• A 26-year-old female with HIV presents to the primary care clinic with a four month history of fever, night sweats, and a cough productive of yellow sputum. She is PPD negative and CD4+ count is 320 cells/μL blood. Chest radiograph reveals pulmonary cavitations confirmed by CT scan of the chest. Sputum is negative for AFB. Bronchoscopy was carried out and a modified Ziehl-Neelsen stain of the aspirate revealed partially acid fast gram-positive filamentous rods.
  • Classification
    • bacteria
      • fungus-like bacteria
        • Nocardia
          • N. asteroides
          • N. brasiliensis
  • Pulmonary nocardiosis
    • cavitary pulmonary disease
    • frequently misdiagnosed as TB
    • immunocompromised patients are at risk
    • can spread hematogenously to brain causing brain abscesses
    • mostly caused by. N. asteroides
  • Cutaneous nocardiosis
    • cellulitis with draining abscesses
    • mostly caused by N. brasiliensis via traumatic implantation
  • Definitive diagnosis made with culture and Gram-stain 
  • Partially acid fast 
  •  Chest manifestations of AIDS
    • pulmonary TB
    • Pneumocystis jiroveci pneumonia
    • coccidioidomycosis
  • Sulfonamides or TMP-SMX 
    • "SNAP" = Sulfa for Nocardia; Actinomyces use Penicillin
Prognosis, Prevention, and Complications
  • Prognosis
    • patient tends to relapse despite appropriate therapy
      • requires prolonged treatment regimens
  • Prevention
    • maintainance-suppressive therapy for immunosuppressed patients
      • TMP-SMX  and doxycycline can be used
  • Complications
    • mycetoma
    • disseminated infection

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