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Nocardia Infection

Nocardiosis

Nocardia infection or nocardiosis is a rare, opportunistic bacterial infection caused by genus Nocardia primarily affecting immunosuppressed patients. Nocardiosis presents in a diverse manner based upon the site of infection. A distribution of three types is available and includes pulmonary, extrapulmonary nocardiosis, and primary cutaneous lesions including mycetoma.


Presentation

The course of Nocardia infection may range in severity (from asymptomatic to acute and chronic) and presentation of patients may vary widely, correlating to the affected organs.

It is important to obtain history data about any chronic rheumatologic diseases that could require immunosuppressive therapy and data about any immunosuppressive disease. It is important because nocardiosis is opportunistic and infects mostly immunocompromised patients [1].

Pulmonary nocardiosis is the most common type of nocardiosis [2] and is characterized by non-specific manifestations such as fever, fatigue and weight loss. Specific findings include productive or a non-productive cough, abscess in lungs, empyema, cavitations, bronchiectasis, pleural effusion, and pneumonia [3]. Symptoms like chest pain, shortness of breath can indicate a chronic condition. An infectious mass in the lungs is prone to dissemination. Dissemination occurs locally to the pericardium, pleura, vena cava, and mediastinum. Systematic dissemination could be the cause of abscess formation in other organs, usually extremities [3].

Extrapulmonary nocardiosis most commonly affects cerebral tissue by forming multiple or solitary deep abscesses. These lesions compress the lobes and are held accountable for neurologic manifestations such as headaches, seizures, and altered mental state [4] [5]. Meningitis and non-specific symptoms such as nausea and vomiting can also be present. These signs and symptoms may evolve gradually or acutely, depending on size and location of the abscess. Extrapulmonary manifestations, although mostly involve the cerebrum (44%) [3], can manifest in any organ, especially in the extremities. Infection in such locations arises due to hematogenous dissemination [3].

Primary cutaneous infection occurs from direct inoculation of Nocardia spp. spores and is prevalent in patients who are not immunocompromised. Patients present with purulent inflammation of dermis that is able to ascend to regional lymph nodes (lymphocutaneous infection) or form local abscesses. These masses are typically in lower extremities in adults and on the face in children [4].

Mycetoma is a characteristic chronic state of primary cutaneous infection. It is characterized by purulent fistulas of many colors and sizes as well as granulomas and nodules that are painless and affect subcutis as well as other soft tissues and bone [3]. Superficial cutaneous infection, on the other hand, manifests with all signs of inflammation like pain, warmth, swelling and erythema. Lymphocutanious lesions originate from primary purulent ulcerations allowing the noxious organism to penetrate deeply in affected areas [4].

Secondary cutaneous infection can arise from dissemination in primary pulmonary infection. This manifestation is relatively common [3].

