|Year : 2008 | Volume
| Issue : 2 | Page : 92-95
Pulmonary nocardiosis in a HIV infected patient
SD Kulkarni1, VP Baradkar2, S Kumar2
1 Yerla Medical Trust, Sector-4, Kharghar, Navi Mumbai - 410 210, India
2 Department of Microbiology,L.T.M.M.C, Sion, Mumbai, India
S D Kulkarni
Yerla Medical Trust, Sector-4, Kharghar, Navi Mumbai - 410 210
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Nocardia infections rarely occur in normal individuals. Most infections occur in an immunocompromised host. Here we report a case of pulmonary Nocardiosis due to Nocardia asteroides in an HIV-infected person presenting as a cavitatory lesion in the lungs.
Keywords: HIV infection, pulmonary nocardiosis, cavitatory lesions
|How to cite this article:|
Kulkarni S D, Baradkar V P, Kumar S. Pulmonary nocardiosis in a HIV infected patient. Indian J Sex Transm Dis 2008;29:92-5
|How to cite this URL:|
Kulkarni S D, Baradkar V P, Kumar S. Pulmonary nocardiosis in a HIV infected patient. Indian J Sex Transm Dis [serial online] 2008 [cited 2020 Jul 5];29:92-5. Available from: http://www.ijstd.org/text.asp?2008/29/2/92/48733
| Introduction|| |
Nocardia is a Gram positive actinomycete that is found worldwide in soil and decaying matters. Nocardia asteroides is the commonest species isolated from clinical specimens.  Human infection is rare and contracted through inhalation.  Infection is more common in immunocompromised hosts, ,,,,,, specially with impaired cell-mediated immunity. It has been reported in patients with HIV infection. , Unless investigations like Gram's stain and Modified Acid Fast stain are specially done, pulmonary infections may be mistaken for Tuberculosis.  We report a case of pulmonary nocardiosis due to Nocardia asteroides mimicking cavitatory pulmonary tuberculosis.
| Case report|| |
A 40-year-old male presented with a history of cough since three months, associated with anorexia and fever. He complained of weight loss for the same duration. Cough had become productive since the last 15 days. On examination, he was found to be moderately built. There were no signs suggestive of anemia, jaundice, cyanosis, or foot edema. There were no palpable lymph nodes. The patient was nondiabetic. There was no history suggestive of collagen disorders or long-term steroid administration. His pulse was 84/min and blood pressure was 120/80 mm of Hg. Respiratory rate was 20/min and he had a fever of 100° F. His hemoglobin was 10 gm% and WBC counts were 4800/mm 3 with a differential count of 80% polymorphs and 20% lymphocytes. Liver function and kidney function tests were within normal range. The patient was HIV seropositive by microwell plate Enzyme-Linked Immunosorbent Assay (ELISA) and Tridot. A chest X ray showed a small cavity in the left upper zone [Figure 1]. Sputum examination by the Ziehl Neelsen staining using 25% sulfuric acid as decoloriser did not show any acid fast bacilli. Gram-stained smears of sputum showed branched, beaded, gram-positive filaments. Modified Ziehl-Neelsen (ZN)-stained smears, with 1% sulfuric acid as a decolorizing agent, showed acid fast filaments [Figure 2]. Sputum was cultured on Sabouraud's Dextrose agar (SDA), Brain Heart Infusion Agar (BHIA), and Lowenstein Jensen's media (LJ), and incubated at 37° C. In the first week the cultures were observed daily for growth, followed by twice a week. The growth on SDA, BHIA, and LJ media appeared on the eighth day with orange colonies [Figure 3]. The growth was confirmed by Gram staining, modified ZN staining, and urease activity. The patient was started on Cotrimoxazole (SMX 3200 mg + TMP 640 mg) per day in two divided doses to which he responded well.
| Discussion|| |
Nocardia are ubiquitous in the environment and can be found worldwide as saprophyte components in fresh and salt water, soil, dust, decaying vegetation, and decaying fecal deposits from animals.  Some species are more prevalent in geographical locations with a specific climate. The most common manifestation of nocardial disease is pulmonary nocardiosis, occurring most frequently in immunocompromised patients. One half of all cases of pulmonary nocardiosis also involve infections in areas other than the lungs, and approximately 20% of the patients with disseminated diseases present solely with extrapulmonary disease, which has usually spread hematogenously from an asymptomatic or healed primary site. Extrapulmonary local extensions may also occur from lungs, resulting in purulent pericarditis, mediastinitis, and/ or superior vena caval syndrome. Nocardia species (bacteremia) is unusual, but has been reported to result from pulmonary or extrapulmonary sites of initial infection. Other common sites of nocardial dissemination include skin, subcutaneous tissue, and central nervous system (CNS). Many cases of disseminated nocardiosis are associated with CNS disease. Patients with CNS disease usually have one or more brain abscesses. , Meningitis is a less common manifestation of the disease. 
