Mycetoma in Yemen: clinicoepidemiologic and histopathologic study

BACKGROUND

Mycetoma is widespread in Yemen, but has not been fully documented.

METHODS

A prospective study of 70 patients (53 male, 17 female; from different regions of Yemen) was performed. The clinical profile of the cases was recorded in a special protocol. The diagnosis was based on clinical features, examination of grains, roentgenographic studies, and histopathology (44 cases).

RESULTS

Fifty cases were diagnosed as eumycetoma and 20 as actinomycetoma. The identification of the causative species was performed in 44 cases by histopathologic studies. Among the cases of eumycetoma, Madurella mycetomatis was recognized in 27 patients, Leptosphaeria senegalensis in two, and pale-grain fungi in two. Among the cases of actinomycetoma, Streptomyces somaliensis was seen in eight patients, Streptomyces madurae in one, and Nocardia species in four. The treatment of eumycetoma patients with ketoconazole and excision in selected cases controlled the disease activity in the majority. Most of the cases of actinomycetoma were better controlled with drug therapy alone, with a combination of penicillin and cotrimoxazole, or cotrimoxazole alone.

CONCLUSIONS

Mycetoma is widespread in Yemen, with a higher incidence of eumycetoma and a maximum number of cases from the Hudaida region. A multicenter study is needed to evaluate the exact extent of disease.

Nocardia pseudovaccinii sp. nov

Comparative 16S rDNA studies of Nocardia type and reference strains revealed that strain DSM 43406T, identified as Nocardia vaccinii, was wrongly classified. The strain was aerobic, gram-positive and produced scarce, white, branched aerial mycelium and a beige-red substrate mycelium. The reverse side of the colonies was yellow-orange. It showed chemotaxonomic markers that were consistent with its classification in the genus Nocardia. The mycolic acids had chain lengths from 50 to 58 carbon atoms. The 16S rDNA sequence showed the highest similarity to Nocardia nova (97.7%) and N. vaccinii (97.6%), but the strain could be clearly separated from these species and other members of the N. vaccinii cluster by significant differences in biochemical test results and unique fatty acid and mycolic acid patterns. These data led to the conclusion that the isolate represents a novel species within the genus Nocardia, for which the name Nocardia pseudovaccinii sp. nov. is proposed. The type strain is strain AR 368,38366-20T (= DSM 43406T = NRRL B-24154T).

Epidemiological aspects of mycetoma from a retrospective study of 264 cases in West Bengal

Between 1981 and 2000, 264 cases of mycetoma were diagnosed clinically and microbiologically at Calcutta School of Tropical Medicine. Retrospective analysis of the records revealed that the ratio of actinomycetomas and eumycetomas was 197 : 67; the male to female ratio was 183 : 81. Ninety-four cases occurred in the 1980s and 170 in 1990s, with significantly more infections of Actinomadura spp. (P < 0.01) and fewer with Nocardia caviae (P < 0.01) during the last decade. Pricking was the most common injury associated with eumycetomas (P < 0.01). A total of 196 infections were in exposed body parts and 68 in covered areas. The localization of mycetomas differed significantly (P < 0.01) according to sex, incidence of actinomycetomas or eumycetomas, and obvious history of trauma. Exposed area cases were more common among agricultural workers (P < 0.01), while covered area mycetomas were almost always actinomycetomas with a remarkably lower incidence of N. caviae, A. madurae and Madurella grisea infections. The peak age of onset was between 16 and 25 years. The delay of diagnosis for the 80th percentile of cases was around 6 years for cases caused by N. brasiliensis and Streptomyces spp.; 8 years for N. caviae and N. asteroides; and 10 years for M. grisea and Actinomadura spp. From the history of trauma in 130 patients, the 80th percentile incubation period (IP) was calculated for N. brasiliensis, N. caviae and N. asteroides as 3 years; for Actinomadura spp. 7 years and for M. grisea 9 years. The minimum IP for all organisms was around 3 months.

Isolation of Nocardia paucivorans from the cerebrospinal fluid of a patient with relapse of cerebral nocardiosis

Nocardia paucivorans represents a new species of the genus Nocardia that has recently been isolated from bronchial secretions of a patient with chronic lung disease. Here, we report on the course of a disseminated infection caused by this species: i.e., cerebral and subsequent meningeal manifestations, isolation from the cerebrospinal fluid, and in vitro susceptibility to various antimicrobial agents.

