Nocardia brasiliensis infection mimicking juvenile idiopathic arthritis in a 4-year-old girl

Nocardia are ubiquitous environmental saprophytes that cause pneumonia and disseminated disease in immunocompromised patients. They can also cause localized cutaneous and soft tissue infections in healthy people after direct percutaneous inoculation. Nocardia arthritis is rare in both forms of the disease. Here we present the first published case of a child with septic arthritis caused by N brasiliensis. Importantly, this otherwise well 4-year-old girl had no known history of trauma but presented with transient cutaneous lesions and a 6-week history of arthritis involving the right fourth digit proximal interphalangeal joint without accompanying fever or raised systemic inflammatory markers. She received a diagnosis of juvenile idiopathic arthritis and underwent antiinflammatory and immunosuppressant therapy. After 2 months she developed frank septic arthritis, which necessitated a surgical joint washout, from which an intraoperative swab grew N brasiliensis. The patient received 6 months of high-dose trimethoprim-sulfamethoxazole and remains well more than 4 years after treatment. This unusual case highlights the importance of considering an indolent infection from slow-growing organisms, including Nocardia, when diagnosing the oligoarthritis subtype of juvenile idiopathic arthritis. This is especially relevant when a single joint is involved and response to antiinflammatory therapy is suboptimal because antiinflammatory agents may mask evolving signs of infection.

Nocardiosis in Mediterranean bivalves: first detection of Nocardia crassostreae in a new host Mytilus galloprovincialis and in Ostrea edulis from the Gulf of Naples (Italy)

In this work M. galloprovincialis and O. edulis specimens were surveyed for a pathological study in the Gulf of Naples (Mediterranean sea, Campania Region, southern Italy). Clusters of Nocardia sp.-like cells were observed in histological slides. PCR amplification, sequencing and in situ hybridization were carried out in order to corroborate Nocardia species identification for both hosts. Blast results showed a 99% of maximum identity with Nocardia crassostreae sequences in Genbank. This is the first report of N. crassostreae in the new host M. galloprovincialis and, in a new area, the Mediterranean Sea.

Molecular identification and antimicrobial susceptibility of Nocardia spp. isolated from bovine mastitis in Brazil

Nocardia spp. infections can cause severe damage to the mammary gland due to suppurative pyogranulomatous lesions and lack of clinical cure in response to conventional antimicrobial therapy. Although Nocardia infections are considered relatively uncommon in cows, there has been an apparent worldwide increase in the incidence of bovine mastitis caused by Nocardia spp, perhaps due to environmental transmission of this ubiquitous pathogen. The objectives of present study were to determine: (i) species distribution of 80 Nocardia isolates involved in bovine mastitis (based on molecular methods); and (ii) antimicrobial susceptibility pattern of all isolates from three geographical areas in Brazil. In this study, Nocardia nova (80%) was the most frequently isolated species, followed by Nocardia farcinica (9%). Additionally, Nocardia puris, Nocardia cyriacigeorgica, Nocardia veterana, Nocardia africana, and Nocardia arthritidis were detected using 16S rRNA sequencing. This is apparently the first report of N. puris, N. veterana, N. cyriacigeorgica, N. arthritidis and N. africana in association with bovine mastitis. Based on the disk diffusion test, isolates were most frequently resistant to cloxacillin (75%), ampicillin (55%) and cefoperazone (47%), whereas few Nocardia spp. were resistant to amikacin, cefuroxime or gentamicin.

Nocardiosis: a 15-year experience in a tertiary medical center in Israel

OBJECTIVES

The objective of this study is to characterize the common risk factors, clinical presentation, imaging findings, treatment and outcome of nocardial infection.

DESIGN AND SETTINGS

A retrospective cohort study. We reviewed the charts of all patients with nocardiosis in the Chaim Sheba Medical Center, a tertiary medical center in Israel, between the years 1996 and 2011.

