Fatal Nocardia paucivorans Lower Respiratory Tract Infection in a Tuberculosis Suspect Who Worked as Gold Miner.

Nocardiosis is an opportunistic infection that affects both immunocompromised as well as immunocompetent patients. The main infections occur as soft tissue and lung infections although they might disseminate to various organs. This is a case study aimed to reflect the severity of the disease and the patient's risk factors associated with the infection. A sputum sample was collected from tuberculosis (TB) suspects for culture. Nocardia-like colonies were isolated, purified, and sent to BGI Company (Hongkong, China). Standard forward sequencing of 16S rRNA was done by ABI Genetic Analyzer (Applied Biosystems). Sequence alignment and nucleotide basic local alignment search tool (BLAST) were done using National Center for Bioinformatics (NCBI) Nucleotide BLAST. Biochemical identification to the colonies was done using an automation system (BD Phoenix™) to confirm the identification. Nocardia paucivorans was identified from the TB suspect. Risk factors were identified as extensive contact to dust, absence of primary care units with complete facilities, and old age. Since the infection of the lungs caused by Nocardia might be similar to pulmonary TB, this case report highlights the importance of accurate diagnosis and identification procedures to differentiate between the two.

Fever of unknown origin revealing testicular nocardiosis: a case report and literature review.

BACKGROUND: Nocardia is an ubiquitous soil organism. As an opportunistic pathogen, inhalation and skin inoculation are the most common routes of infection. Lungs and skin are the most frequent sites of nocardiosis. Testis is a highly unusual location for nocardiosis. CASE PRESENTATION: We report the case of an immunocompromised 75-year-old-man admitted for fever of unknown origin. He presented with skin lesions after gardening and was first suspected of Mediterranean spotted fever, but he did not respond to doxycycline. Then, physical examination revealed new left scrotal swelling that was compatible with a diagnosis of epididymo-orchitis. The patient's condition did not improve despite empirical antibiotic treatment with the onset of necrotic scrotal abscesses requiring surgery. Nocardia brasiliensis yielded from the removed testis culture. High-dose trimethoprim-sulfamethoxazole and ceftriaxone were started. Multiple micro-abscesses were found in the brain and spinal cord on imaging studies. After 6 weeks of dual antibiotic therapy for disseminated nocardiosis, slight regression of the brain abscesses was observed. The patient was discharged after a 6-month course of antibiotics and remained relapse-free at that time of writing these lines. Trimethoprim-sulfamethoxazole alone is meant to be pursued for 6 months thereafter. We undertook a literature review on previously reported cases of genitourinary and urological nocardiosis; to date, only 36 cases have been published with predominately involvement of kidney, prostate and testis. CONCLUSIONS: To the best of our knowledge, this is the first case of Nocardia brasiliensis simultaneously infecting skin, testis, brain and spinal cord in an immunocompromised patient. Knowledge on uncommon forms of nocardiosis remains scarce. This case report highlights the difficulty of diagnosing atypical nocardiosis and the importance of prompt bacteriological sampling in case of empirical antibiotics failure.

Weathering the storm: diagnosis and treatment of a life-threatening disseminated Nocardia otitidiscaviarum infection.

Nocardiosis demonstrates a temporal categorization that includes acute, subacute, and chronic stages alongside distinct typical localizations such as pulmonary, cutaneous, and disseminated forms. Disseminated nocardiosis, commonly caused by Nocardia asteroides, N. brasiliensis, and N. farcinica, continues to result in substantial morbidity and mortality. Herein, we report a life-threatening disseminated nocardiosis caused by Nocardia otitidiscaviarum in a patient with minimal change disease. This study emphasizes the difficulty in the diagnosis and treatment of unknown infections in clinical settings and highlights the important role played by laboratories in solving infectious diseases caused by rare pathogens.

[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.

Nocardia brasiliensis Pyomyositis in an Immunocompetent Patient Following Gardening Activity.