Intracranial Nocardia dissemination during minocycline therapy

Nocardia species is a well-known pathogen in immunocompromised hosts, including renal transplant recipients. Primary pulmonary infection can disseminate to other organs and recommended first-line therapy is high-dose trimethoprim/sulfamethoxazole (TMP/SMX). We report two cases of primary pulmonary Nocardia sp. in immunosuppressed patients who were treated with minocycline, a second-line drug. During treatment with minocycline, both patients developed central nervous system (CNS) lesions of Nocardia sp. and were then treated with TMP/SMX with resolution of disease. The literature on Nocardia and treatment with minocycline is reviewed. Treatment of pulmonary Nocardia sp. with 200 mg minocycline daily is not adequate to prevent disseminated CNS disease.

Nocardia farcinica spinal osteomyelitis

STUDY DESIGN

A case of disseminated Nocardia farcinica infection with spine involvement is reported.

OBJECTIVE

To describe the first case of Nocardia farcinica spinal osteomyelitis, and to propose spine instrumentation with debridement and multiple antibiotics for treatment of nocardia spinal osteomyelitis.

SUMMARY OF BACKGROUND DATA

Only 11 cases involving Nocardia asteroides spinal osteomyelitis have been reported over the past 40 years. These case reports describe various presentations and treatments of nocardia spinal osteomyelitis.

METHODS

A 54-year-old nonambulant, paraparetic man was admitted to the authors' hospital with acutely increased low back pain, fever, and signs of dementia. A disseminated Nocardia farcinica infection including spinal osteomyelitis at T11, T12, L1, L2, and L4; epidural abscess T10-L4, L5-S1 discitis, empyemas, cerebral abscess, and bilateral psoas abscess was noted.

RESULTS

Antibiotic therapy, multiple debridements, and posterior instrumentation were performed to palliate the Nocardia farcinica infection. At a recent 3-year follow-up assessment, the patient was independent and ambulant. He had been off antibiotics for 5 months.

CONCLUSIONS

Previous case reports of nocardia spinal osteomyelitis describe treatment with antibiotics, debridements, and arthrodesis with autologous bone graft. Prolonged recumbency ensued. In the reported case, a combination of antibiotics, debridements, arthrodesis, and posterior instrumentation for immediate stabilization of the spine resulted in a favorable outcome at 3 years.

Diagnosis of nocardiosis by polymerase chain reaction: an experimental study in mice

In this study, we have established a sensitive semi-nested polymerase chain reaction (PCR) for detection of Nocardia in clinical specimens by first amplifying a 422 bp DNA fragment from the groEL gene, followed by a second amplification of 342 bp DNA by targeting sequences internal to the first amplicon. The semi-nested PCR was evaluated in a murine model of nocardiosis for detection of Nocardia in blood and visceral organs. Healthy BALB/c mice were intravenously infected with 0.2 ml suspension of 2.9 x 10(5)/ml cfu of Nocardia asteroides and N. farcinica. Viable counts and seminested PCR were performed post-infection with samples of blood as well as lung, liver, spleen, kidney and brain at 5 minutes, 3 h, and then every 24 h for 3 days. Of the 20 blood samples tested, 15 (75%) were Nocardia positive by culture and 19 (95%) were positive by semi-nested PCR. Likewise, in case of N. asteroides infection, 46% organ samples were positive by culture and 58% by semi-nested PCR. The positivity of organ samples was higher with N. farcinica, 60% by culture and 72% by PCR, which may be attributed to its increased virulence as compared to N. asteroides. These results demonstrate that semi-nested PCR is a rapid and sensitive method for detection of Nocardia in blood and different visceral organs. The diagnostic application of this method provides an additional advantage over culture techniques, as PCR can also detect L-forms of Nocardia in clinical specimens, which otherwise fail to grow on routine isolation medium.

Differentiation of nocardia species by PCR-randomly amplified polymorphic DNA fingerprinting

Representatives of fifteen validly described and three non-validly described species of Nocardia were assigned to nineteen groups based on an optimised PCR-randomly amplified polymorphic DNA fingerprinting technique. Species specific banding patterns were recognised for the representatives of N. brasiliensis, N. crassostreae, N. farcinica, N. otitidiscaviarum and N. seriola. Unique banding patterns were also seen for the type strains of N. brevicatena, N. carnea, N. salmonicida, N. uniformis and N. vaccinii, and for the single representatives of "N. fusca", "N. pseudosporangifera", and "N. violaceofusca". More than one banding pattern was detected for the N. asteroides, N. flavorosea, N. nova, N. pseudobrasiliensis and N. transvalensis strains though in the case of the representative strains of N. nova and N. transvalensis the patterns were similar for each of these species. The results are in line with current trends in nocardial systematics thereby indicating that PCR-randomly amplified polymorphic DNA fingerprinting provides valuable data for the classification and identification of pathogenic nocardiae to the species level.