Fever
  • […] chest pain The symptoms of fever, chills, and weight loss often result in pulmonary nocardiosis being mistaken for tuberculosis ![amboss.com]
  • All the patients had pulmonary involvement and their most common symptoms were fever, cough and pleural pain.[ncbi.nlm.nih.gov]
  • Typical symptoms caused by pulmonary nocardiosis are fever , cough and chest pain .[healthblurbs.com]
  • Lungs (pulmonary nocardiosis): Chest pain when breathing (may occur suddenly or slowly) Coughing up blood Fevers Night sweats Weight loss Brain (cerebral nocardiosis): Fever Headache Seizures Skin: May become chronically infected (mycetoma) and develop[coordinatedhealth.com]
  • Disseminated and/or pulmonary nocardiosis Disseminated and/or pulmonary nocardiosis often begins with a fever, cough, and chest pain.[dermnetnz.org]
Chills
  • Pulmonary nocardiosis is the most common, and its symptoms are a lot like ones you might have with pneumonia or tuberculosis : Chest pain Coughing Sweating Chills Feeling weak Lack of appetite Unexplained weight loss Shortness of breath or a hard time[webmd.com]
  • […] features Pulmonary nocardiosis Onset: acute, subacute, or chronic Constitutional symptoms : fever, weight loss, anorexia, night sweats Respiratory symptoms (recurrent pneumonia ): productive cough, dyspnea, pleuritic chest pain The symptoms of fever, chills[amboss.com]
  • The most common symptoms of pulmonary involvement—cough, fever, chills, chest pain, weakness, anorexia, and weight loss—are nonspecific and may resemble those of TB or suppurative pneumonia. Pleural effusion may also occur.[merckmanuals.com]
  • Other symptoms include chills, night sweats, chest pain, weakness, loss of appetite and weight loss. Nocardiosis does not, however, respond to short-term antibiotics.[medical-dictionary.thefreedictionary.com]
  • Symptoms may include chest pain, cough, bloody sputum, sweats, chills, weakness, lack of appetite, weight loss and difficult or labored breathing. Nocardiosis symptoms are similar to those of pneumonia and tuberculosis.[rarediseases.org]
Fatigue
  • Pulmonary nocardiosis is the most common type of nocardiosis and is characterized by non-specific manifestations such as fever, fatigue and weight loss.[symptoma.com]
  • […] years previously, as well as a history of hypertension, hypercholesterolemia, transient ischemic attack, and acute myelogenous leukemia with induction of remission three months previously, was admitted to our hospital with a five-day history of fever, fatigue[nejm.org]
  • All patients experienced slowly progressive pneumonia, fever, fatigue, dyspnea with no concomitant extrapulmonary involvement. Mean time for diagnosis was 5.8 po months. The mean duration of follow up was 9.6 mo (26-832).[erj.ersjournals.com]
  • Night sweats, fatigue and weakness, lack of appetite and weight loss may also be experienced. In up to 30% of cases the infection enters the bloodstream and spreads to other organs (most commonly the brain) where it causes abscesses.[southerncross.co.nz]
  • If your lungs are infected, you may experience: a fever fatigue chest pain a cough night sweats The Skin The skin is the second most commonly affected area.[healthline.com]
Sulfur Granules
  • Histologically, mycetoma is often granulomatous and fibrosing and is the only clinical form of nocardiosis regularly associated with sulfur granules.[emedicine.medscape.com]
  • The presence of sulfur granules and filamentous, gram-positive bacteria can point to this etiology. Final diagnosis is made by standard aerobic culture and sensitivity for a total of 5 days.[woundsresearch.com]
Malaise
  • Entire Body Symptoms Recurring fever Malaise or general uneasiness or discomfort Night sweats Lung Symptoms Breathing difficulty Cough with mucus Rapid breathing Chest pain which not related to any heart problems Shortness of breath Coughing up blood[primehealthchannel.com]
  • There may be generalized symptoms like a fever, malaise and weight loss which are characteristic of infections. However, these symptoms may be absent in cutaneous (skin) nocardiosis. The symptoms according to each form of nocardiosis are as follows.[healthhype.com]
  • Fever, malaise and anorexia. Night sweats. Weight loss. Haemoptysis, chest pain and difficulty in breathing - may also be present but are usually less prominent.[patient.info]
  • Pulmonary disease• Pneumonia Subacute(more acute in immunosuppressed) Cough** Small amounts of thick, purulent sputum Fever, anorexia, weight loss, malaise• Endobronchial inflammatory mass• Lung abscess• Cavitary disease• Inadequate therapy Progressive[slideshare.net]
  • Pulmonary (respiratory/lungs): chest pain while breathing, coughing (with blood), fever, nigh sweats, chills, malaise, anorexia, weight loss and may resemble those of tuberculosis or suppurative pneumonia (2)(3).[austincc.edu]
Productive Cough
  • As in any other type of pneumonia, productive cough, pleuritic chest pain, and fever are the dominant symptoms, making it difficult to differentiate from other lung infections.[amboss.com]
  • Specific findings include productive or a non-productive cough, abscess in lungs, empyema, cavitations, bronchiectasis, pleural effusion, and pneumonia. Symptoms like chest pain, shortness of breath can indicate a chronic condition.[symptoma.com]
  • He reports that two days ago he developed a productive cough with associated shortness of breath. He also endorses drenching sweats for the last several nights.[medbullets.com]
Facial Swelling
  • Two middle aged men of Asian descent presented to the Endocrine clinic: the first with history of exertional shortness of breath, and weight loss for 1 year, the other with facial swelling, disturbed sleep and lethargy for a month.[ncbi.nlm.nih.gov]
  • Case Presentation: Two middle aged men of Asian descent presented to the Endocrine clinic: the first with history of exertional shortness of breath, and weight loss for 1 year, the other with facial swelling, disturbed sleep and lethargy for a month.[ecommons.aku.edu]
Renal Impairment
  • Frequent episodes of rejection, high-dose prednisolone treatment, renal impairment, and prolonged respiratory support have all been shown to increase the risk of Nocardia infection in this group.[ncbi.nlm.nih.gov]
Headache
  • Signs that the infection has spread to your brain include: Bad headaches Motor skills problem, like balance or hand- eye coordination Extreme sensitivity to loud sounds or bright lights If you have any of these symptoms, see your doctor right away.[webmd.com]
  • These lesions compress the lobes and are held accountable for neurologic manifestations such as headaches, seizures, and altered mental state. Meningitis and non-specific symptoms such as nausea and vomiting can also be present.[symptoma.com]
  • With brain nocardiosis, the symptoms are usually headache, lethargy, confusion, seizures, and sudden onset of neurologic problems. Nocardia is ubiquitous in the environment. It is in the soil and in dust particles.[medicinenet.com]
  • […] fever Malaise or general uneasiness or discomfort Night sweats Lung Symptoms Breathing difficulty Cough with mucus Rapid breathing Chest pain which not related to any heart problems Shortness of breath Coughing up blood Brain Symptoms Fever Seizures Headache[primehealthchannel.com]
  • The broad range of other symptoms caused by nocardia infection are: seizures hepatitis arthralgia dizziness confusion headache hemoptysis night sweats swollen spleen abdominal pain nausea, vomiting fever may undulate shortness of breath swollen lymph[healthblurbs.com]
Neurologic Manifestation
  • These lesions compress the lobes and are held accountable for neurologic manifestations such as headaches, seizures, and altered mental state. Meningitis and non-specific symptoms such as nausea and vomiting can also be present.[symptoma.com]
Stroke
  • The radiologic picture is frequently misdiagnosed as malignancies, vasculitis, or stroke. To avoid misdiagnosis it is necessary to confirm nocardiosis with a microbiologic evaluation.[symptoma.com]

