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 Table of Contents 
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 9  |  Page : 3035-3038  

Primary pulmonary nocardiosis by Nocardia brasiliensis: A case report and review of Indian literature


1 Department of Medical Microbiology, Sardar Patel Medical College, Bikaner, Rajasthan, India
2 Department of Internal Medicine, 4th Floor, F Block, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission23-Jul-2019
Date of Decision21-Aug-2019
Date of Acceptance05-Sep-2019
Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Ashok K Pannu
Department of Internal Medicine, 4th Floor, F Block, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_576_19

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  Abstract 


Infection by Nocardia brasiliensis is usually localized to the skin but can rarely spread to the lung, brain, or multiple sites particularly in the immunocompromised hosts. Moreover, primary systemic involvement without cutaneous disease is an extremely rare case. In the current study, we present a case of primary pulmonary nocardiosis caused by a multi-drug resistant N brasiliensis along with a review of the cases reported from India.

Keywords: India, nocardiosis, Nocardia brasiliensis, pulmonary


How to cite this article:
Pannu S, Pannu AK. Primary pulmonary nocardiosis by Nocardia brasiliensis: A case report and review of Indian literature. J Family Med Prim Care 2019;8:3035-8

How to cite this URL:
Pannu S, Pannu AK. Primary pulmonary nocardiosis by Nocardia brasiliensis: A case report and review of Indian literature. J Family Med Prim Care [serial online] 2019 [cited 2019 Oct 14];8:3035-8. Available from: http://www.jfmpc.com/text.asp?2019/8/9/3035/268055




  Introduction Top


Pulmonary infections, despite being the leading infectious cause of hospitalization and death worldwide, are often misdiagnosed, mistreated, and underestimated. Diagnosis is usually made by clinical features (history and physical examination) and chest imaging. Establishing a microbial etiology is necessary where unusual or drug-resistant pathogens are suspected in patients with immunocompromised states or in patients who are not responding to empirical antimicrobial agents. Culture and susceptibility data enable pathogen-directed therapy and show trends in antimicrobial resistance.[1]

Nocardiosis is an uncommon pulmonary infection and is only kept as differential in cases of nonresolving pneumonia in patients with compromised cell-mediated innate immunity. The majority of cases of pulmonary nocardiosis are caused by Nocardia asteroides and the drug of choice is cotrimoxazole.[2],[3] We recently had the opportunity of observing a patient with acute fatal pulmonary nocardiosis caused by a multi-drug resistant N brasiliensis.


  Case Description Top


A 65-year-old gentleman was admitted with high-grade fever, productive cough, and rapidly progressive dyspnea for 7 days in a medical intensive care unit.

Six years ago the patient was diagnosed with chronic obstructive pulmonary disease (COPD) and pulmonary tuberculosis (PTB) and had received antituberculosis treatment for 6 months. Currently, he was on inhaled corticosteroids and bronchodilators for COPD. He had no history of diabetes mellitus (DM) and use of systemic steroids or chronic alcohol consumption. He was an ex-smoker and was a farmer by occupation.

On admission, the patient had tachypnea with respiratory rate 30 breaths per min and oxygen saturation of 88% while breathing in ambient air. Lung auscultation revealed bilateral diffuse crackles and rhonchi. A provisional diagnosis of acute exacerbation of COPD with community-acquired pneumonia or suspected PTB relapse was made and the patient was started on intravenous antibiotics (ceftriaxone, amikacin, and ofloxacin), high flow oxygen, nebulization with bronchodilators, and intravenous hydrocortisone.

Laboratory investigations showed leukocytosis (11.4 × 109/l), high erythrocyte sedimentation rate (80 mm/h), and normal liver and renal function tests. A chest X-ray (CXR) showed diffuse bilateral airspace opacities with right upper lobe fibrosis. Blood glucose levels were normal and an HIV serology was nonreactive.

Sputum examination showed gram-positive beaded, branching, thin filamentous bacteria resembling Nocardia spp. The bacterium was acid-fast on modified (1%) Ziehl-Neelsen (ZN) stain [Figure 1]. Sputum specimen was cultured on nutrient agar and blood agar and after 72 h of incubation white dry colonies with rough surface were seen [Figure 2]a and [Figure 2]b. Gram and ZN staining of these colonies revealed bacteria resembling Nocardia spp. The bacterium was identified as N brasiliensis by standard biochemical tests. Antibiotic susceptibility testing by disc diffusion method showed that the isolate was susceptible to amikacin, ceftriaxone, doxycycline, chlorpheniramine, and imipenem but resistant to cotrimoxazole and aztreonam [Figure 3].
Figure 1: Branching, thin filamentous acid-fast bacteria on modified (1%) ZN stain

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Figure 2: White dry colonies with a rough surface on nutrient agar (a) and blood agar (b)

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Figure 3: Antibiotic susceptibility testing

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Initially, cotrimoxazole was started after sputum microscopy examination but later it was changed to imipenem after antimicrobial susceptibility results. Despite this, the patient developed rapidly progressive respiratory failure and septic shock and could not be revived.