RESULTS

A total of 39 patients who had positive culture of Nocardia were analyzed. The majority of our patients were immunocompromised (74.5%), mostly due to corticosteroid therapy. None had HIV/AIDS. The clinical presentation was either acute or a chronic smoldering illness. The three major clinical syndromes were pleuropulmonary, neurological and skin/soft tissue infection about 20.5% each. Pathology in the lungs was seen in most of the patients by CT scan; discrete nodules and wedge shaped pleural based consolidations were the most frequent findings. Brain lesions consistent with abscesses were detected in 10 patients by brain imaging. Some cases had relapsing disease in spite of antimicrobial treatment. 25% of examined isolates were resistant to trimethoprim/sulfamethoxazole. The duration of intravenous antimicrobial treatment ranged from one month to over a year in the severe cases. One year mortality rate was 32%.

CONCLUSION

Nocardiosis requires a high clinical index of suspicion in order to diagnose and treat promptly. Disease extent and bacterial susceptibility have important implications for prognosis and treatment.

The incidence of nocardiosis at pulmonary and extra - pulmonary sites

Nocardiosis is a rare but well-established opportunistic infection. We are presenting two cases of Nocardiosis diagnosed in the microbiology laboratory, one in an immuno-competent elderly patient and the other in a immunocompromised patient with AIDS. The first case was of pulmonary Nocardiosis which was caused by the Nocardia asteroides complex and concomitant infections with Staphylococcus aureus and Blastoschizomyces capitatus. In the second case, Nocardia brasiliensis was isolated from the pus which was extracted from an HIV positive patient, with lymphoadenopathy in the neck, at the upper right clavicular region. Interestingly, in both the cases, the primary identification Was done using 20% H2SO4 as decolourizer for ZN staining method.

A life-threatening case of disseminated nocardiosis due to Nocardia brasiliensis

Nocardiosis is a rare disease caused by infection with Nocardia species, aerobic actinomycetes with a worldwide distribution. A rare life-threatening disseminated Nocardia brasiliensis infection is described in an elderly, immunocompromised patient. Microorganism was recovered from bronchial secretions and dermal lesions, and was identified using molecular assays. Prompt, timely diagnosis and appropriate treatment ensured a favorable outcome.

First case report of Nocardia veterana causing nodular lymphangitis in an immunocompromised host

We report a unique case of ascending cutaneous lymphangitis in a 72-year-old immunocompromised man from which a newly described Nocardia species was isolated by 16S ribosomal gene sequencing. Treatment with trimethoprim-sulfamethoxazole resulted in successful resolution of symptoms. To the best of our knowledge, this is the first case report of N. veterana implicated in causing ascending cutaneous lymphangitis.

Molecular identification and susceptibility pattern of clinical Nocardia species: Emergence of Nocardia crassostreae as an agent of invasive nocardiosis

BACKGROUND

Nocardia species are rare, opportunistic organisms that cause disease in both immunocompetent and immunocompromised individuals.

OBJECTIVE

To investigate the clinical presentations of various Nocardia infections based on the 16S ribosomal RNA gene of the isolate, as well as related risk factors and susceptibility patterns to antimicrobial agents.

METHODS

Thirteen patients with a diagnosis of nocardiosis were included in the present study. Seven Nocardia species were identified by 16S ribosomal RNA. Susceptibility testing was performed using six antimicrobial agents.

RESULTS

Five patients were immunocompromised, and eight were immunocompetent with predisposing factors including cystic fibrosis, tuberculosis and ophthalmic infections. Nocardia caused pulmonary infections in eight patients (61.5%), invasive systemic infections in three patients (23%) and local (ophthalmic) infections in two patients (15.4%). In the patients with pulmonary disease, nocardiosis was caused by six species (Nocardia cyriacigeorgica, Nocardia otitidiscaviarum, Nocardia farcinica, Nocardia carnea, Nocardia testacea and Nocardia asiatica). The seventh species identified in the present study was Nocardia crassostreae.

DISCUSSION

N crassostreae is a multidrug-resistant organism that was reported to be an emerging human pathogen causing invasive nocardiosis in a patient with non-Hodgkin's lymphoma. N farcinica was isolated from blood in a patient with breast cancer. None of the Nocardia isolates were resistant to linezolid. One N otitidiscaviarum isolate was a multidrug-resistant organism. All patients in the present study were treated with the appropriate antibiotics and their condition resolved without further sequelae.