Workup

The most important workup findings in nocardiosis infection are those of microbiology and radiology.

If pulmonary nocardiosis is suspected, a chest X-ray or computed tomography (CT) is usually performed. Discovery of solitary or multifocal lesions is typically made. The lesions can be either nodular or of an infiltrative kind, cavitations and pleural effusions can also be identified [6] [7]. Nevertheless, radiography is non-specific and no radiologic signs point specifically to nocardiosis.

An imaging study of central nervous system (CNS) should be performed for patients suffering from severe nocardiosis. Particularly pulmonary nocardiosis and suspected systemic infection or if neurologic symptoms are present, imaging is of vital significance. Magnetic resonance imaging (MRI) is the investigation of choice for such cases [8]. Abscesses either solitary or multiple can be found in different lobes of the cerebrum, perifocal edema usually is also present. The radiologic picture is frequently misdiagnosed as malignancies, vasculitis, or stroke [8]. To avoid misdiagnosis it is necessary to confirm nocardiosis with a microbiologic evaluation.

Depending on the affected site different types of specimens should be collected. A specimen of sputum or bronchial washing in pulmonary nocardiosis, cerebrospinal fluid (CSF) in suspected meningitis, skin biopsy or aspiration from abscess masses in cutaneous nocardiosis. It is necessary to inform laboratories about possible Nocardia infection as haste and slow growth of Nocardia may be the cause of altered results. Nocardia spp. stains with modified acid-fast and Gram stain with cultures being generally isolated in 3-5 days [4].