Nocardia pyomyositis in immunocompetent patients is a rare occurrence. The diagnosis may be missed or delayed with the risk of progressive infection and suboptimal or inappropriate treatment. We present the case of a 48-year-old immunocompetent firefighter diagnosed with pyomyositis caused by Nocardia brasiliensis acquired by direct skin inoculation from gardening activity. The patient developed a painful swelling on his right forearm that rapidly progressed proximally and deeper into the underlying muscle layer. Ultrasound imaging of his right forearm showed a 7-mm subcutaneous fluid collection with surrounding edema. Microbiologic analysis of the draining pus was confirmed to be N brasiliensis by Matrix-Assisted Laser Desorption/Ionization Time-of-Flight (MALDI-TOF) Mass Spectrometry. After incision and drainage deep to the muscle layer to evacuate the abscess and a few ineffective antibiotic options, the patient was treated with intravenous ceftriaxone and oral linezolid for 6 weeks. He was then de-escalated to oral moxifloxacin for an additional 4 months to complete a total antibiotic treatment duration of 6 months. The wound healed satisfactorily and was completely closed by the fourth month of antibiotic therapy. Six months after discontinuation of antibiotics, the patient continued to do well with complete resolution of the infection. In this article, we discussed the risk factors for Nocardia in immunocompetent settings, the occupational risks for Nocardia in our index patient, and the challenges encountered with diagnosis and treatment. Nocardia should be included in the differential diagnosis of cutaneous infections, particularly if there is no improvement of "cellulitis" with traditional antimicrobial regimens and the infection extends into the deeper muscle tissues.

Disseminated nocardiosis presenting as a superinfected thyroglossal duct cyst in a patient with diabetes.

We introduce the case of a male patient in his 60s who was admitted to our emergency department with a persisting sore throat for the last 3 weeks and dysphagia. Fibre-endoscopic evaluation revealed an asymmetry at the base of the tongue. In combination with elevated white cell count and C reactive protein, a computerized tomography showed a superinfected thyroglossal duct cyst. Intravenous antibiotics were initiated, and the patient was taken to the operating room for cervicotomy. The microbiological swab taken intraoperatively detected Nocardia paucivorans Additional imaging revealed disseminated nocardiosis with cerebral and pulmonary manifestations.The patient was treated with oral trimethoprim/sulfamethoxazole and, over time, showed complete remission of central nervous system lesions and improvement of pulmonary involvement. Following this, the treatment was stopped 8 months after the initial diagnosis. In this report, we discuss treatment standards and outcomes of nocardiosis based on our management strategies of our patient.

Chronic inflammatory demyelinating polyneuropathy with pulmonary nocardiosis: A case report.

RATIONALE: Chronic inflammatory demyelinating polyneuropathy (CIDP) is an immune-mediated motor sensory peripheral neuropathy that is rare in clinical practice. This treatment method aims to suppress potential immunopathology. Nocardiosis is a rare, destructive, opportunistic disease. We report a case of failed treatment of CIDP combined with pulmonary nocardiosis, and for the first time, we link these 2 diseases together. PATIENT CONCERNS: A 65-year-old man developed symmetrical limb weakness. Four months later, he was diagnosed with CIDP and started receiving glucocorticoid (GC) treatment. The disease progressed slowly and was treated with mycophenolate mofetil (MMF) in combination. He did not follow the doctor requirements for monthly follow-up visits, and the preventive medication for sulfamethoxazole/trimethoprim was not strictly implemented. Two months after the combination therapy, the patient developed fever, coughing and sputum production, as well as fatigue and poor appetite. Based on imaging and etiological results, he was diagnosed with pulmonary nocardiosis. DIAGNOSES: Chronic inflammatory demyelinating polyneuropathy, pulmonary nocardiosis. INTERVENTIONS: After treatment with antibiotics, the patient lung infection temporarily improved. However, the patient CIDP condition progressed, limb weakness worsened, respiratory muscle involvement occurred, and intravenous immunoglobulin (IVIG) was administered. However, there was no significant improvement in the condition, and the patient died. OUTCOMES: In this report, we present a case of a patient with CIDP and pulmonary nocardiosis. It is worth noting that in order to avoid the progression and recurrence of CIDP, we did not stop using related therapeutic drugs during the treatment process, the patient had repeatedly refused to use IVIG. Despite this, the patient condition worsened when lung inflammation improved, leading to persistent respiratory failure and ultimately death. Treatment contradictions, medication issues, and patient compliance issues reflected in this case are worth considering. LESSONS: For patients with CIDP receiving immunosuppressive therapy, attention should be paid to the occurrence and severity of Nocardia infection. Therefore, early detection and treatment are necessary. We need to pay attention to the compliance of patients with prophylactic use of antibiotics, strengthen the follow-up, and urge them to return to their appointments on time.

