Diagnosis Of Pulmonary Nocardiosis Research Articles

Mild Pulmonary Nocardiosis Caused by Nocardia terpenica in an Immunocompetent Patient: A Case Report.

A 53-year-old immunocompetent man was admitted to our hospital because of paroxysmal cough with a low fever for more than 5 months. On admission, chest computed tomography showed multiple plaques and nodules, some with small central cavities, in both lungs and cystic and columnar bronchiectasis of the right middle bronchus. Treatment with various antibiotics was ineffective. Metagenomic next-generation sequencing of the bronchoalveolar lavage fluid showed Nocardia terpenica, and this organism was cultured from bronchoalveolar lavage fluid, resulting in a diagnosis of pulmonary nocardiosis. After administration of trimethoprim-sulfamethoxazole for 5 weeks, chest computed tomography showed a significant reduction in the lung lesions that had been detected on admission. Immunosuppressed patients are particularly prone to nocardiosis infection, which is usually severe. N. terpenica has rarely been detected in clinical samples, and its characteristics require further study with the accumulation of more clinical cases.

The Findings of Pulmonary Nocardiosis on Chest High Resolution Computed Tomography: Single centre experience and review of literature.

ObjectivesPulmonary nocardiosis is a rare opportunistic infection that is often encountered in immunocompromised patients, in particular those with the HIV infection and in solid organ transplant recipients. As the number of immunocompromised patients increase, the number of patients with pulmonary nocardiosis is also expected to increase. This study aimed to analyse both the chest high resolution computed tomography (HRCT) findings of patients with confirmed pulmonary nocardiosis and review the imaging features of pulmonary nocardiosis in the literature.MethodsThis retrospective study was conducted at The Royal Hospital, Muscat, Oman, to identify patients with a diagnosis of pulmonary nocardiosis between January 2006 and January 2019. Accordingly, nine patients with pulmonary nocardiosis were identified, but three patients were excluded as no chest HRCT images were available. Patient clinical presentation was recorded and chest HRCT images were retrospectively reviewed.ResultsA total of six patients were enrolled in this study. All were male and with a mean age of 41 ± 11 years. Three patients were immunocompromised, two of whom had undergone a renal transplant. The main HRCT findings were cavitary nodules/masses, non-cavitary nodules/masses, septal thickening, centrilobular nodules, ground glass opacities, consolidation, pleural effusion, pleural thickening, enlarged lymph nodes and necrotic lymph nodes.ConclusionPulmonary nocardiosis shows various findings in a chest CT, the most common of which are pulmonary nodules and masses. Awareness of these findings can help radiologists with a diagnosis in the appropriate clinical settings.

1996. Addressing Pulmonary Nocardiosis Risk in Immunocompromised Patients: Development and Validation of a Commercially Available PCR

BackgroundPulmonary nocardiosis is an infection targeting immunocompromised patients characterized by high mortality and requires nonfrontline antibiotics for treatment. Nocardiosis is currently confirmed or excluded by BAL fluid culture followed by further phenotypic identification steps. A culture-independent method with more timely results would accelerate the administration of appropriate treatment. A rapid Nocardia (NOC) PCR assay for BAL has neither been previously validated nor offered for clinical testing to our knowledge.MethodsOligonucleotides for a rapid NOC PCR comprehensive of the causative agents of nocardiosis were aligned to the 16S regions of common NOC species and over 30 others. Specificity was verified against publically available bacterial 16S sequences. Rapid automated nucleic acid extraction (<1 hour for 24 samples) followed by fast PCR (<1 hour) was validated according to relevant compliance standards. Spiked/unspiked human BAL samples were used to assess analytical specificity, limit of detection (LOD), precision and accuracy using NOC and non-NOC strains.ResultsThe NOC PCR detected, among others, the most common NOC species (N. cyriacigeorgica, N. nova, N. farcinica and N. brasiliensis). We estimate more than 95% of causative agents of nocardiosis are detectable by the assay. No cross reactivity was detected from 30 non-NOC bacterial pathogens except for Rhodococcus and Crossiella spp. LOD in BAL fluid was determined to be 206, 41, and 26 copies/mL for N. cyriacigeorgica, N. nova, and N. transvalensis, respectively. Intra- and inter-assay precision studies revealed copies/mL %CV’s of <10% and <8% at a high concentration and <21% and <26% at a low concentration, respectively. Accuracy studies yielded 100% concordance with 33 BAL positives and 20 BAL negatives.ConclusionThe specificity, inclusivity, sensitivity, precision and accuracy of a qualitative PCR have been deployed as an aid in the diagnosis of pulmonary nocardiosis. NOC PCR allows for a culture-independent method that can rapidly detect clinically relevant NOC species with an improved turnaround time, leading to prompt diagnosis and administration of appropriate treatment.Disclosures E. Smith, Viracor Eurofins Clinical Diagnostics: Employee, Salary. K. Bartlett, Viracor Eurofins Clinical Diagnostics: Employee, Salary. J. Grantham, Viracor Eurofins Clinical Diagnostics: Employee, Salary. N. Powell, 1987: Employee, Salary. M. Altrich, Viracor Eurofins Clinical Diagnostics: Employee, Salary. S. Kleiboeker, Viracor Eurofins Clinical Diagnostics: Employee, Salary. M. Wissel, Viracor Eurofins Clinical Diagnostics: Employee, Salary.

