Updated: 6/1/2018

Nocardiosis

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Snapshot
  • A 40-year-old woman presents to the emergency room for fever and cough for the past few nights. Her past medical history includes systemic lupus erythematosus, for which she is currently on a long prednisone taper. On physical exam, she is in moderate distress and dyspneic. There are bilateral crackles and rhonchi on pulmonary exam. A chest radiograph shows multifocal consolidation. She is started on antibiotics following a bronchoalveolar lavage.
Introduction
  • Classification
    • Nocardia
      • an aerobic gram + bacteria with branching filaments
      • weakly acid fast
      • urease + and catalase +
    • transmission
      • inhalation
      • direct contact with skin break
  • Epidemiology
    • demographics
      • mainly in immunocompromised patients
    • location
      • pulmonary (most common)
      • may spread to central nervous system
    • risk factors
      • immunocompromised status
      • chronic steroid use
      • HIV infection
      • trauma
  • Pathogenesis
    • Nocardia can inhibit phagolysosome fusion
    • immunocompromised patients, especially those with defective cell-mediated immunity, are at higher risk
  • Associated conditions
    • pulmonary nocardiosis
      • in immunocompromised patients
    • cutaneous nocardiosis
      • can happen in immunocompetent patients
Presentation
  • Symptoms
    • constitutional symptoms
      • weight loss
      • night sweats
  • Physical exam
    • fever
    • pulmonary nocardiosis
      • cough
      • dyspnea
      • sputum production
      • chest pain
      • pleural effusion
    • neurologic nocardiosis
      • focal neurologic defects based on location of abscess
      • altered mental status
    • cutaneous nocardiosis
      • nodular lymphangitis
        • painful lymphadenopathy with drainage
      • cellulitis
Imaging
  • Chest radiography
    • indication
      • pulmonary nocardiosis
    • findings
      • multifocal consolidation
      • cavitary lesions
  • Computed tomography (CT) of the brain
    • indication
      • suspected central nervous system involvement
    • findings
      • abscesses appear as rim-enhancing lesions
Studies
  • Labs
    • gram + staining with multi-branching beaded filamentous bacteria
    • Ziehl-Neelsen stain
      • weakly acid fast
    • culture
  • Making the diagnosis
    • based on clinical presentation and isolation of organism
 Differential
  • Actinomyces infection
    • distinguishing factors
      • although Actinomyces is also gram + and forms branching filaments, it is not acid fast and causes oral/facial abscesses associated with dental procedures
      • SNAP treatment
        • Sulfa for Nocardia; Actinomyces uses Penicillin
  • Tuberculosis
    • distinguishing factor
      • negative PPD
Treatment
  • Medical
    • trimethoprim-sulfamethoxazole (TMP-SMX) 
      • indication
        • all patients
    • carbapenems
      • indication
        • patients contraindicated to TMP-SMX
Complications
  • Disseminated infection

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Questions (1)

(M2.ID.17.4766) A 28-year-old male presents to the emergency department with fever and cough. He reports that two days ago he developed a productive cough with associated shortness of breath. He also endorses drenching sweats for the last several nights. The patient’s past medical history is otherwise significant for Crohn's disease for which he has been taking prednisone for the past several months. He reports that the symptoms of his Crohn's disease have largely remitted since being on the prednisone. He has a 10-pack-year smoking history and drinks 2-3 beers a few nights per week. He is sexually active with a male partner and has a recent negative HIV test. The patient’s temperature is 101.0°F (38.3°C), blood pressure is 121/68 mmHg, pulse is 110/min, and respirations are 22/min. On physical exam, he is in moderate distress and tachypneic. He has crackles and rales throughout the right middle and lower lung zones. His chest radiograph can be seen in Figure A. Gram stain of a sample obtained from a bronchoalveolar lavage can be seen in Figure B.

Which of the following is the treatment of choice for this patient?

QID: 109048
FIGURES:
1

Amphotericin

15%

(4/27)

2

Levofloxacin

4%

(1/27)

3

Penicillin

7%

(2/27)

4

Rifampin, isoniazid, pyrazinamide, and ethambutol

22%

(6/27)

5

Trimethoprim-sulfamethoxazole

52%

(14/27)

M 7 E

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