on cyclosporine.

Leg Pain in a Patient with Myasthenia Gravis

“…Disseminated nocardial infection typically presents with deep abscess especially in the lower extremities or CNS. 1 Treatment requires a long course of therapy: 6 months for pulmonary or systemic nocardiosis and at least 12 months for immunocompromised patients. 2 Suspect norcardiosis in patients with CNS, soft tissue, or cutaneous lesions and a concurrent pulmonary process.…”

Overcome by weakness

“…In cases of nocardiosis in patients taking steroids, the median daily prednisone dose was 25 mg (range, 10-80 mg) for a median duration of 3 months. 2,3 Nocardia should be considered in any patient with unexplained pulmonary, CNS, or cutaneous disease and appropriate risk factors. Pulmonary disease is most common, seen in approximately two-thirds of patients, and is typically bilateral.…”

“…6,7 Prophylaxis with TMP-SMX, which is usually prescribed to prevent Pneumocystis jirovecii in susceptible hosts, also reduces the incidence of Nocardia. 2,3,6 Nocardia's restricted susceptibility pattern presents a challenge for hospitalists, as TMP-SMX and aminoglycosides are rarely administered empirically for cases of suspected pneumonia or atypical pulmonary infections (other than P. jirovecii). When confronted with the pattern of simultaneous pulmonary and CNS lesions, hospitalists must consider infections (lung abscess, mycobacteria, fungi, Nocardia), malignancies, and autoimmune conditions (sarcoidosis, Wegener's granulomatosis).…”

“…White blood cell count was 20,100 per mm 3 with 90% neutrophils, 9% lymphocytes, and 1% monocytes. Hemoglobin was 13.7 g/dL, platelet count was 464,000 per mm 3 . Thyroid stimulating hormone (TSH) was 6.0 lIU/mL (normal, <5.5).…”

Multidrug-Resistant Disseminated Nocardia Farcinica Infection in a Systemic Lupus Erythematosus Patient

“…[1] Furthermore, Nocardia can disseminate from a pulmonary or cutaneous focus to virtually any organ. [2,3] Herein, we present a case of disseminated nocardiosis in a SLE patient who was treated with difficulty.…”