Rare Case of Nocardia asteroides Pericarditis in a Human Immunodeficiency Virus-Infected Patient

Abstract

Nocardia asteroides was isolated after prolonged culture from the pericardial fluid of a human immunodeficiency virus-infected patient. The lengthy duration required for culture growth and identification of this N. asteroides isolate affected both initial therapeutic decisions and patient management. A proposed algorithm for the microbiological workup of pericardial fluid for possible Nocardia spp. is described in an effort to improve the timeliness of results. CASE REPORTThe patient was a 44-year-old Filipino male with a medical history significant for newly diagnosed human immunodeficiency virus (HIV) infection and AIDS. In March 2005, he was admitted to the hospital for persistent fever of unknown origin. He was found to have HIV on this admission, and the CD4 cell count was 42/mm 3 . The initial workup included sputum Gram stain, silver stain, and culture, which showed only normal flora. In addition, sputum acid-fast bacillus (AFB) stain and culture were negative for Mycobacterium spp. and routine urine and blood cultures were also negative. During this admission, he was noted to have a pericardial effusion, which prompted a pericardiocentesis. Direct Gram and AFB stains on the pericardial fluid were negative, and no significant growth was detected on routine bacterial cultures. After pericardiocentesis, a repeat echocardiogram showed no pericardial fluid and the patient was discharged in stable condition. However, the AFB culture of the pericardial fluid subsequently became positive at week 6. Both the AFB and modified AFB stains were positive, and the morphology at that time was interpreted as being consistent with Mycobacterium spp. The specimen was sent to a local reference laboratory for further workup. The patient was empirically treated with isoniazid, rifampin, pyrazinamide, and ethambutol for possible Mycobacterium tuberculosis, and he was discharged on this four-antimycobacterial-drug regimen, as well as trimethroprim-sulfamethoxazole (TMP-SMX) and azithromycin for empirical coverage of Pneumocystis jiroveci and Mycobacterium avium complex. Highly active antiretroviral therapy was not successfully initiated due to poor drug compliance.The patient continued to have persistent fever, fatigue, and weakness. Two weeks later, he was readmitted to the hospital with a fever of 102.6°F and severe tachycardia (heart rate of 144 beats/min). His blood pressure on admission was 128/93. A chest X-ray showed a widened mediastinum, and the echocardiogram showed a moderate pericardial effusion which appeared loculated on a subsequent computed tomography (CT) scan (Fig. 1). By this time, the additional workup performed by the local reference lab on the pericardial fluid taken during the first admission demonstrated a partially acid-fast-positive bacillus with infrequent branching. In addition, the culture of the same pericardial fluid showed tiny, dry, white colonies resembling Nocardia spp. on sheep blood agar. The specimen was then sent to a second reference lab for bacterial identification and susceptibility tes...

Nocardia beijingensis pericarditis presenting with cardiac tamponade: A case report

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Cardiovascular Abnormalities in Patients With Hiv Infection: A Bolt in Blue

“…27 Nocardia. 28,29 lymphoma and immune reconstitution inflammatory syndrome secondary to Mycobacterium tuberculosis (TB). 30 In Africa, the majority of pericardial disease in HIV infected patients is caused by TB.…”

Fatal Systemic Nocardia Infection Revealed by Cardiac Tamponade

“…Here, we report a rare case of severe nocardia infection revealed by initial cardiac tamponade, in a non-HIV patient. Acute pericarditis due to Nocardia is scarcely reported (1); the few reports are mainly in immunodeficient patients, such as AIDS (2), or in patients with other predisposing factors like alcoholism (3), or with immunologic disorders such as mixed connective tissue disease (4). Cardiac tamponade is rarely described (5)(6)(7).…”