Disseminated Endobronchial Nocardiosis Masquerading as a Bronchogenic Tumor

SESSION TITLE: Lung Pathology 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Nocardia is a weak gram positive, partial acid fast branching filamentous organism. Pulmonary Nocardiosis is infrequently reported in immunocompetent patients and delay in diagnosis occurs due to non-specific clinical symptoms and radiological signs [1]. Our case highlights an unusual presentation of disseminated endobronchial Nocardiosis, initially mistaken for metastatic lung cancer. CASE PRESENTATION: A previously healthy 61-year-old male presented with a worsening right occipital headache. He denied any changes in vision. No fever, chills, anorexia, cough or shortness of breath were reported. His physical examination was unremarkable. Laboratory work up was unrevealing. A Computed Tomography (CT) of the head showed three hypoattenuating lesions in the right cerebral convexity (figure 1). A PET/CT of the body was obtained for concerns of metastatic disease and showed two infrahilar nodules and a right sided subcarinal lymph node with high FDG avidity suspicious for malignancy. These findings prompted a diagnostic bronchoscopy with EBUS-FNA of an endobronchial lesion found in the bronchus intermedius (figure 2). The pathology was negative for malignancy but cultures grew Nocardia. Speciation later showed Nocardia wallacei. A biopsy of the right occipital brain lesion was also consistent with Nocardia. The patient was started on trimethoprim-sulfamethoxazole and imipenem. His follow up visit with repeat CT imaging showed an interval decrease in the size of the right infrahilar mass. DISCUSSION: Pulmonary Nocardiosis has been rarely reported in immunocompetent individuals. Risk factors for this opportunistic infection include solid organ transplant, leukemia, steroid use and HIV [2]. Diagnosis of pulmonary Nocardiosis is usually heralded by the insidious onset of fever, anorexia, cough or shortness of breath. Our patient had a unique presentation with symptoms related to brain dissemination but had absent pulmonary symptomatology [2]. Radiological features of Nocardia in lungs include lobar infiltrates, nodules or cavitary lesions. Treatment consists of a combination of sulfonamides and Imipenem [3]. CONCLUSIONS: We hereby present a rare case of pulmonary Nocardiosis with dissemination to brain in an immunocompetent host. The presentation mimicked malignancy. Our case highlighted the importance of including pulmonary Nocardia in the differential diagnosis of lung nodules with brain lesions even in the absence of respiratory symptoms or known factors of immunosuppression. Reference #1: Ramana KV, Sabitha K, Venkata Bharatkumar P, Sharada CHV, Ratna Rao, Ratna Mani, Sanjeev DR: Invasive Fungal Infections: A Comprehensive Review. American Journal of Infectious Diseases and Microbiology. 2013, 1:64-69 Reference #2: Martínez Tomas R, Menéndez Villanueva R, Reyes Calzada S, et al: Pulmonary nocardiosis: risk factors and outcomes. Respirology. 2007, 12:394-400 Reference #3: Shariff M, Gunasekaran J: Pulmonary Nocardiosis: Review of cases and an update. Canadian Respiratory Journal. 2016:749202 DISCLOSURE: The following authors have nothing to disclose: Sara Assaf, Pujan Patel, David Stoeckel No Product/Research Disclosure Information

Clinical spectrum and outcome of pulmonary nocardiosis: 5-year experience.

Background:Pulmonary nocardiosis is a rare but a life-threatening infection caused by Nocardia spp. The diagnosis is often missed and delayed resulting in delay in appropriate treatment and thus higher mortality.Aim:In this study, we aim to evaluate the clinical spectrum and outcome of patients with pulmonary nocardiosis.Methods:A retrospective, 5-year (2009–2014) review of demographic profile, risk factors, clinical manifestations, imaging findings, treatment, and outcome of patients with pulmonary nocardiosis admitted to a tertiary care hospital.Results:The median age of the study subjects was 54 years (range, 16–76) and majority of them (75%) were males. The risk factors for pulmonary nocardiosis identified in our study were long-term steroid use (55.6%), chronic lung disease (52.8%), diabetes (27.8%), and solid-organ transplantation (22.2%). All the patients were symptomatic, and the most common symptoms were cough (91.7%), fever (78%), and expectoration (72%). Almost two-third of the patients were initially misdiagnosed and the alternative diagnosis included pulmonary tuberculosis (n = 7), community-acquired pneumonia (n = 5), lung abscess (n = 4), invasive fungal infection (n = 3), lung cancer (n = 2), and Wegener's granulomatosis (n = 2). The most common radiographic features were consolidation (77.8%) and nodules (56%). The mortality rate for indoor patients was 33% despite treatment. Higher mortality rate was observed among those who had brain abscess (100.0%), HIV positivity (100%), need for mechanical ventilation (87.5%), solid-organ transplantation (50%), and elderly (age > 60 years) patients (43%).Conclusion:The diagnosis of pulmonary nocardiosis is often missed and delayed resulting in delay in appropriate treatment and thus high mortality. A lower threshold for diagnosing pulmonary nocardiosis needs to be exercised, in chest symptomatic patients with underlying chronic lung diseases or systemic immunosuppression, for the early diagnosis, and treatment of this uncommon but potentially lethal disease. Despite treatment mortality remains high, especially in those with brain abscess, HIV positivity, need for mechanical ventilation, solid-organ transplantation, and elderly.