  Discussion Top


Pulmonary nocardiosis is typically regarded as an uncommon opportunistic infection which causes high mortality. Dysfunction of cell-mediated immunity is a major predisposing factor and patients with uncontrolled DM, HIV, malignancy, organ or stem cell transplant, alcoholism, and long-term use of immunosuppressive agents (e.g. steroids) are particularly at risk.[2],[4],[5]

Pulmonary nocardiosis usually has a subacute (weeks to months) or chronic (months to years) presentation and may mimic tuberculosis or lung cancer. Acute pulmonary infection (days) is usually fulminant and is commoner in immuno-suppressed individuals. Clinical features are nonspecific and a constellation of fever, cough, dyspnea, chest pain, anorexia, or weight loss. As pulmonary nocardiosis is a great mimicker, it may have a plethora of radiological findings; common being consolidation, nodules, or lung mass; solitary or multiple; and with or without breakdown or cavitation. For diagnosis, a strong clinical suspicion is needed, and it requires isolation and identification of Nocardia from a clinical specimen that is, sputum, broncho-alveolar lavage (BAL), fine needle aspiration, or biopsy.[2],[4],[5]

N asteroides accounts for up to 90% of the reported cases. N brasiliensis is usually limited to cutaneous and lymphocutaneous disease but can rarely spread to produce pulmonary or disseminated disease in immunosuppressed hosts.[2],[4],[5]

A PubMed/MEDLINE search of literature tracked a total of eight adult Indian patients with a diagnosis of pulmonary nocardiosis by N brasiliensis [Table 1].[6],[7],[8],[9],[10],[11],[12] Age and sex distribution (mean age 51.66 years; median age 45 years; male preponderance); underlying conditions (common being chronic lung disease and chronic steroid use); clinico-radiological features; and mortality (more with acute presentation and cotrimoxazole resistant cases) are similar to overall pulmonary nocardiosis cases. The involvement of the lung is usually thought to occur after transcutaneous inoculation by N brasiliensis; however, in the reviewed cases, only two out of nine had primary cutaneous nocardiosis.
Table 1: Review of cases of pulmonary nocardiosis by N brasiliensis reported from India

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In conclusion, inhalation may be the primary route of infection by N brasiliensis. Primary care physicians should have awareness of pulmonary nocardiosis as correct and efficient diagnosis is quite challenging. Moreover, cotrimoxazole resistant cases have poor outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflict of interest

There is no conflict of interest.



 
  References Top

1.
Wunderink RG. Guidelines to manage community-acquired pneumonia. Clin Chest Med 2018;39:723-31.  Back to cited text no. 1
    
2.
Agterof MJ, van der Bruggen T, Tersmette M, ter Borg EJ, van den Bosch JM, Biesma DH. Nocardiosis: A case series and a mini review of clinical and microbiological features. Neth J Med 2007;65:199-202.  Back to cited text no. 2
    
3.
Tan YE, Chen SC, Halliday CL. Antimicrobial susceptibility profiles and species distribution of medically relevant Nocardia species: Results from a large tertiary laboratory in Australia. J Glob Antimicrob Resist 2019. doi: 10.1016/j.jgar. 2019.06.018.  Back to cited text no. 3
    
4.
Farina C, Andrini L, Bruno G, Sarti M, Tripodi MF, Utili R, et al. Nocardia brasiliensis in Italy: A nine-year experience. Scand J Infect Dis 2007;39:969-74.  Back to cited text no. 4
    
5.
Safdar N, Kaul DR, Saint S. Clinical problem-solving. Into the woods. N Engl J Med 2007;356:943-7.  Back to cited text no. 5
    
6.
Wadhwa V, Rai S, Kharbanda P, Kabra S, Gur R, Sharma VK. A fatal pulmonary infection by Nocardia brasiliensis. Indian J Med Microbiol 2006;24:63-4.  Back to cited text no. 6
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7.
Shivaprakash MR, Rao P, Mandal J, Biswal M, Gupta S, Ray P, et al. Nocardiosis in a tertiary care hospital in North India and review of patients reported from India. Mycopathologia 2007;163:267-74.  Back to cited text no. 7
    
8.
Chawla K, Mukhopadhyay C, Payyanur P, Bairy I. Pulmonary nocardiosis from a tertiary care hospital in Southern India. Trop Doct 2009;39:163-5.  Back to cited text no. 8
    
9.
Amatya R, Koirala R, Khanal B, Dhakal SS. Nocardia brasiliensis primary pulmonary nocardiosis with subcutaneous involvement in an immunocompetent patient. Indian J Med Microbiol 2011;29:68-70.  Back to cited text no. 9
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10.
Rawat V; Umesh, Thapliyal N, Punera DC. Primary pulmonary infection caused by 20% acid fast Nocardia brasiliensis. Indian J Med Microbiol 2011;29:446-7.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Khare V, Gupta P, Himanshu D, Kumar D. Emergence of co-trimoxazole resistant Nocardia brasiliensis causing fatal pneumonia. BMJ Case Rep 2013. doi: 10.1136/bcr-2013-009069.  Back to cited text no. 11
    
12.
Bagali S, Mantur P. Pleural Nocardiosis in an Immunocompetent Patient: A case report. J Clin Diagn Res 2016;10:DD01-2.  Back to cited text no. 12
    


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