Immunocompetent patient with a brain abscess caused by Nocardia beijingensis in Latin America: A case report

Persistent Nocardia beijingensis infection in a patient with postoperative abscess and misuse of antibiotics in China

Here we describe the first case of abscess infection caused by Nocardia beijingensis in China. The patient was immunocompetent but suffered from postoperative abscess for 6 years. This study highlights the necessity of long-term infected foci to be thoroughly examined to identify the pathogen, as well as the importance of accurate Nocardia identification and antimicrobial susceptibility tests for understanding the pathogen's epidemiology, clinical significance, and treatment strategy.

Cerebral Abscess Infected by Nocardia gipuzkoensis

Purpose

Nocardia gipuzkoensis is a novel species that solely identified in patients with pulmonary infections by far. Growing evidence showed the excellent performance of metagenomics next-generation sequencing (mNGS) on pathogenic identification, especially for new species. Here, we described the first case of an elderly female patient suddenly suffering from neurological disorders owing to N. gipuzkoensis infection. And linezolid could effectively treat N. gipuzkoensis infection.

Patients and Methods

The results of imaging, laboratory cultures, and mNGS, as well as therapeutic process are shared.

Results

An elderly female patient suddenly suffered from neurological disorders with dysphasia and right limb trembles under no obvious causes. Subsequently, she was diagnosed as intracranial space-occupying lesions by magnetic resonance imaging (MRI). The isolate from brain secretion was further identified as N. gipuzkoensis through mNGS. The targeted therapy with linezolid according to the antimicrobial susceptibility was used to treat cerebral abscess induced by N. gipuzkoensis. During the follow-up, no relapse was observed for the patient after surgery for 104 days.

Conclusion

Cerebral abscess induced by N. gipuzkoensis is rare disorder with high mortality. mNGS has been identified as a promising tool in pathogen diagnosis for timely therapy. Linezolid as one of the antimicrobial drugs could effectively treat N. gipuzkoensis infection and prevent adverse outcomes.

Nocardia Brain Abscess in a Patient With Sarcoidosis

Nocardia species are aerobic, gram-positive, filamentous bacteria. Infection occurs either through inhalation leading to pulmonary symptoms or inoculation presenting with skin findings. Hematogenous dissemination, although uncommon, is possible and can lead to central nervous system involvement. Nocardia brain abscess is a rare manifestation that comprises 2% of all brain abscess etiologies, mostly occurring in immunocompromised patients. Establishing a diagnosis is often difficult, especially due to its rare occurrence and the fact that it can mimic other etiologies on brain imaging including necrotic tumors. High mortality rates have been reported due to delays in establishing a diagnosis and a lack of precise treatment guidelines.

Nocardia beijingensis isolated from an adrenal abscess in a diabetic host

We describe the case of a 57-year-old man with poorly controlled type 2 diabetes mellitus who presented with 30 days of left-sided abdominal pain. He was found to have a left adrenal abscess and underwent adrenalectomy. Intraoperative cultures grew Nocardia beijingensis, which is an uncommonly identified Nocardia species rarely affecting immunocompetent patients. We review the published literature on cases of N. beijingensis among immunocompetent patients. This is the first report summarizing the diagnosis and management of N. beijingensis isolated from an adrenal abscess.

Multiple Brain Abscesses Caused by Nocardia Beijingensis in a Patient With HIV Infection

The etiologic agents of central nervous system infections in HIV-infected patients comprise a broad range of opportunistic pathogens. We presented a 49-year-old male patient with HIV infection and low adherence to antiretroviral therapy. He presented with multiple cerebral abscesses, and his microbiological diagnosis approach resulted in the isolation of Nocardia beijingensis, a species rarely reported in America. Central nervous system nocardial infection in HIV-infected patients should be considered, and a diagnosis at species level is mandatory because the antibiotic susceptibility profile varies among species.