A rare case of primary cutaneous Nocardia vinacea in an immunocompetent patient: A case report and a review of the literature.

The nocardiae are a complex group of bacteria belonging to the aerobic saprophytes actinomycetes. Although nocardiosis typically occurs in immunocompromised patients, infection may occasionally develop in immunocompetent patients as well. Here we describe a rare case of primary cutaneous nocardiosis due to Nocardia vinacea in an immunocompetent 79-year-old patient. Since cutaneous nocardiosis presents variably and mimics other cutaneous infections, acid-fast and Gram stainings on clinical samples are significant to obtain a rapid and presumptive diagnosis.

Nocardia keratitis after small incision lenticule extraction (SMILE).

We report the case of a female patient in her late 20s who visited the clinic with concerns about poor vision, redness, watering and a burning sensation in her left eye 2 weeks after undergoing a small incision lenticule extraction. She had no history of systemic illness or immunosuppressed status. On slit lamp examination, she was found to have corneal stromal infiltrates in the interface at multiple locations. Given the clinical diagnosis of microbial keratitis, corneal scraping of the interface infiltrate was performed and sent for microbiological examination revealing gram-positive, thin, beaded filaments that were acid-fast positive and later identified by growth in culture media as Nocardia species. This case was managed successfully with the use of topical amikacin and systemic trimethoprim-sulfamethoxazole with complete resolution of infection.

Bacteremia caused by Nocardia farcinica: a case report and literature review.

BACKGROUND: Nocardia farcinica is one of the most common Nocardia species causing human infections. It is an opportunistic pathogen that often infects people with compromised immune systems. It could invade human body through respiratory tract or skin wounds, cause local infection, and affect other organs via hematogenous dissemination. However, N. farcinica-caused bacteremia is uncommon. In this study, we report a case of bacteremia caused by N. farcinica in China. CASE PRESENTATION: An 80-year-old woman was admitted to Peking Union Medical College Hospital with recurrent fever, right abdominal pain for one and a half month, and right adrenal gland occupation. N. farcinica was identified as the causative pathogen using blood culture and plasma metagenomics next-generation sequencing (mNGS). The clinical considerations included bacteremia and adrenal gland abscess caused by Nocardia infection. As the patient was allergic to sulfanilamide, imipenem/cilastatin and linezolid were empirically administered. Unfortunately, the patient eventually died less than a month after the initiation of anti-infection treatment. CONCLUSION: N. farcinica bacteremia is rare and its clinical manifestations are not specific. Its diagnosis depends on etiological examination, which can be confirmed using techniques such as Sanger sequencing and mNGS. In this report, we have reviewed cases of Nocardia bloodstream infection reported in the past decade, hoping to improve clinicians' understanding of Nocardia bloodstream infection and help in its early diagnosis and timely treatment.

Nocardiosis diseminada a punto de partida de infeccion de piel y partes blandas. Serie de casos de un centro de tercer nivel / Disseminated nocardiosis at the starting point of skin and soft parts infection. Series of cases from a third level center

Nocardia es una bacteria grampositiva con amplia distribución en el medio ambiente. Puede producir variadas de infecciones. Si bien, las vías respiratorias son la principal puerta de entrada de Nocardia sp. ­y como consecuencia de lo mismo 50% de los pacientes posee compromiso pulmonar- las infecciones por Nocardia van desde infecciones de piel y partes blandas hasta abscesos cerebrales. La piel puede ser el órgano de afectación primaria y el primer signo clínico de infección o formar parte de una infección diseminada. La nocardiosis diseminada, es una grave enfermedad que involucra a dos sitios no contiguos de infección o el rescate del agente causal en hemocultivos. Afecta a pacientes debilitados con condiciones o con cierto grado de inmunodepresión; particularmente de inmunidad celular; como trasplantados de órganos sólido o hematopoyeticos, uso de corticoides, neoplasias, VIH, alcoholismo ­aunque se describen infecciones en pacientes inmunocompetentes­. El diagnóstico es dificultoso y la sospecha clínica es fundamental para el inicio de la terapéutica. Se describen dos casos de infecciones de piel y partes blandas ocasionadas por Nocardia; de evolución subaguda-cronica;. Una de ellas localizada: micetoma de pie, la segunda, una celulitis abdominal recurrente complicada con compromiso sistémico; en ambas estuvo presente la demora en el diagnóstico.

