Volume 12, Issue 3 (9-2024)                   JoMMID 2024, 12(3): 235-242 | Back to browse issues page

XML Print

Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Ashraf A A, Bhat U. P. Nocardiosis: An Essential Diagnostic Challenge in Suspected Pulmonary Tuberculosis. JoMMID 2024; 12 (3) :235-242
URL: http://jommid.pasteur.ac.ir/article-1-666-en.html
Nocardiosis: An Essential Diagnostic Challenge in Suspected Pulmonary Tuberculosis
Asem Ali Ashraf , Pratibha Bhat U. *
Nitte (Deemed to be University), KS Hegde Medical Academy (KSHEMA), Department of Microbiology, Mangalore, Karnataka, India
Abstract:   (116 Views)
Introduction: Nocardiosis is a globally recognized opportunistic infection that predominantly affects immunocompromised individuals, leading to a diverse range of clinical manifestations, from cutaneous to severe systemic forms. The similarity of pulmonary nocardiosis symptoms to those of pulmonary tuberculosis often leads to misdiagnosis, presenting a significant diagnostic challenge for clinicians. We present an illustrative case of a 48-year-old male, newly diagnosed with HIV, who exhibited symptoms initially suggestive of pulmonary tuberculosis but was subsequently diagnosed with pulmonary nocardiosis. Methods: Bronchoalveolar lavage (BAL) fluid samples were obtained and subjected to microbiological culture, Gram staining, and modified acid-fast (Ziehl-Neelsen) staining for the identification of Nocardia species. Results: Gram staining of BAL fluid revealed thin, branched, beaded, filamentous, Gram-positive bacilli. Modified acid-fast staining identified branching acid-fast bacilli (1-2 organisms per high-power field (HPF)), consistent with Nocardia. Diagnosis of Nocardia is crucial as it necessitates targeted therapy, particularly in immunocompromised hosts. Nocardia was cultured after one week, highlighting its slow growth characteristic, which can delay diagnosis and treatment. The patient was commenced on trimethoprim-sulfamethoxazole (800/160 mg four times daily), showing significant clinical improvement within two weeks. After 12 months of treatment, there was complete resolution of symptoms, radiological improvement, and normalization of laboratory parameters, indicating successful treatment of pulmonary nocardiosis. Conclusion: Pulmonary nocardiosis must be considered in immunocompromised patients with persistent respiratory symptoms. Comprehensive imaging and bronchoscopy with BAL are pivotal for effective sample collection and accurate laboratory diagnosis. Modified Ziehl-Neelsen staining is critical for the definitive identification of Nocardia infection. Early and proactive screening in high-risk groups, such as HIV patients, cancer patients, or organ transplant recipients, is crucial for the prompt initiation of targeted therapy, typically with trimethoprim-sulfamethoxazole, to improve outcomes.
Keywords: Nocardia species, pulmonary nocardiosis, immunocompromised, diagnostic challenge, tuberculosis mimic, BAL fluid analysis, acid-fast staining, HIV-related infections
Full-Text [PDF 725 kb]   (68 Downloads)    
Type of Study: Case Report | Subject: Infectious diseases and public health
Received: 2024/04/14 | Accepted: 2024/09/11 | Published: 2024/12/22
References
1. U.S. Centers for Disease Control and Prevention (CDC). (2024, May 2). About Nocardiosis. United States Government. Accessed 2024, November 5. Retrieved from: https://www.cdc.gov/nocardiosis/about/index.html
2. U.S. Centers for Disease Control and Prevention (CDC). (2024, May 2). Clinical Overview of Nocardiosis. United States Government. Accessed 2024, November 5. Retrieved from: https://www.cdc.gov/nocardiosis/hcp/clinical-overview/index.html
3. Guerra AC, Batista D, Aleixo MJ, Saraiva P, Aguas MJ. Disseminated Nocardiosis: A Successful Blind Strategy of Treatment in an HIV Infected Patient. Case Rep Infect Dis. 2015; 2015: 260640. [DOI:10.1155/2015/260640] [PMID] [PMCID]