Disseminated nocardiosis in an immunocompetent host with occupational exposure

Nocardia is a genus of Gram-positive, partially acid-fast bacteria consisting of over 120 species, of which 50 are recognized as human pathogens. Nocardia spp. are common colonizers in the environment, particularly in soil and water. Nocardia spp. typically cause opportunistic infections in the immunocompetent host, although cases of nocardiosis have been described in those with a normal immune system. Nocardiosis can be localized, most often in the skin or lung, or be disseminated, with involvement of the brain, bone, and visceral organs. Treatment of nocardiosis is complex, as multiple culture-directed antibacterials with appropriate tissue penetration may need to be used for a prolonged duration. To our knowledge, we describe the first successfully treated case of disseminated Nocardia beijingensis infection in an immunocompetent host with doxycycline and trimethoprim-sulfamethoxazole and hypothesize that his occupational exposure to ubiquitous saprophytes may have led to his infection.

Clinical Characteristics and Treatment Outcome of Central Nervous System Nocardiosis: A Systematic Review of Reported Cases

BACKGROUND

The clinical spectrum of systemic nocardiosis encompasses pulmonary and disseminated disease. Central nervous system (CNS) involvement is an important feature of disseminated disease with significant mortality and high relapse rate, especially in those with suppressed cell-mediated immunity. This systematic review aimed to evaluate the epidemiology, clinical features, diagnosis, therapeutic interventions, and outcome in patients with CNS nocardiosis.

METHODS

A literature search was performed in major databases (PubMed, Google Scholar, and Scopus) by using distinct keywords: "CNS disease," "Nocardia," "meningitis," "brain abscess," "disseminated disease," and "Cotrimoxazole." We included all patients ≥18 years with CNS nocardiosis reported between January 2000 and December 2020.

RESULTS

A total of 129 papers were included in the final analysis. The mean age of patients was 55 ± 16 years, and the majority were male (70.8%). Nocardia farcinica was the commonest species (39.6%), followed by Nocardia nova (5.9%). Thirty-four percent of the patients were found to be immunocompetent. Corticosteroid use was the most common predisposing factor (55.8%). Among neuroimaging findings, brain abscess was most common (86.9%), followed by leptomeningeal enhancement (12.1%). The overall case-fatality rate in CNS disease was 22.8%. On multivariate analysis, patients who underwent surgery (OR 2.4, 95% CI 0.99-4.11, p value 0.046) had better survival than those treated with antimicrobial therapy alone. Immunodeficient state (OR 0.32, 95% CI 0.15-0.90, p value 0.019) was independently associated with poor outcome.

CONCLUSION

CNS nocardiosis carries significant mortality, especially in immunodeficient patients. We advocate the use of surgery combined with antimicrobials to improve clinical outcome.

Stroke like presentation of disseminated CNS Nocardia beijingensis infection in an immunocompetent patient: Case report and review of the literature

We describe a rare case of pulmonary and central nervous system (CNS) Nocardia beijingensis infection in an immunocompetent patient presenting with stroke like symptoms and newly discovered pulmonary and brain mass. Initial work up suggested lung cancer with metastasis to the brain. However, further evaluation revealed disseminated N. beijingensis. A literature review of N. beijingensis infections in immunocompetent host is also presented.

Species diversity and molecular analysis of opportunistic Mycobacterium, Nocardia and Rhodococcus isolated from the hospital environment in a developing country, a potential resources for nosocomial infection

Background

Hospital environmental resources have a significant role in cross-transmission of opportunistic pathogens such as actinomycetes species to the patients. Actinomycetes have a remarkable capability to survive in adverse and harsh conditions of hospital environments; therefore, they are a threat to the health of patients. Due to this issue, we aimed to determine the frequency and diversity of actinomycetes species in hospital soil, water and dust by using a combination of conventional and molecular methods including the phenotypic and biochemical tests for preliminary identification and the PCR amplification of the specific region of the 16S rRNA, hsp65 gene and sequence analyses of 16S rRNA for the genus and species identification.

