Nocardiosis in Kidney Disease Patients under Immunosuppressive Therapy: Case Report and Literature Review.

The increased use of novel and powerful immunosuppressive drugs in kidney diseases may concomitantly expose the patients to higher risk of opportunistic infections, some of which still remain underdiagnosed thus mishandled. As such, we recently had a less prepared encounter of pulmonary nocardial infection in an ANCA-associated renal vasculitis patient under steroid therapy. Despite the use of broad-spectrum antimicrobials including micafungin, the infection was still unbridled and eventually culminated in lethal brain abscess. We thus chose to renew the knowledge of the clinical features, imaging manifestations, differential diagnosis, specific laboratory tests and unique treatment about this rare infection in kidney diseases patients under immunosuppressive therapy. In addition, CT images of easily confused pulmonary lesions superimposed on kidney diseases were also retrieved from our depository. Moreover, impaired renal function as a risk factor for infection and pharmacological options for the treatment were also focused. By sharing our hard-learnt experience and reviewing the literatures, our report may contribute to the awareness among the clinicians in general and nephrologists in particular of this rare disease in susceptible patients and facilitate a swift thus life-saving treatment.

Management of Nocardia Interface Keratitis After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To report the clinical course and management of graft-host interface Nocardia keratitis after Descemet membrane endothelial keratoplasty (DMEK). METHODS: A 70-year-old man presented with a corneal epithelial defect, stromal edema, graft infiltrate, and graft-host interface infection 5 months after an uneventful DMEK performed for bullous keratopathy in the left eye. Corneal scrapings from the margin of epithelial defect showed gram-positive bacillus, and the organism was identified as Nocardia asteroides. RESULTS: Intensive and appropriate topical and systemic antibiotic therapy resulted in complete resolution of infection. Three months later, the patient underwent a repeat DMEK, which resulted in clearing of corneal edema and improvement in visual acuity. CONCLUSIONS: Nocardia interface keratitis is a rare entity, which can occur after DMEK. Proper clinical evaluation and microbiological workup helped us in accurate diagnosis and management. Repeat DMEK after complete resolution of the infection resulted in good outcomes regarding corneal clarity and vision improvement.

The Complexities of Nocardia Taxonomy and Identification.

Nocardia species are a complex group of organisms considered to belong to the aerobic actinomycetes. Of the validly described species, many have been implicated as the cause of serious human infections, especially in immunocompromised patients. The genus has a complicated taxonomic history; this is especially true for Nocardia asteroides, the type species of the genus and previously the most frequently reported nocardial taxon from human specimens. We provide background on the current taxonomy of Nocardia, with a focus on clinically relevant species, and discuss the currently available methods used to accurately identify isolates to the species, complex, or group level.

Nocardia Arthritidis Keratitis: Case Report and Review of the Literature.

INTRODUCTION: Keratitis due to Nocardia infection is not commonly encountered in clinical practice and may therefore be mistaken for fungal or viral keratitis leading to delayed treatment and increased risk of permanent visual impairment. CASE: An otherwise healthy 27 years old Caucasian Active Duty military member presented to the clinic with three days of light sensitivity and irritation of his right eye. He carried a history of PRK in both eyes six years prior and admitted to recent contact lens overuse. With empiric treatment for typical bacterial keratitis including corticosteroids, his condition worsened on close follow-up. While awaiting cultures, a shift to fortified topical antibiotics tobramycin, moxifloxacin and ciprofloxacin showed improvement with closure of the epithelial defect. Ulcerative relapse occurred with withdrawal of therapy. Culture proven Nocardia arthritidis prompted successful treatment with topical antibiotic amikacin. On follow-up at three months, the patient was doing well with a small peripheral anterior stromal scar without permanent visual sequelae. Visual acuity returned to baseline of 20/20 in the affected eye. CONCLUSION: Keratitis caused by Nocardia species, including arthritidis, responds well to amikacin. Late diagnosis and early treatment withdrawal may lead to a prolonged recovery. Current literature indicates that corticosteroids may be harmful in the treatment of Nocardia keratitis. Increased awareness of Nocardia as an ocular pathogen has the potential to reduce unnecessary morbidity related to delayed diagnosis, inadequate therapy and inappropriate use of corticosteroids.