CONCLUSIONS

The present study is the first report on N crassostreae as a human pathogen. The detection of multidrug-resistant species necessitate molecular identification and susceptibility testing, and should be performed for all Nocardia infections. Nocardiosis manifests various clinical features depending on the Nocardia species and underlying conditions.

Unusual suspects: pulmonary opportunistic infections masquerading as tumor metastasis in a patient with adrenocorticotropic hormone-producing pancreatic neuroendocrine cancer

Pancreatic neuroendocrine tumors (p-NETs) are a rare group of neoplasms but with increasing incidence. The atypical complications that arise in the setting of functional endocrine tumors are underreported and therefore have not received sufficient attention and the necessary mention in the oncology literature. The clinical implications of these complications pose management challenges starting with the difficulty in establishing diagnosis, accurate staging and optimal treatment of the primary process. We present the case of a middle-aged woman diagnosed with adrenocorticotropic hormone-producing carcinoma arising from the pancreas whose case was complicated by excessive uncontrolled hypercortisolism and reactivation of pulmonary opportunistic infections that confounded her management. We believe that this case illustration will be of value to practicing oncologists and other groups of physicians who are called upon to participate in the multidisciplinary treatment of these relatively rare but highly challenging cases.

Successful management of sequential pulmonary infections in a cardiac transplant recipient

A case of a cardiac allograft recipient who had an initial combined pulmonary infection with cytomegalovirus, Aspergillus fumigatus and Nocardia asteroides, successfully treated with liposomal amphotericin B and sulfisoxazole and followed by an episode of respiratory syncytial virus pneumonitis, is presented. This case illustrates the role of computed tomographic imaging in the recognition, diagnosis and monitoring of complex opportunistic pulmonary infections and the benefits of liposomal amphotericin B in the treatment of aspergillosis.

Four cases of nocardial brain abscess

BACKGROUND

Nocardial brain abscesses are a rare central nervous system infection with high morbidity and mortality. Infection is acquired through inhalation or direct innoculation and then spreads hematogenously. They are usually associated with immunocompromised patients but may appear in otherwise healthy individuals. Treatment is based on surgical aspiration and antibiotics for several months.

CASE DESCRIPTION

We present four cases of nocardial brain abscesses treated at our institution and review the literature regarding these lesions. Ages ranged from 22 to 71 years. One patient was a healthy individual without any predisposing condition. Patients were treated with surgical evacuation and long term parenteral antibiotics. Two patients made a full recovery; one patient died and one recovered with significant morbidity. In one case malignancy was suspected, probably delaying diagnosis.

CONCLUSIONS

Nocardial brain abscesses are a rare condition that needs to be considered in the differential diagnosis of brain lesions. They are not necessarily associated with predisposing factors such as immunosupresion. Treatment must be started as soon as possible with surgical evacuation and long term parenteral antibiotics in order to avoid significant morbidity.

Nocardia brain abscess in a liver transplant recipient

Nocardia brain abscess is rare. We report on a unique case of N. farcinica brain abscess in a liver transplant recipient, following Aspergillus fumigatus pneumonia. A 43-year-old liver transplant recipient presented with altered mentality at 2 months after A. fumigates pneumonia. He was successfully treated with surgical removal and antibiotic therapy with trimethoprim-sulfamethoxazole and ceftriaxone.

Nocardiosis in a tertiary care hospital in saudi arabia

BACKGROUND

Nocardiosis is an uncommon bacterial infection that is caused by aerobic actinomycetes of the genus Nocardia. This pathogen has emerged as an important cause of mortality and morbidity among both immunocompetent and (more commonly) immunocompromised hosts. The prevalence of nocardiosis is unknown in Saudi Arabia. Only sporadic cases of cutaneous nocardiosis have been reported. In this study, we performed a 10-year retrospective review of all cases of nocardiosis identified at the King Fahad National Guard Hospital in Riyadh. Clinical presentation, risk factors, site of disease involvement, radiological features, and outcomes of 30 patients with pulmonary and disseminated nocardiosis are presented.

MATERIALS AND METHODS

A retrospective chart review of all cases of nocardiosis over the last ten years.