Nocardia is a gram-positive bacteria with wide distribution in the environment. It can cause a wide range of infections. Although the respiratory tract is the main entry point for Nocardia sp. ­ and as a consequence of the same, 50% of patients have lung involvement ­ nocardia infections range from skin and soft tissue infections to brain abscesses. The skin can be the primary organ of involvement and the first clinical sign of infection or be part of a disseminated infection, secondary to a primary pulmonary form. Disseminated nocardiosis is a serious disease that involves two non-contiguous sites of infection or the recovery of the causative agent in blood cultures. It commonly affects patients with weakened conditions or a certain degree of immunosuppression; particularly cellular immunity, such as solid or hematopoietic organ transplants, use of corticosteroids, neoplasms, HIV, alcoholism - although infections are described in immunocompetent patients. The diagnosis is difficult and clinical suspicion is essential for the initiation of therapy. Two cases of skin and soft tissue infections caused by Nocardia were described of subacute-chronic evolution. One of them localized: mycetoma of the foot, the second, a recurrent abdominal cellulites complicated with systemic involvement; Delay in diagnosis was present in both

Pancytopenia following adjuvant therapy with interferon-gamma in a patient with disseminated nocardiosis.

A patient with disseminated nocardiosis developed pancytopenia after treatment with recombinant interferon-gamma (IFN-γ). While no previous clinical reports link pancytopenia to IFN-γ, our observations align with basic research on myelosuppressive effects of IFN-γ. Adjunctive IFN-γ may improve standard nocardiosis therapy, but vigilant monitoring of its hematologic effects is necessary.

Lumpy jaw caused by Nocardia farcinica in a Holstein cow.

A 3-year-old Holstein cow was examined in an intensive system due to unilateral swelling in the mandible. A right mandibular mass was associated with painful mastication and Ptyalism. In palpation, the mass was raised, ulcerated, attached to the mandible bone and firm, approximately 17 × 12 × 10 cm3 in size. The lesion was sampled, and after routine bacteriology and histopathology procedures, the occurrence of lumpy jaw caused by Nocardia farcinica was confirmed. The bacterium was analysed using genome sequencing and new strain called Najm 114. Due to the risk of zoonosis of the isolated agent, the cow was euthanized. This is the first report of lumpy jaw caused by N. farcinica in a cow. This study showed that N. farcinica should be considered a possible etiological agent for lumpy jaw in cattle.

A rare case of a hard-to-heal ulcer caused by pulmonary Nocardia infection.

DECLARATION OF INTEREST: The authors have no conflicts of interest.

Nocardiosis in kidney transplant recipients: A tertiary care center experience.

INTRODUCTION: Kidney transplant recipients are at increased risk of opportunistic infections, including Nocardia. The incidence of nocardiosis in kidney transplant recipients is 0.4-1.3%. The data regarding its epidemiology and outcomes is limited. METHODS: This was a 10-year retrospective observational study from January 2012 to December 2021 at a tertiary care center in northern India, in which all kidney transplant recipients with Nocardia infection were included and followed. RESULTS: 12 (1.1%) patients had a Nocardia infection among the 1108 kidney transplant recipients. All were living donor kidney transplant recipients, and the mean age at diagnosis was 48.67 ± 12.60 years. Nocardia infection occurred at a median of 26 months (range 4-235) post-transplantation, with 4 (33.1%) of the cases occurring within a year of transplant. Breakthrough infection occurred in 7 (58.3%) patients on cotrimoxazole prophylaxis. 41.7% (n = 5) cases had an episode of rejection in the preceding year of Nocardia diagnosis. Concurrent cytomegalovirus (CMV) infection was present in one (8.3%) case. The lung was the most frequently involved organ. Microscopy was positive in all the cases; while culture was positive in 10 cases, and antimicrobial susceptibility testing (AST) were performed for these isolates. The majority (60%) of isolates were resistant to cotrimoxazole. All tested isolates remained susceptible to Amikacin, Imipenem, and Linezolid. No patients experienced Nocardia recurrence after completion of antibiotic therapy. The mortality at 12 months was 66.7% (n = 4), and only one death was Nocardia-related. CONCLUSION: Nocardia may cause a late-manifesting infection beyond the traditional window. The cotrimoxazole prophylaxis may not be sufficient for Nocardia prevention.

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.