SUBTENON AMIKACIN INJECTION FOR THE TREATMENT OF NOCARDIA ASTEROIDES ORBITAL CELLULITIS IN A PATIENT WITH A HISTORY OF SCLERAL BUCKLING.

PURPOSE: To evaluate the use of subtenon amikacin injection for the treatment of Nocardia asteroides orbital cellulitis in a patient with a history of scleral buckle surgery. METHODS: Case report. RESULTS: A 79-year-old diabetic woman presented with an 8-month history of diplopia, discharge, and swelling around her left eye. She had a scleral buckle surgery in this eye about 15 years ago. Examination of the left eye showed a visual acuity of 20/80, swollen and ptotic upper eyelid, chemotic conjunctiva, and limited extraocular motility. Magnetic resonance imaging showed an abscess under the scleral buckle. The scleral buckle was removed, and the abscess under the scleral buckle was drained. N. asteroides grew on the culture. Despite 4 months of the systemic trimethoprim/sulfamethoxazole and the topical fortified amikacin therapy, her infection worsened. After 5 monthly subtenon amikacin injections, the infection regressed dramatically, and her vision improved to 20/70. She used the systemic trimethoprim/sulfamethoxazole for 10 more months. After a 1-year follow-up, her external examination was normal, except for the left upper eyelid ptosis. CONCLUSION: Subtenon amikacin injection can be added to the regimen for N. asteroides orbital cellulitis, of which surgical drainage, systemic and topical antibiotic therapies are not enough to control infection.

Therapeutic Femtosecond Laser-Assisted Lamellar Keratectomy for Multidrug-Resistant Nocardia Keratitis.

PURPOSE: To describe the novel use of femtosecond laser technology for therapeutic resection of infectious foci in a case of multidrug-resistant Nocardia asteroides keratitis. METHODS: A 30-year-old man presented with a corneal infiltrate. Cultures were taken, and fortified vancomycin and tobramycin were initiated. After 3 negative cultures and minimal improvement on various broad-spectrum antibiotics, all topical medications were stopped and a final fourth corneal culture grew N. asteroides. Treatment with topical amikacin was initiated, but the infection continued to worsen. With drug sensitivities still pending, the patient's clinical status continued to deteriorate rapidly, despite treatment with amikacin, gatifloxacin, and polymyxin B/trimethoprim. The femtosecond laser was then used to perform targeted lamellar keratectomy. RESULTS: Femtosecond laser-assisted lamellar keratectomy successfully removed the infected tissue and allowed for increased penetration of topical antibiotics. Drug sensitivities finally returned, revealing multidrug resistance and sensitivity only to trimethoprim/sulfamethoxazole and tobramycin, some of which the patient had previously tried and failed. The infection fully resolved after readministering polymyxin B/trimethoprim and tobramycin, leaving minimal residual scarring. CONCLUSIONS: Multidrug-resistant N. asteroides keratitis can be difficult to manage even with appropriate antibiotic therapy based on drug sensitivity testing. Femtosecond laser-assisted resections may facilitate treatment in these cases by safely and precisely debulking infected tissue and enhancing penetration of topical medications.

Nocardia choroidal abscess-a Case report with Review of literature.

INTRODUCTION: Nocardia is a common cause of corneal infections but is a rare cause of choroidal abscess. We report a rare case of choroidal abscess, secondary to Nocardia and its management. CASE: We report a case of choroidal abscess secondary to Nocardia asteroides species in an immunocompetent young male diagnosed by culture positivity of vitreous biopsy. He was managed by oral trimethoprimsulfamethoxazole and intravitreal Amikacin injections. CONCLUSION: All the previous reported cases were found to be immunocompromised patients. However, our patient was immunocompetent and the confirmation of diagnosis was done by culture of vitreous biopsy in comparison to a retinochoroidal biopsy, in all other previous cases.

