Medical Journal of Dr. D.Y. Patil Vidyapeeth

CASE REPORT
Year
: 2017  |  Volume : 10  |  Issue : 1  |  Page : 89--91

A cluster of cases of Nocardiosis


Rabindranath Misra1, Kalpana Mohan Angadi1, Nabamita Chaudary1, Tushar A Dighe2,  
1 Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
2 Department of Nephrology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Correspondence Address:
Dr. Kalpana Mohan Angadi
Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Maharashtra
India

Abstract

Human Nocardiosis has become more common in last two decades due to increase in the number of immunocompromised states of patients and the availability of better detection methods. We report three cases of Nocardiosis in which one was a renal allograft recipient who had developed pneumonia due to a relatively uncommon pathogen Nocardia brasiliensis. Other two cases were seen in immunocompetent hosts where ophthalmic infection due to Nocardia farcinica and subcutaneous infection in the leg due to N. brasiliensis were reported. The patients responded well to treatment. High level of suspicion helped in the detection of these cases.



How to cite this article:
Misra R, Angadi KM, Chaudary N, Dighe TA. A cluster of cases of Nocardiosis.Med J DY Patil Univ 2017;10:89-91


How to cite this URL:
Misra R, Angadi KM, Chaudary N, Dighe TA. A cluster of cases of Nocardiosis. Med J DY Patil Univ [serial online] 2017 [cited 2020 Oct 27 ];10:89-91
Available from: https://www.mjdrdypu.org/text.asp?2017/10/1/89/197920


Full Text

 Introduction



Nocardia is aerobic actinomycetes, ubiquitous in the environment as saprophytes in soil, water, and organic matter. They can cause both localized and disseminated disease in humans and animals.[1] Human infections have increased in the last two decades due to increase in the number of immunocompromised patients and better detection methods.[1],[2],[3] The pathogenic groups belong to Nocardia asteroids complex which causes disseminated and systemic disease and Nocardia brasiliensis which causes superficial and subcutaneous lesions. However, with molecular methods, many newer Nocardia species are identified.[4] Pulmonary manifestations include pneumonia, cavitary lesions, and lung abscess. Nocardial mycetomas are presented with suppurative granuloma, sinus formation, and destruction of adjacent structures, progressive fibrosis, and necrosis with visible granules.[5] In our laboratory, we detected different species of Nocardia causing different type of lesions in both immune-competent and immunocompromised patients in a span of 1 year due to high index of suspicion.

 Case Reports



Case 1

A 23-year-old male renal allograft recipient had reported to this tertiary care hospital with cough and expectoration of 8 days duration, chest pain and dyspnea on exertion, signs of pneumonitis in the right middle and lower lobes as well as with multiple skin abscesses on the left foot. He was on irregular follow-up for treatment. On admission, he was having intermittent fever, mild splenomegaly. His cardiovascular system and other systems were normal. He was continued to be on immunosuppressive agents and antibiotics. The High resolution computed tomography image showed consolidation of lung parenchyma with multiple lung abscesses, suggestive of bacterial/fungal etiology [Figure 1]. His total white blood cell count was 13,700/cmm with 90% neutrophils and 4% band forms. His blood sugar levels were within normal limits. He had blood urea 60 mg/dl, creatinine 1.5 mg/dl, and serum electrolytes showed low serum sodium 127 (mEq/L). Ultrasonography detected mild splenomegaly and small native right kidney with parenchymal disease. The sputum was examined directly with Gram-stain, Ziehl–Neelsen stain and 10% KOH mount. There were thin Gram-positive branching bacterial bodies with bacilli structures at the branching ends. Acid-fast stain showed acid-fast bacilli [Figure 2] with 1% but negative with 25% sulfuric acid. Culture was done on blood agar, chocolate agar, Sabouraud dextrose medium, and LJ medium. There were dry colonies on chocolate agar in 3 days, and paraffin bait test was positive. The species identification of N. brasiliensis was done biochemically by gelatin liquefaction, no growth at 42°C after 3 days of incubation, antibacterial sensitivity to gentamicin and resistance to erythromycin.{Figure 1}{Figure 2}

Case 2

A 32-year-old male patient had reported to the ophthalmic outpatient department (OPD) with foreign body sensation in the left eye and watering, blurring of vision, and clinical presentation of corneal ulcer. There was a history of entry of foreign body in the left eye 1 week earlier. On examination, there was ciliary congestion, stromal edema, and corneal ulcer 1 mm × 3 mm. He was treated with natamycin, moxifloxacin, and fluconazole. The exudate was examined directly with Gram-stain, Ziehl–Neelsen stain and 10% KOH mount. Thin Gram-positive branching bacterial bodies were seen with bacilli structures at the branching ends. Modified acid-fast stain and culture were carried out as above. After 3 days, dry colonies on chocolate agar were seen [Figure 3]. The species was identified and confirmed as Nocardia farcinica biochemically by growth at 42°C, gelatin liquefaction, and antibacterial resistance to gentamicin but sensitive to amikacin.{Figure 3}