Results

A total of 50 (35.2%) actinomycetes isolates from 7 genera were isolated from 142 hospital environmental samples. The three most prevalent species were M. setense 10%, R. erythropolis and M. fortuitum 8% followed by N.cyriacigeorgica and M. gordonae 6%, M. chelonae, M. abscessus, M. lentiflavum, M. mucogenicum, N. asteroides, N. farcinica, R. equi and L. shinushuensis 4% and the single isolates of M. conceptionense, M. septicum, N. rhamnosophilia, N. bravicatena, M. flavescens, M. arupense, M. doricum, M. frederiksbergense, S. heliomycini, S. albus, S. albogriseolus, R. facians, D. maris, G. terae and A. globiformis.

Conclusions

In conclusion we showed that the hospital environment is a potential reservoir for a broad range of actinomycetes species, due to the remarkable survival capability of these microorganisms in adverse hospital environment, carrying a threat to the health of patients.

Isolated Nocardiosis, an Unrecognized Primary Immunodeficiency?

Nocardiosis is an infectious disease caused by the gram-positive bacterium Nocardia spp. Although it is commonly accepted that exposure to Nocardia is almost universal, only a small fraction of exposed individuals develop the disease, while the vast majority remain healthy. Nocardiosis has been described as an "opportunistic" disease of immunocompromised patients, suggesting that exposure to the pathogen is necessary, but a host predisposition is also required. Interestingly, increasing numbers of nocardiosis cases in individuals without any detected risk factors, i.e., without overt immunodeficiency, are being reported. Furthermore, a growing body of evidence have shown that selective susceptibility to a specific pathogen can be caused by a primary immunodeficiency (PID). This raises the question of whether an undiagnosed PID may cause nocardiosis affecting otherwise healthy individuals. This review summarizes the specific clinical and microbiological characteristics of patients with isolated nocardiosis published during the past 30 years. Furthermore, it gives an overview of the known human immune mechanisms to fend off Nocardia spp. obtained from the study of PIDs and patients under immunomodulatory therapies.

Disseminated Nocardia beijingensis Infection in an Immunocompetent Patient

Nocardia is a genus of aerobic, non-motile and non-spore-forming filamentous branching bacteria with fragmentation into bacillary or coccoid forms. Infections caused by Nocardia often occur in immunocompromised hosts and are potentially life-threatening. Nocardia beijingensis has rarely been reported to cause infection in immunocompetent hosts. We present a case of disseminated infection due to Nocardia beijingensis in a patient with no known medical comorbidities, who presented with new-onset seizure. Another interesting finding in our case is that our patient did not have any pulmonary symptoms despite chest CT showing the pulmonary system as the likely primary site of infection. As per our literature review, this is the seventh reported case of infection due to Nocardia beijingensis in an immunocompetent host.

LEARNING POINTS

To recognize Nocardia beijingensis, a slow-growing weakly acid-fast filamentous bacteria commonly causing opportunistic infections in immunocompromised hosts, as an emerging pathogen in immunocompetent patients.Tissue biopsy with Gram staining showing variable filamentous bacteria and confirmation of species using restriction enzyme analysis and 16S rRNA analysis is needed to establish a diagnosis of infection.Trimethoprim/sulfamethoxazole has been successfully used to treat infection due to Nocardia beijingensis.

Multiple brain abscesses due to Nocardia spp. in an immunocompetent patient

La infección por Nocardia spp. no es común en pacientes inmunocompetentes. El tratamiento antimicrobiano empírico dirigido según las regiones anatómicas, no contempla las particularidades del germen y el análisis microbiológico se hace necesario para el tratamiento específico.

A continuación, se presenta el caso de una paciente previamente sana, inmunocompetente y sin factores de riesgo conocidos para la infección por Nocardia spp., con evidencia de compromiso en el parénquima pulmonar y la piel, que posteriormente desarrolló varios abscesos cerebrales.