A case of atypical nocardia asteroides sclerouveitis resistant to fourth-generation fluoroquinolones / Um caso atípico de esclero-uveíte por Nocardia Asteroides resistente a fluorquinolona de quarta-geração

ABSTRACT We describe an unusual case of Nocardia spp scleritis in a health girl resistant to topical fourth-generation fluoroquinolones. Clinically, there was only partial response of the scleritis to initial therapy. Treatment was changed to meropenem intravenously and topical amikacin. Following several weeks of antibiotic treatment, the patient's infection resolved but her vision was reduced to no light perception. Nocardia asteroides must be considered as a possible agent in cases of necrotizing scleritis in patients without a clear source. Antibiotic sensitivity testing has a definitive role in view of the resistance to these new medications.

RESUMO Nós descrevemos um raro caso de esclerite por Nocardia spp em uma criança sadia resistente a utilização tópica de fluorquinolona de quarta-geração. Clinicamente, a paciente apresentou apenas uma resposta parcial do quadro de esclerite a terapêutica inicial. O tratamento foi então modificado para meropenem intravenoso e amicacina tópica. Após várias semanas de tratamento com antibiótico, o quadro infeccioso regrediu porém a visao da pacientes evoluiu para perda da percepção luminosa. Em casos de esclerite necrotizante em pacientes sem fatores de risco aparente é necessário considerer a Nocardia Asteroides como possível agente causador. Os testes de sensibilidade medicamentosa apresentam importância significativa em virtude do aparecimento de resistência aos novos medicamentos.

Nocardia asteroides peritoneal dialysis-related peritonitis: First case in pediatrics, treated with protracted linezolid.

Nocardia asteroides is a rare pathogen in peritoneal dialysis-related peritonitis. We report on a 13-year-old female with Nocardia asteroides peritonitis complicated by an intra-abdominal abscess. Linezolid was administered intravenously for 3 months and followed by oral therapy for an additional 5 months with close monitoring for adverse effects. The patient was discharged after 3 months of hospitalization on hemodialysis. The diagnosis and management of such cases can be problematic due to the slow growth and difficulty of identifying Nocardia species. The optimal duration of treatment for Nocardia peritonitis is not known. Linezolid can be used for prolonged periods in cases of trimethoprim/sulfamethoxazole-resistant cases with close monitoring for adverse effects.

Nocardia asteroides Keratitis Resistant to Amikacin.

PURPOSE: To describe 2 cases of Nocardia keratitis resistant to topical compounded amikacin therapy. METHODS: A 24-year-old woman presented with a corneal infiltrate. Cultures were taken, and topical moxifloxacin was administered. Corneal biopsy was performed when clinical status deteriorated, which confirmed infection with Nocardia. The patient was administered topical compounded amikacin. When clinical status further deteriorated, she was switched to compounded trimethoprim-sulfamethoxazole, which resulted in rapid resolution. Separately, a 22-year-old woman presented with contact lens-related keratitis that grew Nocardia asteroides. Corneal cultures and drug sensitivity testing revealed a strain of N. asteroides resistant to amikacin and imipenem, but sensitive to tobramycin. After a protracted clinical course, the keratitis ultimately responded to topical tobramycin leaving the patient with a pericentral corneal scar. CONCLUSIONS: Nocardia keratitis is an atypical infection for which standard management algorithms exist. However, atypical cases require that these patients be followed closely for the response to therapy.

Primary cutaneous nocardiosis.

Nocardiosis is a rare human infection due to ubiquitous soil born gram-positive, filametous aerobic bacteria. First signs are frequently cutaneous either as part of systemic infection disseminated to the skin, or as primary cutaneous inoculation. An 88 years old man presented with a 3-day history of red papules and pustules with pain on his forehead. The combination of the unusual clinical presentation, laboratory examinations, and a favorable response to co-trimoxazole therapy were consistent with a diagnosis of primary cuteneous nocardiosis. Early recognition and treatment of the disease will improve the cure rate.

Nocardia asteroides subretinal abscess in patient with acute myelogenous leukemia after allogeneic stem cell transplant.

