Disseminated Nocardia farcinica: Literature Review and Fatal Outcome in an Immunocompetent Patient

Department of Pathology, Pritzker School of Medicine, Chicago, Illinois, USA.
Surgical Infections (Impact Factor: 1.45). 05/2012; 13(3):163-70. DOI: 10.1089/sur.2011.012
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Nocardia farcinica is a gram-positive, partially acid-fast, methenamine silver-positive aerobic actinomycete. Nocardia spp. are opportunistic pathogens, and N. farcinica is the least common species of clinical importance.
Review of the recent literature and description of a immunocompetent patient with no known risk factors who contracted fatal N. farcinica sepsis.
Positive pre-mortem and post-mortem cultures from the lung and synovium correlated with acute bronchopneumonia and synovitis at autopsy. Colonies of filamentous bacteria, which were not apparent in conventional hematoxylin and eosin-stained sections, were observed with gram and methenamine silver stains, but acid-fast stains were negative. A literature review revealed that disseminated N. farcinica often is associated with an underlying malignant tumor or autoimmune disease (88% of patients). Chemotherapy or corticosteroid treatments are additional risk factors.
Trimethoprim-sulfamethoxazole typically is the first-line therapy for N. farcinica; treatment with amikacin and imipenem-cilastatin is used less often (7% of patients). Despite aggressive therapy, we observed that the death rate (39%) associated with N. farcinica in recent publications was eight percentage points higher than reported in a review from 2000.

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    • "As intrinsic infection, N. farcinica caused community-acquired pneumonia associated with influenza A virus infection this time. Nocardia infections are rare but potentially fatal, typically more problematic in patients with cell-mediated immunosuppressive conditions [21], but occasionally inimmunocompetent patients as well [22]. N. farcinica is a ubiquitous, Gram-positive actinomycete saprophyte that lives in soil, organic matter and water. "
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    ABSTRACT: Nocardia spp. has not been reported previously as a cause of post-influenza pneumonia. Here we present a first case of post-influenza bacterial pneumonia due to Nocardia farcinica. Initial reason for hospitalization of the 90 year old female patient was a pneumonia with the symptoms of fever and productive cough. A rapid test for influenza antigen was positive for influenza A virus. Treatment with Zanamivir and piperacillin was initiated. However, after 1 week of treatment, the infiltration shadows on chest X-ray had worsened. Because the expectorated sputum collected on admission for culture was found to be positive for Nocardia spp., piperacillin was replaced with trimethoprim/sulfamethoxazole, and a chest X-ray showed some improvement. Although pulmonary nocardiosis with co-infection with influenza A is extremely rare, clinicians should be alert to the possibility.
    Journal of Infection and Chemotherapy 05/2014; 20(7-8). DOI:10.1016/j.jiac.2014.04.008 · 1.49 Impact Factor
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    • "Gram staining is the most sensitive method for visualizing and recognizing nocardia. Nocardia is partially acid-fast by conventional Ziehl-Nielsen staining and is reactive with Gomori methenamine silver.16 It is important to obtain cultures from tissue biopsies when disseminated infection is considered to allow for prompt organism identification and perhaps better patient care.17 "
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    ABSTRACT: Nocardia species are aerobic, gram positive filamentous branching bacteria that have the potential to cause localized or disseminated infection. Nocardiosis is a rare disease that usually affects immunocompromised patients and presents as either pulmonary, cutaneous or disseminated nocardiosis. Forty-two year-old hispanic male presented to our care with bilateral lower extremity weakness, frontal headache, subjective fever, nausea, and vomiting. Brain computed tomography (CT) revealed multiple hyperdense lesions with vasogenic edema in the frontal, parietal and left temporal lobes. Chest CT demonstrated bilateral cavitary nodules in the lung and right hilar lymphadenopathy. Brain magnetic resonance imaging revealed multiple bilateral supratentorial and infratentorial rim enhancing lesions involving the subcortical gray-white matter interface with vasogenic edema. Patient was started on empiric therapy for unknown infectious etiology with no response. He eventually expired and autopsy findings revealed a right hilar lung abscess and multiple brain abscesses. Microscopic and culture findings from tissue sample during autopsy revealed nocardia wallacei species with multidrug resistance. The cause of death was stated as systemic nocadiosis (nocardia pneumonitis and encephalitis). The presence of simultaneous lung and brain abscesses is a reliable indication of an underlying Nocardia infection. An increased awareness of the various presentations of nocardiosis and a high index of clinical suspicion can help in a rapid diagnosis and improve survival in an otherwise fatal disease. This case highlights the importance of obtaining a tissue biopsy for definitive diagnosis on the initial presentation when an infectious process is considered in the differential diagnosis and early treatment can be initiated.
    Infectious disease reports 02/2014; 6(1):5327. DOI:10.4081/idr.2014.5327
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    ABSTRACT: : Anti-tumor necrosis factor (anti-TNF) therapy is beneficial in the management of many chronic immune-mediated inflammatory diseases. However, its use is associated with increased risk of bacterial, fungal and viral infections. We present a case of cutaneous nocardiosis that occurred in a 61-year-old man, whose Crohn's disease was treated for nearly 1.5 years with infliximab. Prompt therapy with trimethoprim-sulfamethoxazole led to complete resolution. Only few cases of nocardiosis complicating anti-TNF therapy are reported in the literature. We present the case report and summary of the available literature with updates on the management and the treatment of the disease.
    The American Journal of the Medical Sciences 03/2013; 346(2). DOI:10.1097/MAJ.0b013e3182883708 · 1.39 Impact Factor
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