[Isolation of three species of Nocardia in a patient receiving long-term corticosteroid therapy]

INTRODUCTION

Nocardia are saprophyte bacteria of the environment responsible for systemic infections in immunodepressed patients, due essentially to long-term corticosteroids.

OBSERVATION

A patient having received corticosteroids for sarcoidoses for a year was hospitalised because of disseminated granulomatosis (neurological, respiratory, abdominal and cutaneous). Culture of various bacteriological samples isolated three species of Nocardia: N. otitidiscaviarum in uretheral pus and pus from the right gland, N. nova and N. asteroides in respiratory samples (protected distal sampling and broncho-alveolar washing).

COMMENTS

Other than the mixed Nocardia infections described habitually, infections with two different species of Nocardia have recently been reported. Our case report is the first to have isolated three concomitant species of Nocardia.

Fatal pulmonary Nocardia farcinica infection

Nocardia farcinica infections are rare and potentially life threatening. Identification is based on growth at 45 degreesC, opacification of Middlebrook 7H10 agar, and resistance to antibiotics. We describe a case of fatal pulmonary N. farcinica infection in a patient with pneumoconiosis that was diagnosed by culture of sputum onto selective media.

First results from a screening of filamentous organisms present in Buenos Aires's activated sludge plants

Activated sludge samples from municipal and industry plants were evaluated with the aim to recognise the mainly filamentous bacteria found. The routine tests recommended were performed: Gram, Neisser, PHB-Nilo blue epifluorescence reaction and S. The morphologic characteristics were determined. Correlation between environmental conditions and abundance of dominant bacteria were made. All plants were completely mixed configurations with anoxic reactor for denitrification ahead of main aerobic reactor. Also all systems were working at low F/M values or high sludge age (> ten days) and in some cases with low oxygen concentration. The dominant species were Type 021 N, Thiothrix I, Sphaerotilus natans, Microthrix parvicella, Nocardia sp, Type 1701, Type 1863, Type 0041 and Type 0092.

Nocardial brain abscess: observation of treatment strategies and outcome in Switzerland from 1992 to 1999

BACKGROUND

Brain abscesses caused by Nocardia spp. are rare, but life-threatening infections that are notoriously difficult to diagnose and treat and which occur mainly in immunocompromised patients. Standard treatment guidelines are not available.

METHODS

A systematic search for nocardial brain abscesses from 1992 to 1999 was conducted in Switzerland for the comparison of clinical presentation, treatment strategies and outcome.

RESULTS

Seven cases were found, for which data of six were available. In 4/6 patients antimicrobial therapy led to a decrease in the size of abscesses. Four of six patients died. The cause of death was likely due to underlying co-morbidities, rather than the nocardial infection.

CONCLUSION

The finding that treatment was different in each case underscores the lack of therapeutic guidelines.

Primary cutaneous nocardiosis in an immune-competent patient

We present a patient who was hospitalized due to a purulent skin lesion with a surrounding erythematous area in the region of the right paranasal crease accompanied by a swelling of the right eyelid. Initially the diagnosis of a carbuncle caused by an infection with Staphylococcus aureus was supposed. A surgical debridement was performed and an antibiotic therapy was started. Only special microbial investigations requested by the clinician led to the diagnosis of a cutaneous infection with Nocardia brasiliensis. The presented case is remarkable because the nocardia infection was in an immune-competent patient and the patient showed a primary cutaneous nocardiosis without dissemination.

Nocardia beijingensis sp. nov., a novel isolate from soil

The taxonomic status of a soil isolate, provisionally assigned to the genus Nocardia, was established following a polyphasic study. An almost complete sequence of the 16S rDNA of the strain was determined and aligned with available sequences for nocardiae and phylogenetic trees were inferred using four tree-making algorithms. The organism was associated consistently with the type strains of Nocardia brasiliensis and Nocardia farcinica in the neighbour-joining analysis, albeit with low bootstrap values. It was also found to have chemotaxonomic and morphological properties consistent with its assignment to the genus Nocardia. The organism was readily separated from representatives of other Nocardia species by a broad range of phenotypic properties. The name proposed for the novel species is Nocardia beijingensis sp. nov. The type strain is AS4.1521T (= IFO 16342T = JCM 10666T).