PURPOSE: Nocardia asteroides is the most common bacterial cause of subretinal abscesses; however, the diagnosis is often delayed because of the lack of suspicion leading to poor visual prognosis and possible enucleation. METHODS: A 40-year-old man with a history of allogeneic stem cell transplant presents with decreased vision and a macular subretinal abscess. RESULTS: Examination revealed decreased vision at 20/100 with a peripapillary creamy subretinal lesion extending to the nasal margin of the fovea associated with intraretinal and subretinal hemorrhages without vitritis. Workup revealed disseminated N. asteroides, confirmed with a skin biopsy with the involvement of skin, eyes, lungs, and brain. Intravitreal amikacin and vancomycin were promptly given along with systemic vancomycin, sulfamethoxazole/trimethoprim, and meropenem. Vision improved rapidly to 20/40 with stabilization and eventual scarring of the lesion. CONCLUSION: This case illustrates that rapid diagnosis and treatment of subretinal N. asteroides can possibly have a good visual outcome and stabilization of the ocular manifestations.

Central nervous system nocardiosis with granulomatous pachymeningitis and osteomyelitis of skull vault.

A 34-year-old immunocompetent man weighing 95 kg was operated for a small left parietal scalp swelling in the year 2002. He was well until 2008, when he developed chronic diffuse headache, vomiting and drowsiness. The left parietal dura and overlying vault biopsy showed evidence of granulomatous pachymeningitis with osteomyelitis secondary to nocardiosis. He had responded well to inadequate antibiotic therapy. After a dormant period of 3 years, there was recrudescence of severe raised intracranial tension symptoms in 2011. Magnetic resonance imaging showed diffuse pachymeningeal thickening mainly involving the occipital dura, posterior falx, and tentorium cerebelli. In addition, well-defined small nodules with hypointense signals on both T1- and T2-weighted images were seen in occipital lobes. Patient was treated with three drug regime with good recovery at 3 months follow-up. This is a rare case of central nervous system nocardiosis with skull vault osteomyelitis and a protracted clinical course.

Co-infection with Nocardia asteroides complex and Strongyloides stercoralis in a patient with autoimmune hemolytic anemia.

We describe an unusual case of pulmonary nocardiosis co-existing with Strongyloides stercoralis hyperinfection syndrome in a patient with autoimmune hemolytic anemia who was being treated with corticosteroids. This case highlights the importance of being aware of the possibility that infections can co-exist in immunosuppressed patients. To the best of our knowledge, this is the first report of co-infection with Nocardia asteroides and S. stercoralis.

Contact lens-associated nocardial necrotizing scleritis.

A 52 year-old, contact lens-wearing man presented with progressive right eye pain and redness for one month. He had been evaluated and treated for necrotizing scleritis by multiple eye care specialists prior to presentation. He underwent a complete systemic work-up for both autoimmune and infectious causes of scleritis, including a culture. The culture revealed heavy growth of Nocardia asteroides complexes. The patient was treated with topical amikacin and oral Bactrim. Following several weeks of antibiotic treatment, the patient's infection resolved completely, and his visual acuity returned to baseline status. Nocardia is a rare but potentially devastating cause of necrotizing scleritis that may affect contact lens wearers without an associated keratitis. Prompt recognition and early treatment with appropriate antimicrobial agents are critical to achieve a favorable outcome.

Pulmonary nocardiosis--a rare case of pulmonary nocardiosis in an immunocompetent patient.

Nocardiosis is localised or disseminated infection caused by soil dwelling aerobic actinomycetes, which habitually enter through the respiratory tract. There has been an increase in the incidence of nocardia species infections probably due to higher degree of clinical suspicion, aggressive diagnostic examinations, increased use of immunosuppressive treatments (chemotherapy agents and immunosuppressive agents) and the appearance of AIDS. Here we are presenting an atypical case of Nocardia asteroides in a 45-years-old immunocompetent female patient presenting with history of cough with scanty expectoration, haemoptysis and fever for 4 months. Clinical and radiological diagnostic consideration were tuberculosis and malignancy. Diagnosis of nocardiosis was confirmed microbiologically and the patient responded to cotrimoxazole.