Clinical manifestations of nocardiosis: Study of risk factors and outcomes in a tertiary care hospital

Abstract

PURPOSE:The aim of this study is to evaluate the predisposing risk factors, clinical presentations, laboratory parameters, and treatments taken and outcomes in patients of nocardiosis in the span of 5 years in a tertiary care hospital.MATERIALS AND METHODS:The patients whose specimens showed Nocardia like organism in Gram-staining, Kinyoun staining and characteristic colonies in culture were included in the retrospective analysis study. Retrospective analysis of associated risk factors, clinical presentations, and radiological findings was performed.RESULTS:Of the thirteen patients, 11 (76.9%) had immunosuppressive pathologies including solid organ transplantation, autoimmune disease, use of steroids, and immunosuppressive drugs as important risk factors. Four types of clinical manifestations were observed, pulmonary (46.1%), cutaneous (23.07%), cerebral (15.3%), and bacteremia (15.3%). The most common presentation was pulmonary with steroid therapy as a significant risk factor. Consolidation and pleural effusion were the common radiological findings in these cases. In eight of the nine patients anti-nocrdial drugs were given. Cotrimoxazole as monotherapy was given in four cases (44.44%), cotrimoxazole in combination with meropenem in two cases (22.22%); minocycline and linezolid were given in one case each. The overall mortality was 36.36% and was seen in patients with pulmonary nocardiosis.CONCLUSIONS:The study indicates that Nocardial infections are re-emerging on account of an increase in numbers of immunocompromised patients due to increased organ transplants, autoimmune diseases, malignancies, and use of immunosuppressive drugs and steroids. The diagnosis is often missed/not suspected and delayed because of the clinical resemblance to many other infections. Nocardial infection should be suspected and assessed particularly in immunocompromised patients not responding to treatment/improving clinically.

Nocardiosis: A Neglected Disease

“…Ninan et al [32], 2016 South India 131 cases: N. asteroides (73), Nocardia spp. (32), N. brasiliensis (2), aerobic actinomycetes (24) Skin (36), eye (36), pulmonary (35), immunosuppressive therapy (48) Nampoory et al [47], 1996 Kuwait 6 cases: N. asteroides (4), N. otitidiscaviarum (1), N. farcinica (1) Pulmonary nocardiosis (3: with 2 cerebral abscess, 1 meningitis); perinephric abscess (1), thigh abscess (1), ischiorectal abscess (1) Lai et al [65], 2011 Taiwan 138 isolates: N. brasiliensis (58), N. cyriacigeorgica (22), N. farcinica (11), N. beijingensis (8), N. otitidiscaviarum (7), N. nova (6), N. puris (6), N. asiatica (5), N. flavorosea (5), N. abscessus (3), others 7Skin and soft-tissue, respiratory tract specimens, brain biopsy, blood, lymph node…”

“…Tan et al [57], 2020 Australia 270 cases: N. nova complex (80), N. cyriacigeorgica (61), N. brasiliensis (52), N. farcinica (38), N. pseudobrasiliensis (8), N. beijingensis (6) (13), N. cyriacigeorgica (11), N. terpenica (8), N. abscessus (5), N. otitidiscaviarum (4) Lower respiratory tract (31) [2,3]. Nocardial infections are transmitted either by inhalation, ingestion, or inoculation; inhalation is considered the most common route.…”

“…It has been broadly classified as pulmonary, central nervous system (CNS), cutaneous, or disseminated nocardiosis depending on the location and extent of involvement though no site in the body is exempted [4]. Infections are often seen in immunocompromised hosts, especially in those with deficient cell-mediated immunity such as persons with organ transplantation, malignancy, diabetes mellitus, AIDS, autoimmune diseases, and prolonged corticosteroid therapy [5, 6]. Neutrophils form the first line of defense in early stages, and abscess formation is the hallmark of such infections.…”

Nocardia spp.: A Rare Cause of Pneumonia Globally

“…5,16 Nocardiosis is more common in males. 36,79,80 Additionally, chronic lung disease, 5,11,12,16,81,82 bronchiectasis, 10 prior tuberculosis, 12 cystic fibrosis (CF), 83 diabetes mellitus, 16,17 and alcohol abuse 16 may predispose to pulmonary nocardiosis even without overt evidence for impaired immunity. Well-recognized risk factors for nocardiosis include corticosteroid (CS) use 11,21,84,85 ; IS status 2,32,86,87 ; chronic granulomatous disease (CGD) [88][89][90] ; solid organ transplant (SOT) [6][7][8]54,91,92 ; HSCT 3 ; hematological malignancies, cancer, or chemotherapy 3,93,94 ; human immunodeficiency virus (HIV) infection 11,77,[95][96][97] ; and pulmonary alveolar proteinosis.…”

“…12 In a referral hospital in India, 13 cases of nocardiosis were diagnosed from January 2010 to 2015; 77% were IS. 79 Sites of organ involvement included: lung (46%), skin/soft tissue (23%); CNS (15%); and bloodstream (15%). Nine of 13 were treated with Nocardiaspecific therapy; overall mortality was 36.6%.…”