In the present study, five cases of pulmonary nocardiosis (PN), four males and one female, were encountered among patients attending Vallabhbhai Patel Chest Institute, a tertiary care respiratory diseases hospital in Delhi, India. They were admitted with complaints of breathlessness and increased cough with sputum production from a week to 3-month duration. They all had fever and weight loss. All were immunocompromised with four of them having the chronic obstructive pulmonary disease (COPD) with tuberculosis and one with COPD and diabetes mellitus. Sputum samples from four and bronchial alveolar lavage, bronchial aspirate, and sputum from one case showed Gram-positive filamentous branching rods with beaded appearance on Gram’s staining and acid fast branching filamentous rods with beaded appearance on modified Ziehl-Neelsen staining suggestive of
Details of patients with pulmonary nocardiosis.
Case |
Case |
Case |
Case |
Case |
|
---|---|---|---|---|---|
Age | 76 | 70 | 57 | 70 | 42 |
Diagnosis | COPD with pulmonary T.B. | COPD with pulmonary T.B. | COPD with DM | Treated pulmonary T.B. | Treated pulmonary T.B. |
H/o ATT | Yes | Yes | No | Yes | Yes |
H/O DM | No | No | Yes | No | No |
HIV | No | No | No | No | No |
H/O smoking | Yes | Yes | Yes | No | No |
COPD | Yes | Yes | Yes | No | No |
Chief complaints | Breathlessness and increased cough with sputum for 4-5 days and loss of weight and loss of appetite | Breathlessness and cough with sputum for 20 years acutely increased for two weeks and fever for 1 week | Breathlessness and cough with sputum for 15 days | Breathlessness and cough with sputum for three months, intermittent fever for three months, and loss of weight | Persistent symptoms of fever, loss of appetite, and mucopurulent sputum for two months after ATT course |
X-ray | Bilateral pneumonia | Bilateral pneumonia | — | Rt lower zone opacity | Left lower lobe collapse with consolidation |
Clinical samples | Sputum | Sputum | Sputum | Sputum | BAL, BA, and sputum |
SMEAR Grams | Gram positive branching filamentous rods with beads | Gram positive branching filamentous rods with beads | Gram positive branching filamentous rods with beads | Gram positive branching filamentous rods with beads | Gram positive branching filamentous rods with beads |
Modified acid fast staining | Acid fast branching filamentous rods with beads | Acid fast branching filamentous rods with beads | Acid fast branching filamentous rods with beads | Acid fast branching filamentous rods with beads | Acid fast branching filamentous rods with beads |
Culture on sheep blood agar | Positive after 48 hrs of incubation | Positive after 48 hrs of incubation | Culture-negative after seven days of incubation | Positive after three days of incubation | Positive after 48 hrs of incubation |
Treatment | T. Septran 4 days |
T. TMP-SMX 20 days |
T. TMP-SMX 5 days |
Inj Amikacin 2 weeks |
Inj Amikacin 2 weeks |
Outcome | Patient expired after six days of admission | Discharged with advice to continue TMP-SMX for six months and to come for follow-up | Patient expired after six days of admission | Sputum negative after a week. Discharged with advice to continue TMP-SMX for six months and to come for follow-up | Sputum was negative after one wk of treatment. Discharged with advice to continue TMP-SMX for six mths and to come for follow-up |
Follow-up | — | The patient was lost to follow-up | — | Sputum samples taken at one and two months of follow-up were negative. Complete resolution of the lesion at four months of treatment with TMP-SMX and no complaints | Smear-negative after seven days and after two weeks follow-up |
COPD: chronic obstructive pulmonary disease.
ATT: antituberculous treatment.
DM: diabetes mellitus.
TMP-SMX: trimethoprim-sulfamethoxazole.
T.B.: tuberculosis.
Nocard first described
Pulmonary nocardiosis can present as acute, subacute, or chronic suppurative infection with a tendency to remit or exacerbate. PN is usually suppurative but granulomatous, or mixed variety may occur. Clinical manifestation includes pneumonia, endobronchial inflammatory masses, lung abscess, and cavitary disease with contiguous extension leading to effusion and empyema.
Irregular nodules, reticulonodular or diffuse pneumonic infiltrates, and pleural effusions are seen in X-ray. The progressive fibrotic disease may develop following inadequate therapy, and the diagnosis is often difficult. It can be fatal in patients with advanced HIV infection and often presents as alveolar infiltrates rather than cavitary lesion. In this situation, the X-ray findings are nonspecific and hence should be considered as a differential diagnosis of indolent pulmonary disease along with
Demonstration of
Gram’s stain smear shows Gram-positive, beaded, fine, right-angled branching filaments (<1
Some commercial identification systems like API 20C (Biomerieux) allow for rapid identification of
Molecular identification of
DNA sequencing is currently the best tool for species identification of
Currently, there are no serological tests available for diagnosis of active nocardiosis due to the cross-reactivity among different
Trimethoprim-sulfamethoxazole (TMP-SMX) is the mainstay of treatment and has improved the outcomes. In adults, with normal renal function and localized disease, the recommended daily dose of TMP-SMX is 5 to 10 mg/kg TMP and 25 to 50 mg/kg SMX in two to four divided doses, depending on the extent of disease. Higher initial doses (15 mg/kg TMP and 75 mg/kg SMX), given intravenously or orally, are frequently used in patients with cerebral abscesses; severe, extensive, or disseminated infection; or AIDS. Sulfonamides are the treatment of choice for disease due to
Isolation of nocardiae from sputum or blood occasionally represents colonization, transient infection, or contamination. In cases of respiratory tract colonization, Gram-stained specimens are usually negative, and cultures are only intermittently positive. Until a better tool to determine the virulence of
Work was carried out at Department of Microbiology, Vallabhbhai Patel Chest Institute, Delhi University, Delhi, India.
The authors declare that there are no competing interests associated with this work.
Jayanthi Gunasekaran processed the samples and compiled the data. Malini Shariff supervised the lab work, interpreted the results, reviewed the subject, and wrote the paper.
The study was supported by Vallabhbhai Patel Chest Institute through their annual governmental funding.