Case 3

A 35-year-old female patient from a rural background reported to the surgical OPD with an ulcer in the lower part of the leg. She gave a history of thorn prick a few weeks back. The ulcer started as a papule, progressed to become a nodule before ulceration, which failed to heal even after many courses of antibiotic treatment and antiseptic dressing. On examination, there was an indurated 7 cm × 5 cm area with ulcers with floor of the ulcers covered with dirty slough. On expression, there was purulent discharge with whitish pin head sized sulfur granules from multiple sinuses [Figure 4]. The systemic examination was normal. The granules were examined and identified by phenotypic methods as N. brasiliensis.{Figure 4}

 Discussion



In this study, all three patients were relatively young, and one of them was on immunosuppressive drugs after renal transplant. He was possibly infected with the Nocardia by inhalation. Other two patients had thorn prick injuries which were possibly the route of entry of Nocardia. These organisms are known to establish superficial infection after injuries which may be trivial and may not be noticed by the patient. The absence of thorn prick injuries should not dissuade the clinician from suspecting nocardial infections.[6]

The Nocardia speciescause invasive diseases in some patients by inhibition of phagosome-lysosome fusion by the mycolic acid component of cell wall and survive in macrophage and neutrophils for a long time. It may remain as L-forms and cause relapses and chronicity. Administration of high doses of corticosteroids and infection with cytomegalovirus in previous 6 months increase the susceptibility to nocardiosis.[7],[8],[9]

Initial infections with Nocardia are usually pyogenic and may be confused with staphylococcal infections. However, the presence of sinuses with sulfur granules gave clue to their diagnosis. The early diagnosis is important as they respond very well to trimethoprim and sulfamethoxazole combination. The majority of pulmonary infections are usually caused by N. asteroides but in this case, it was caused by N. brasiliensis.[4] Co-trimoxazole can be given as chemoprophylaxis to organ transplant cases.

The laboratory diagnosis of Nocardia speciesis not difficult particularly if the clinician suspects and communicates in advance to the laboratory staff about its presence, otherwise valuable time may be lost in diagnosis. Speciation is a challenge in many laboratories as it is time consuming. However, we could diagnose the Nocardia to species level by the biochemical methods. At present, a lot of molecular methods particularly detection of 16SRNA by polymerase chain reaction is a valuable method for speciation as newer organisms can be found out. These methods can be used for speciation with the help of which identification of many new species can be carried out.[10]

 Conclusion



We have reported three cases of nocardiosis, one in an immuno compromised case and two in immunocompetent cases. This was possible by high index of suspicion and accurate identification that early and successful treatment of the cases could be carried out.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Conville PS, Witebsky FG. Nocardia, Rhodococcus, Gordonia, Actinomadura, Streptomyces and other aerobic Actinomyces. In: Murray PR, Baron EJ, Jorgensen JH, Landry ML, PFaller MA. Manual of Clinical Microbiology. 9th ed. Washington, DC: ASM Press; 2007. p. 515-42.
2Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ Jr. Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy. Clin Microbiol Rev 2006;19:259-82.
3Lerner PI. Nocardia species. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 4th ed., Vol. 2. New York: Churchill Livingstone; 1995. p. 2273-80.
4Sorrell TC, Mitchell DH, Iredell JR, Chen SC. Nocardia species. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett's Principles and Practice 0f Infectious diseases. 7th ed. Philadelphia: Churchill Livingstone, Elsevier; 2010. p. 3199-207.
5Kwon-Chung KJ, Bennett JE, editors. Mycetoma. In: Medical Mycology. Philadelphia: Lea and Febiger; 1992. p. 560-93.
6Forbes BA, Sahm DF, Weissfeld AS. Nocardia, Streptomyces, Rhodococcus and similar organisms. In: Bailey and Scott's Diagnostic Microbiology. 12th ed. St. Louis, Missouri: Mosby Elsevier; 2007. p. 311-22.
7Deem RL, Doughty FA, Beaman BL. Immunologically specific direct T lymphocyte-mediated killing of Nocardia asteroides. J Immunol 1983;130:2401-6.
8Beaman BL, Scates SM. Role of L-forms of Nocardia caviae in the development of chronic mycetomas in normal and immunodeficient murine models. Infect Immun 1981;33:893-907.
9Dorman SE, Guide SV, Conville PS, DeCarlo ES, Malech HL, Gallin JI, et al. Nocardia infection in chronic granulomatous disease. Clin Infect Dis 2002;35:390-4.
10Koneman EW, Allen SD, Janda WM, Schreckenberger PC, Winn WC Jr. The aerobic gram-positive Bacilli. In: Koneman EW, editor. Color Atlas and Textbook of Diagnostic Microbiology. 5th ed.. Philadelphia: Lippincott; 1997. p. 651-708.