Abstract
ObjectiveThe multicenter literature review and case studies of 3 patients were undertaken to provide an updated understanding of nocardiosis, an opportunistic bacterial infection affecting immunosuppressed nephrotic syndrome (NS) patients receiving long-term glucocorticoid and immunosuppressant treatment. The results provided clinical and microbiological data to assist physicians in managing nocardiosis patients.MethodsThree cases between 2017 and 2018 from a single center were reported. Additionally, a systematic review of multicenter cases described in the NCBI PubMed, Web of Science, and Embase in English between January 1, 2001 and May 10, 2021 was conducted.ResultsThis study described three cases of Nocardia infection in NS patients. The systematic literature review identified 24 cases with sufficient individual patient data. A total of 27 cases extracted from the literature review showed that most patients were > 50 years of age and 70.4% were male. Furthermore, the glucocorticoid or corticosteroid mean dose was 30.9 ± 13.7 mg per day. The average time between hormone therapy and Nocardia infection was 8.5 ± 9.7 months. Pulmonary (85.2%) and skin (44.4%) infections were the most common manifestations in NS patients, with disseminated infections in 77.8% of patients. Nodule/masses and consolidations were the major radiological manifestations. Most patients showed elevated inflammatory biomarkers levels, including white blood cell counts, neutrophils percentage, and C-reactive protein. Twenty-five patients received trimethoprim-sulfamethoxazole monotherapy (18.5%) or trimethoprim-sulfamethoxazole-based multidrug therapy (74.1%), and the remaining two patients (7.4%) received biapenem monotherapy. All patients, except the two who were lost to follow-up, survived without relapse after antibiotic therapy.ConclusionsNephrotic syndrome patients are at high risk of Nocardia infection even if receiving low-dose glucocorticoid during the maintenance therapy. The most common manifestations of nocardiosis in NS patients include abnormal lungs revealing nodules and consolidations, skin and subcutaneous abscesses. The NS patients have a high rate of disseminated and cutaneous infections but a low mortality rate. Accurate and prompt microbiological diagnosis is critical for early treatment, besides the combination of appropriate antibiotic therapy and surgical drainage when needed for an improved prognosis.
Highlights
Nocardia species are aerobic, Gram-positive, filamentous, beaded, weakly acid-fast branching bacilli found worldwide in soil and water (Brown-Elliott et al, 2006; Wilson, 2012)
Three days before the admission, the patient was initially treated with cefoperazone/sulbactam in a local hospital because the radiographic manifestations suspected bacterial pneumonia
Chest computed tomography (CT) scan revealed cordlike high-density shadows in both lungs and consolidation in the left lower lobe with left-sided pleural effusion (Figure 1)
Summary
Gram-positive, filamentous, beaded, weakly acid-fast branching bacilli found worldwide in soil and water (Brown-Elliott et al, 2006; Wilson, 2012). More than 100 different Nocardia species have been identified by phenotypic identifications, molecular methods and 16S rRNA gene sequencing Bacterio.net) up to now, and over 50 of them have been reported pathogenic to humans (Conville et al, 2018). An opportunistic pathogen, infects humans via respiratory inhalation and injured skin. Chronic lung disease and immunosuppression caused by glucocorticoids or other immunosuppressive therapies, human immunodeficiency virus (HIV) infection, solid organ transplantation, and chemotherapy for neoplasm are the common risk factors for Nocardia infections (Conville et al, 2003; Liu et al, 2011; Molina et al, 2018; Zia et al, 2019). Recent years have seen an increase in nocardiosis incidences with extensive immunosuppressive therapies
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