Cavitary Lesion
  • The chest radiograph can be variable, displaying focal or multifocal disease with nodular and/or consolidation infiltrate as well as cavitary lesions. 18,19 Pleural effusions can develop in up to one-third of patients.[ncbi.nlm.nih.gov]
  • Hemoptysis is rare, but can develop in patients with large cavitary lesions. CNS infection—approximately 5% of patients with a Nocardia infection suffer CNS involvement.[infectiousdiseaseadvisor.com]
Nocardia Asteroides
  • The taxonomy has been challenging and likely remains in evolution. [1, 2] Most human infections are due to members of the formerly called Nocardia asteroides complex.[emedicine.medscape.com]
  • A case of Nocardia asteroides pneumonia was diagnosed after death in a patient with AIDS. Six sputum cultures and one bronchoalveolar lavage fluid contained no pathogens, and no growth was obtained from one pleural fluid aspirate.[ncbi.nlm.nih.gov]
  • Nocardia brasiliensis and Nocardia otitidiscaviarum (caviae) may cause pulmonary nocardiosis resembling that produced by Nocardia asteroides but more characteristically they may present as Mycetomas.[histopathology-india.net]
Nocardia Brasiliensis
  • Conclusion Nocardia brasiliensis is a rare cause of chronic wounds that can have deadly consequences without appropriate treatment. It is associated with traumatic inoculation of contaminated soil.[woundsresearch.com]
  • Nocardia brasiliensis and Nocardia otitidiscaviarum (caviae) may cause pulmonary nocardiosis resembling that produced by Nocardia asteroides but more characteristically they may present as Mycetomas.[histopathology-india.net]
  • Nocardia nova was the most common species (found in 17 [49%] of the patients), followed by Nocardia farcinica (9 [28%]), Nocardia asteroides (8 [23%]), and Nocardia brasiliensis (1 [3%]).[ncbi.nlm.nih.gov]
  • brasiliensis is a common cause of localized chronic mycetoma.[emedicine.medscape.com]
Gram-Positive Rods
  • Nocardia is a Gram-positive rod; however, the appearances on Gram staining can be misleading.[patient.info]
  • They are aerobic, filamentous, branching, beaded, Gram positive rods that are partially acid-fast (8)(9). They are variably acid fast due to presence of intermediate mycolic acids in cell wall (10).[austincc.edu]
  • Ribosomal DNA sequencing for identification of aerobic gram-positive rods in the clinical laboratory (an 18-month evaluation). J Clin Microbiol 41, 4134 –4140.[jmm.microbiologyresearch.org]
  • Pleural fluid was obtained by puncture and microscopic examination revealed numerous polymorphonuclear leucocytes and modified acid fast positive, filamentous-branched, gram-positive rods.[ann-clinmicrob.biomedcentral.com]
  • Ribosomal DNA sequencing for identification of aerobic Gram-positive rods in the clinical laboratory (an 18-month evaluation). J Clin Microbiol 2003 ; 41 : 4134 –40.[jcp.bmj.com]
Actinomyces Israelii
  • Actinomycetoma can be caused by N brasiliensis, N asteroides, Nocardia madurae, Streptomyces somaliensis, Streptomyces pelletieri, Actinomyces israelii, and Nocardia boironii. [8] Mycetoma caused by true fungi is termed eumycetoma.[emedicine.medscape.com]
Nocardia Otitidis Caviarum
  • Nocardia pseudobrasiliensis, Nocardia otitidis-caviarum (formerly Nocardia caviae ), Nocardia farcinica, Nocardia nova, and Nocardia transvalensis have also been rarely associated with human systemic disease. [1] A recent report of infections with Nocardia[emedicine.medscape.com]

Treatment

  • TMT/SMX was the most commonly prescribed treatment, but needed to be changed for another treatment because of side effects or lack of efficacy in a considerable proportion of patients.[ncbi.nlm.nih.gov]
  • Moreover, in four patients receiving oral treatment, the treatment was considered to be a therapeutical failure, and two of these patients died.[jcp.bmj.com]

Prognosis

  • Higher index of suspicion is needed for earlier diagnosis and treatment to improve prognosis.[ncbi.nlm.nih.gov]
  • The prognosis can vary with those with disseminated nocardiosis having mortality rates up to 40%. Subtherapeutic levels of antibiotics can result in flare-ups while patients are on treatments.[radiopaedia.org]
  • The prognosis of nocardiosis is highly variable. The state of the host's health, site, duration, and severity of the infection all play parts in determining the prognosis.[en.wikipedia.org]
  • Prognosis Prognosis varies with the site of infection of nocardia. Involvement of the central nervous system increases the mortality and morbidity.[patient.info]