Unlike pulmonary or disseminated nocardiosis, pulmonary cutaneous nocardiosis is usually seen in immunocompetent hosts. ,,,,,,,, Primary cutaneous infection usually presents as lymphocutaneous infection, superficial cellulitis, or a localized abscess, and usually involves the face in children or the lower extremities in adults. Mycetoma is a late stage infection and is characterized by a chronic, localized, slowly progressive, often painless, subcutaneous and bone disease usually involving the foot. 
Currently there are more than 30 species of Nocardia of human clinical significance, with the majority of isolates being Nocardia asteroids, Nocardia brasiliensis, Nocardia nova ex, Nocardia farcinia, and Type VI ( Nocardia cyriacigeorgica ) , which have been reported to cause brain abscess. 
Pulmonary nocardiosis is subacute or chronic pneumonia caused mostly by Nocardia asteroids complex, other species being Nocardia brasiliensis . Pulmonary infection is usually acquired by direct inhalation of Nocardia species from contaminated soil and person-to-person transmission is rare.  Pulmonary nocardiosis usually occurs in immunocompromised patients such as those suffering from lymphoreticular malignancies, Cushing's disease, organ transplant recipients, persons receiving high-dose steroids, chronic alcoholism, diabetes mellitus, and AIDS. , Menendez et al .  reported 10 cases of pulmonary nocardiosis from Spain. Chronic obstructive pulmonary disease (COPD), neoplastic disease, and HIV infection were the underlying predisposing factors. The disease remained localized in five cases. In the other five cases the disease disseminated, affecting subcutaneous tissue, the CNS, and kidneys. Three patients died, one with disseminated disease and two others who were receiving steroids. Mari et al .,  in the year 2001, also reported 10 cases of pulmonary disease. The underlying diseases observed were COPD in six cases, HIV infection in three cases and polymyalgia rheumatica in one case. The infection was restricted to the lungs in nine cases, while in one case the CNS and subcutaneous tissue were affected. Resolution was achieved with Cotrimoxazole in five cases. Four patients died: one HIV patient with disseminated disease and three COPD patients, two of whom had received corticosteroid therapy.
Despite the association between the loss of cell-mediated immunity and nocardial infection, AIDS patients rarely develop symptomatic infection. The incidence varies between 0.19 and 2%. 
Subhash et al .,  in the year 2001, reported a case of pulmonary nocardiosis in a HIV-infected person. It was initially misdiagnosed as pulmonary tuberculosis, since the clinical manifestations were similar. The patient presented with fever, cough with expectoration, and weight loss since two months. A chest radiograph showed opacity in the right midzones. The patient was treated with cotrimoxazole.
Mathur et al .  reported three cases of pulmonary nocardiosis from Delhi in the year 2005. One patient was on steroid therapy for nephrotic syndrome, the second patient was on an immunosupressant therapy after renal transplantation, and the third patient was HIV positive. The diagnosis was initially suspected on Papanicolaou stain and Modified Ziehl Neelsen stain, and Gomori's silver methenamine stains were used to confirm the diagnosis.
The clinical presentation of Nocardiosis is variable and nonspecific with a chronic course. Patients often complain of low-grade fever, fatigue, malaise, anorexia, weight loss, and productive cough. It may mimic pulmonary tuberculosis in both, clinical symptoms and radiological characteristics.  In the present case history of fever, weight loss, malaise, and productive cough was present.
Chest radiographic manifestations are pleiomorphic and non specific-consolidations, large irregular nodules, often cavity are the most common. Upper lobes are most commonly involved. , In our case cavity was seen in upper left zone.
The treatment of choice for Nocardial infection includes sulfonamides and trimethoprim and sulpfamethoxazole, associated with surgical drainage when required.  Our patient responded well to trimethoprim and sulfamethoxazole. If patients do not respond to this regime, a combination of it, along with Amikacin and either Ceftriaxone or Imipenem is recommended. The recently introduced agent Linezolid offers an additional option with the advantage over Amikacin, Ceftriaxone, or Imipenem, which is administered orally. If patients are allergic to sulfonamides, a minocycline (400-600 mg/daily) regimen has also been successfully used in the treatment of pulmonary nocardiosis. 
The present case highlights the need for suspicion of pulmonary nocardiosis in immunocompromised patients, especially when clinical and radiological pictures mimic pulmonary tuberculosis, but the sputum is negative for AFB and the patient is not responding to antitubercular drugs.
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[Figure 1], [Figure 2], [Figure 3]