Clinical Analysis of Pulmonary Nocardiosis in Patients With Autoimmune Disease.

Nocardiosis is an opportunistic infection that most commonly involves the lung; however, only a few case reports of autoimmune disease complicated by pulmonary nocardiosis exist in the literature.We conducted a retrospective analysis of 24 cases of both autoimmune disease and pulmonary nocardiosis at the Peking Union Medical College Hospital between 1990 and 2012.Fifty-two cases were hospitalized with nocardiosis, 24 of whom had at least 1 autoimmune disease before the diagnosis of pulmonary nocardiosis. The cohort patients consisted of 5 men and 19 women, with a mean age of 44.2 years. All were negative for human immunodeficiency virus. All but 1 patient had received immunosuppressants, including corticosteroids, cyclophosphamide, azathioprine, methotrexate, or hydroxychloroquine. Fever (87.5%), cough (83.3%), and sputum (79.2%) were the most common clinical manifestations. Ten cases were accompanied by subcutaneous nodules and/or cutaneous abscesses, and 4 had brain abscess. Half of them were lymphocytopenic. Thirteen of the 16 cases who underwent lymphocyte subtype analysis had decreased CD4+ T-cell counts. Nineteen cases had decreased serum albumin levels. Nocardia was isolated from sputum (13/24), bronchoalveolar lavage fluid (4/6), lung tissue (5/6), pleural effusions (3/5), skin or cutaneous pus (7/10), and brain tissue (1/1). The most common imaging findings were air-space opacities (83.3%), followed by nodules (62.5%), cavitations (45.8%), and masses (37.5%). Five were administered co-trimoxazole only, and the others were treated with 2 or more antibiotics. All 5 cases with skin abscesses and 2 of the 4 cases with brain abscesses were treated by surgical incision and drainage. None underwent thoracic surgery. Corticosteroid dosages were decreased in all cases, and cytotoxic agents were discontinued in some cases. Twenty-two cases recovered, and 2 died.Pulmonary nocardiosis associated with an underlying autoimmune disease showed a female predominance and presentation at younger age. Immunosuppressant therapy, lymphocytopenia, particularly low CD4+ T-lymphocyte counts, and low serum albumin levels may be disease susceptibility factors. Air-space opacities and nodules were the most common chest imaging features, and disseminated nocardiosis with lung and skin involvement was more common among them. Early diagnosis and anti-nocardial antibiotics with modulation of the basic immunosuppressive therapy were important for them.

Pulmonary Nocardiosis Mimicking Tuberculosis

Pulmonary nocardiosis is an infrequent and severe infection due to Nocardia species, microorganisms that may behave both as opportunists and as primary pathogens. Diagnosis of pulmonary nocardiosis is frequently delayed and a high level of suspicion is required in patients with underlying diseases or chronic corticosteroid therapy. Hereby we are presenting a case of pulmonary nocardiosis mimicking tuberculosis in an immonocompromised patient.

A general evaluation on pulmonary nocardiosis due to three patients presenting with a mass like radiographic appearance on chest X-ray

Pulmonary nocardiosis is an important cause of opportunistic infection in immune-compromised patients. Pulmonary nocardiosis manifests as an acute, subacute or chronic infection. Although, there is specific treatment, there are usually difficulties in its diagnosis and, therefore nocardiosis already has a high rate of mortality. All of the nocardia infections of our study were pulmonary nocardiosis. The first case of our study was receiving immunosuppressive drugs after renal transplantation; second patient was receiving high dose corticosteroid and methotrexate due to the systemic lupus erithematosus; and third patient was newly diagnosed acute renal failure. All the diagnosis of pulmonary nocardiosis was done by isolation of the organism from bronchial lavage fluids. All patients were healed and discharged. The duration of therapy was 12 months in the first patients, 2 months in the second and 3 months in the third patient. According to results of our cases we concluded that nocardia tends to affect patients with cellular immune-compromised, physicians should notify the laboratory staff when Nocardia is suspected and the duration of therapy depends on the severity and the host’s immune status.

EUS-guided fine needle aspiration diagnosis of pulmonary nocardiosis

EUS-guided fine needle aspiration diagnosis of pulmonary nocardiosis