Etiology

  • Etiology Pathogen Nocardia species : ubiquitous in soil worldwide Transmission : inhalation (most common), ingestion, and inoculation through a skin wound or injury Risk factors Immunocompromise ; ( HIV infection, organ transplant, glucocorticoid therapy[amboss.com]
  • (Etiology) Pulmonary Nocardiosis is caused by inhalation of the bacteria Nocardia asteroids.[dovemed.com]
  • The presence of sulfur granules and filamentous, gram-positive bacteria can point to this etiology. Final diagnosis is made by standard aerobic culture and sensitivity for a total of 5 days.[woundsresearch.com]
  • The latter, N.brasiliensis, is the most common etiologic agent for skin infections (2).[austincc.edu]
  • The Etiology of Actinomycosis. The Presence of Actinomycetes in the Contents of Carious Teeth and Tonsilar Crypts of Patients without Actinomycosis, J.A.M.A., 55: 1261, 1910. Google Scholar Crossref Ludwig, T.G.[doi.org]

Epidemiology

  • Nocardia abscessus was responsible for one third of infections, deviating significantly from the results reported by other epidemiological investigations and highlighting the key role of molecular identification tests.[ncbi.nlm.nih.gov]
  • We present a summary of the English literature from 1966 to 2003 with a focus on the teaching points of each of our 5 cases as well as the background epidemiology and microbiology of the Nocardia genus.[doi.org]
  • Epidemiology References: [1] Epidemiological data refers to the US, unless otherwise specified.[amboss.com]
Sex distribution
Age distribution

Pathophysiology

  • […] corticosteroid use in Nocardia keratitis observed the development of large granulomatous lesions with extension into the anterior chamber in those treated with topical steroids, whereas no extension was noted in those not treated with steroids. [6] Pathophysiology[eyewiki.aao.org]

Prevention

  • Antibiotics should be given in adequate doses to control the initial infection and be maintained for a prolonged period to prevent relapses.[ncbi.nlm.nih.gov]
  • SOURCE: Centers for Disease Control and Prevention (CDC), Coordinating Center for Infectious Diseases, Division of Bacterial and Mycotic Diseases. See Also Antibacterial Drugs ; Bacterial Disease ; CDC (Centers for Disease Control and Prevention).[encyclopedia.com]
  • Nocardiosis Prevention Prevention may be difficult in susceptible individuals. However, taking some preventive measures can decrease their risk of developing the disease. They should avoid working outdoors without protection.[primehealthchannel.com]
  • Preventive measures for Pulmonary Nocardiosis include: Drugs, such as corticosteroids should be used cautiously, at a minimum dose and for a minimum possible period of time Individuals with weak immune systems may require antibiotics to prevent this disease[dovemed.com]

References

Article

  1. Yamagata M, Hirose K, Ikeda K, and Nakajima H. Clinical Characteristics of Nocardia Infection in Patients with Rheumatic Diseases. Clinical and Developmental Immunology. 2013 ID 818654: 4 pages.
  2. Aggarwal D, Garg K, Chander J, Saini V, Janmeja AK. Pulmonary nocardiosis revisited: A case series. Lung India : Official Organ of Indian Chest Society. 2015;32(2):165-168.
  3. Wilson JW. Nocardiosis: Updates and Clinical Overview. Mayo Clin Proc. 2012 Apr; 87(4): 403–407.
  4. Brown-Elliott B.A., Brown J.M., Conville P.S., Wallace R.J., Jr. Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy. Clin Microbiol Rev. 2006;19(2):259–282.
  5. Chedid MBF, Chedid MF, Porto NS, Severo SB, Severo LC. Nocardial infections: report of 22 cases. Rev. Inst. Med. Trop. S. Paulo. 2007 Jul-Aug; 49 (4).
  6. Blackmon KN, Ravenel JG, Gomez JM, Ciolino J, Wray DW. Pulmonary nocardiosis: computed tomography features at diagnosis. J Thorac Imaging. 2011; 26: 224–229.
  7. Chen J, Zhou H, Xu P, Zhang P, Ma S, Zhou J. Clinical and Radiographic Characteristics of Pulmonary Nocardiosis: Clues to Earlier Diagnosis. PLoS ONE. 2014; 9(3): e90724.
  8. Zheng Y, Wang T, Hsu J, et al. Clinical Pathway in the Treatment of Nocardial Brain Abscesses following Systemic Infections. Case Reports in Neurological Medicine. 2014; Article ID 584934.

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Last updated: 2019-07-11 21:27