RESULTS

Thirty cases of nocardiosis were identified. The disease was more common in males. Fever and cough was the most common presentation. Most of the patients had an underlying pulmonary disease. Consolidation was the most prevalent radiological feature. Pleural effusion was common. Unfortunately, none of the isolates were sub-speciated. Cure was possible in 40% of the cases. Ten percent of patients died, while follow-up on the rest of the patients was lost.

CONCLUSION

Nocardiosis is not uncommon in Saudi Arabia. Cases are not restricted to the classical immunocompromised host. A database is urgently needed to better evaluate the prevalence of the illness among the Saudi population.

Potential nosocomial acquisition of epidemic Listeria monocytogenes presenting as multiple brain abscesses resembling nocardiosis

Listerial brain abscesses are rare, and are found mostly in patients with underlying hematological malignancies or solid-organ transplants. A case of a patient with Crohn's disease and multiple brain abscesses involving the left cerebellum and right sylvian fissure is described. The Gram stain and histopathology of the cerebellar abscess revealed Gram-positive, beaded rods suggestive of Nocardia. However, on culture, Listeria monocytogenes was identified. Listeria may appear Gram-variable and has been misidentified as streptococci, enterococci and diphtheroids. The present case is the first reported case of L monocytogenes resembling Nocardia on both microbiological and histopathological assessment. Reported cases of listerial brain abscesses are sporadic, while the current case was part of a nationwide listerial outbreak linked to consumption of contaminated deli meats. Broad antimicrobial therapy (including antilisterial coverage) in immunosuppressed patients presenting with brain abscess is crucial, until cultures confirm the identification of the organism.

A case of amniotic membrane transplantation in non-healing Nocardia asteroides keratitis

A patient with severe non-healing microscopically proven Nocardia keratitis was treated with maximal topical amikacin followed by amniotic membrane transplantation (AMT) 2 months later (single-layer epithelial side-down). Epithelial healing was achieved, but neovascularization continued. This case report indicates that AMT combined with topical antibiotic provides pain relief and allows epithelial healing in severe Nocardia keratitis.

Detection and characterization of nocardia from patients diagnosed as tuberculosis in egypt

Pulmonary tuberculosis and pulmonary nocardiosis are similar in most clinical symptoms and radiological manifestation. In the developing countries like Egypt where tuberculosis is very common, anti-tuberculosis drugs are started on basis of radiology and clinical symptoms. This study included 600 sputum specimens collected from 200 patients diagnosed as pulmonary tuberculosis from three chest hospitals in Egypt. IS6110 specific primer were selected for PCR to identify the Mycobacterium tuberculosis and hsp65 gene specific primers were used for PCR and sequencing for the identification of Mycobacterium and Nocardial species. The region of the gene coding for 16S rRNA in Nocardia species were selected as genus specific primer sequences for a PCR and Real Time PCR assays. Our result confirmed that four whole DNA samples, extracted from sputum specimen from the pulmonary tuberculosis patients on anti-tuberculosis treatment, were Nocardia species. Three of them matched (99% homology) with Nocardia farcinica (formerly Nocardia asteroid type V) and one match (83% homology) with Nocardia pneumonia. Molecular methods such as PCR and real-time PCR for identification of Nocardia are rapid and accurate methods. No cross-reactions were observed using Real Time PCR specific for Nocordia with other closely related genera.

A Case of Disseminated Nocardiosis Secondary to the Skin Nodules in an Elderly Woman

Nocardiosis refers to a locally invasive or disseminated infection associated with the Nocardia species. Most infections enter through the respiratory tract and then disseminate systemically. Rarely can a primary nocardial infection of the skin spread to contiguous structures or disseminate to other internal organs in immunocompromised hosts. We describe a 70-year-old woman who suffered from recurrent nodular skin lesions on her right hand, forearm and elbow following inoculation of a traumatic injury. Analysis of the purulent exudates obtained from the nodule revealed Nocardia species. After 20 days, a chest X-ray showed newly developed multiple nodules in both lungs. The diagnosis of systemic nocardiosis was established, and we treated this case with trimethoprim-sulfamethoxazole.