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Updated: Dec 23 2021

Nocardiosis

Images
https://upload.medbullets.com/topic/121816/images/nocardiact.jpg
https://upload.medbullets.com/topic/121816/images/nocardia.jpg
https://upload.medbullets.com/topic/121816/images/screen_shot_2018-05-29_at_2.56.02_pm.jpg
https://upload.medbullets.com/topic/121816/images/gram_positive_by_moises_dominguez_corrected.jpg
  • 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
    • Associated conditions
      • pulmonary nocardiosis
        • in immunocompromised patients
      • cutaneous nocardiosis
        • can happen in immunocompetent patients
  • 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
  • ETIOLOGY
    • Pathogenesis
      • Nocardia can inhibit phagolysosome fusion
      • immunocompromised patients, especially those with defective cell-mediated immunity, are at higher risk
  • 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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