Surgery for other pulmonary fungal infections, Actinomyces, and Nocardia

Treatment of refractory localized pulmonary nocardiosis caused by Nocardia mexicana with a combination of medication and surgery

Pulmonary nocardiosis is a rare disease that is often difficult to cure because of its tendency to recur. Here, we report a case of refractory localized pulmonary nocardiosis caused by Nocardia mexicana. A 60-year-old Japanese woman had recurring pulmonary nocardiosis four times previously and each time she was treated with antibiotics for a sufficient duration; nevertheless, the disease continued to recur, probably because of resistance to antibiotics. As a fifth treatment, we performed middle lobe resection and pre- and post-operative antimicrobial therapy for 6 months. The combination of medication and surgery was useful for treating refractory localized pulmonary nocardiosis.

Nocardia farcinica Brain Abscess in an Immunocompetent Host With Pulmonary Alveolar Proteinosis: A Case Report and Review of the Literature

A 55-year-old immunocompetent male presented with new-onset seizures and acute respiratory failure requiring intubation and a stay in the medical intensive care unit. Magnetic Resonance Imaging (MRI) of the brain revealed ring-enhancing lesions, and Computed Tomography (CT) chest showed ground-glass opacity. The patient underwent craniotomy and bronchoscopy, followed by culture of the purulent aspirate from lesions in the brain and bronchoalveolar lavage (BAL). After extensive infectious workup, the patient was diagnosed with a Nocardia farcinica brain abscess plus underlying pulmonary alveolar proteinosis (PAP). Based on a recommendation from an infectious disease expert, the patient was treated with trimethoprim-sulfamethoxazole (TMP/SMX).

This case highlights the importance of understanding that, though rare, infections such as nocardiosis can present in immunocompetent patients and cause severe morbidity.

Infectious Lung Disease

Infectious diseases are one of the main causes of morbidity and mortality worldwide. With new pathogens continuously emerging, known infectious diseases reemerging, increasing microbial resistance to antimicrobial agents, global environmental change, ease of world travel, and an increasing immunosuppressed population, recognition of infectious diseases plays an ever-important role in surgical pathology. This becomes particularly significant in cases where infectious disease is not suspected clinically and the initial diagnostic workup fails to include samples for culture. As such, it is not uncommon that a lung biopsy becomes the only material available in the diagnostic process of an infectious disease. Once the infectious nature of the pathological process is established, careful search for the causative agent is advised. This can often be achieved by examination of the hematoxylin and eosin-stained sections alone as many organisms or their cytopathic effects are visible on routine staining. However, ancillary studies such as histochemical stains, immunohistochemistry, in situ hybridization, or molecular techniques may be needed to identify the organism in tissue sections or for further characterization, such as speciation.

Surgical management of non-mycobacterial fungal infections

Fungal infections of the lung are common in endemic areas and in immunocompromised patients. Antifungal therapy is the cornerstone of medical therapy for most pulmonary fungi but surgery is an important adjunct in cases of complicated disease or resistant organisms. A multidisciplinary approach including pulmonary medicine, infectious disease, interventional radiology, and thoracic surgery is favored. This article reviews the surgical management of common fungal pulmonary infections and their sequelae.

Successful Treatment by Surgery of a Primary Cutaneous Mucormycosis Caused by Mucor irregularis

We report a case of primary cutaneous mucormycosis caused by Mucor irregularis. A 66-year-old man was presented to our hospital with a history of gradually enlarging plaque on the right leg for about a year. The identification of pathogen based on the fungus morphology and DNA sequencing revealed M. irregularis as the responsible fungus for skin lesion. The lesion was removed incidentally by a surgery procedure, and no recrudescence was seen during a follow-up of 24-month observation.

A Case of Nocardia farcinica Pneumonia and Mediastinitis in an Immunocompetent Patient

Nocardia species are aerobic, gram-positive pathogens found worldwide in soil. Nocardia is considered an opportunistic pathogen, and its infection mostly occurs in immunocompromised patients. We report a case of Nocardia farcinica induced mediastinitis and pneumonia that occurred in a 64-year-old male patient who had no significant medical history except for hypertension. He visited another hospital with a complaint of dyspnea and left chest wall pain. The symptoms arose 7 days ago without any trauma and they worsened. A mediastinal mass was found on computed tomography scan. After being transferred to our hospital for further evaluation, he was diagnosed with mediastinitis and pneumonia. As N. farcinica was found to be the causative organism by 16S rRNA sequencing, proper antibiotic therapy including trimethoprim/sulfamethoxazole was initiated immediately. After this, the patient improved and he was discharged. If an infection has a disseminating course, nocardiosis cannot be excluded even in immunocompetent patients. Once the diagnosis is established, prompt antibiotic therapy should be performed based on the severity.