Disseminated nocardiosis in a patient with X-linked chronic granulomatous disease and human immunodeficiency virus infection

We report the first case of HIV infection in a patient with underlying X-linked chronic granulomatous disease (CGD) who presented with hepatopulmonary nocardiosis. Despite the coexistence of CGD and HIV, the response to therapy was normal, and no unusual sequelae were noted. The patient's high virus burden was successfully repressed with antiretroviral therapy, suggesting that the nicotinamide adenine dinucleotide phosphate oxidase system is not essential for active viral replication or response to antiretroviral agents.

Nocardiosis in South Texas children

Primary cutaneous nocardiosis can present as cellulitis or abscess with or without lymphadenitis. In South Texas children with suspected Staphylococcus aureus or Streptococcus pyogenes skin and soft tissue infections who do not improve as expected with appropriate antibiotics, physicians should consider Nocardia brasiliensis in the differential diagnosis, especially if there are multiple lesions in a lymphocutaneous distribution.

Actinomycotic mycetoma due to Nocardia brasiliensis in a case of leprosy

Various bacterial and fungal infections associated with non-healing ulcers in cases of leprosy have been reported (G Ebenzer et al, 2000, Rama Ramani et al, 1990). There are no reports of mycetoma associated with leprosy patients in the literature. We report here a case of actinomycotic mycetoma due to Nocardia brasiliensis associated with the non-healing plantar ulcer of a leprosy patient.

Treatment and outcome of nocardia keratitis

OBJECTIVE

To report our experience in treatment and outcome ofNocardia keratitis.

METHODS

Medical and microbiology records of seven cases of culture-provenNocardia keratitis seen between January 1997 and March 1999 were reviewed retrospectively. In all patients, corneal scrapings were obtained for direct microscopic evaluation and culture. Drug sensitivity was determined by the Kirby-Bauer disk-diffusion method. The minimum inhibitory concentration of ciprofloxacin and amikacin for these isolates was determined by agar dilution method. Response to medical therapy and the end result were analyzed.

RESULTS

By the in vitro Kirby-Bauer disk-diffusion techniques, all isolates were sensitive to amikacin; six of these isolates were sensitive to gentamicin and four were sensitive to ciprofloxacin. The minimum inhibitory concentration (MIC) of amikacin for all isolates by the agar-dilution technique was well below the MIC breakpoint forNocardia resistance, whereas the MIC of ciprofloxacin was above the MIC breakpoint forNocardia resistance. All patients responded to medical therapy. The corneal infection resolved in three patients after treatment with ciprofloxacin, in one patient after fortified gentamicin, and in three patients after fortified amikacin. Outcome details were available for six patients. There was good visual recovery in four patients, with visual acuity of 20/25 or better in three. The cornea of two patients developed nonvascularized scars, and in four patients in whom the infiltrates were peripheral, vascularization was seen.

CONCLUSIONS

Although patients ofNocardia keratitis may respond to other antibiotics, amikacin appears to be a drug of choice. In this small series, when appropriate therapy was initiated,Nocardia keratitis resolved promptly with good visual recovery.

Nocardia cyriacigeorgici sp. nov

Chemotaxonomic and 16S rRNA gene sequence analyses of an isolate from the bronchial secretions of a patient with chronic bronchitis demonstrated clearly that it belongs to the genus Nocardia. The 16S rRNA gene sequence data, as well as the biochemical characteristics of the isolate, indicated that it belongs to a new species that differs from previously described members of the genus Nocardia. The name Nocardia cyriacigeorgici sp. nov. is proposed for this isolate, and is represented by strain IMMIB D-1627T (= DSM 44484T).

Widespread nocardiosis in two patients with Behçet's disease

Nocardia spp., a group of gram-positive variably acid-fast aerobic bacteria, are opportunistic pathogens in immunocompromised hosts. We here-within describe 2 cases of widespread nocardiosis in patients with Behcet's disease. In addition to endogen endophthalmitis in case 1, both cases developed lung, brain and skin involvement. Despite brain involvement, the prognosis was good, although vision was completely lost in case 1, which was directly attributable to a delay in both diagnosis and treatment.