4. González-Jiménez P, Méndez R, Latorre A. Pulmonary Nocardiosis. A case report. Rev Esp Quimioter. 2022; 35 Suppl 1: 114-116. [DOI:10.37201/req/s01.24.2022] [PMID] [PMCID]
5. Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ. Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy. Clin Microbiol Rev. 2006; 19 (2): 259-82. [DOI:10.1128/CMR.19.2.259-282.2006] [PMID] [PMCID]
6. Duggal SD, Chugh TD. Nocardiosis: A Neglected Disease. Med Princ Pract. 2020; 29 (6): 514-23. [DOI:10.1159/000508717] [PMID] [PMCID]
7. Engelbrecht A, Saad H, Gross H, Kaysser L. Natural Products from Nocardia and Their Role in Pathogenicity. Microb Physiol. 2021; 31 (3): 217. [DOI:10.1159/000516864] [PMID]
8. Arai MA, Ebihara I, Makita Y, Hara Y, Yaguchi T, Ishibashi M, et al. Isolation of nocobactin NAs as Notch signal inhibitors from Nocardia farcinica, a possibility of invasive evolution. J Antibiot (Tokyo). 2021; 74 (4): 255-9. [DOI:10.1038/s41429-020-00393-z] [PMID]
9. Abbasian L, Dehghan Manshadi SA, Hassan Nezhad M , Masoumzadeh N, Ghaderkhani S, Keyvanfar A, et al. A Case Report of Disseminated Nocardiosis in a Patient with HIV Infection: Concurrent Liver, Pulmonary, and Brain Involvements. Arch Clin Infect Dis. 2024; 19 (2): e140527. [DOI:10.5812/archcid-140527]
10. Gonzalez LM, Venkatesan R, Amador P, Sanivarapu RR, Rangaswamy B. TB or Not TB: Lung Nocardiosis, a Tuberculosis Mimicker. Cureus. 2024; 16 (3): e55412. [DOI:10.7759/cureus.55412]
11. Chen J, Zhou H, Xu P, Zhang P, Ma S, Zhou J. Clinical and radiographic characteristics of pulmonary nocardiosis: clues to earlier diagnosis. PLoS One. 2014; 9 (3): e90724. [DOI:10.1371/journal.pone.0090724] [PMID] [PMCID]
12. Restrepo A, Clark NM, Infectious Diseases Community of Practice of the American Society of Transplantation. Nocardia infections in solid organ transplantation: Guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation. Clin Transplant. 2019; 33: e13509. [DOI:10.1111/ctr.13509] [PMID]
13. Clark NM, Reid GE, AST Infectious Diseases Community of Practice. Nocardia infections in solid organ transplantation. Am J Transplant. 2013; 13 Suppl 4: 83-92. [DOI:10.1111/ajt.12102] [PMID]
14. Wilson JW. Nocardiosis: updates and clinical overview. Mayo Clin Proc. 2012; 87 (4): 403-7. [DOI:10.1016/j.mayocp.2011.11.016] [PMID] [PMCID]
15. Wadhwa T, Baveja U, Kumar N, Govil D, Sengupta S. Clinical manifestations of nocardiosis: study of risk factors and outcomes in a tertiary care hospital. J Lab Physicians. 2017; 9 (4): 288-95. [DOI:10.4103/JLP.JLP_111_16] [PMID] [PMCID]
16. De S, Desikan P. Pulmonary nocardiosis mimicking relapse of tuberculosis. BMJ Case Rep. 2009; 2009: bcr0620080233. [DOI:10.1136/bcr.06.2008.0233] [PMID] [PMCID]
17. Sakyi SA, Danquah KO, Ephraim RD, Enimil A, Frimpong V, Ahenkorah Fondjo L, et al. Evaluating the Contribution of Nocardia spp. and Mycobacterium tuberculosis to Pulmonary Infections among HIV and Non-HIV Patients at the Komfo Anokye Teaching Hospital, Ghana. Can J Infect Dis Med Microbiol. 2018; 2018: 2910198. [DOI:10.1155/2018/2910198] [PMID] [PMCID]
18. Hoza AS, Mfinanga SGS, Moser I, König B. Isolation, biochemical and molecular identification of Nocardia species among TB suspects in northeastern, Tanzania; A forgotten or neglected threat? BMC Infect Dis. 2017; 17 (1): 407. [DOI:10.1186/s12879-017-2520-8] [PMID] [PMCID]
19. Baio PVP, Ramos JN, dos Santos LS, Soriano MF, Ladeira EM, Souza MC, et al. Molecular identification of Nocardia isolates from clinical samples and an overview of human nocardiosis in Brazil. PLoS Negl Trop Dis. 2013; 7 (12): e2573. [DOI:10.1371/journal.pntd.0002573] [PMID] [PMCID]
20. Ekrami A, Khosravi AD, Samarbaf-Zadeh AR, Hashemzadeh M. Nocardia co-infection in patients with pulmonary tuberculosis. Jundishapur J Microbiol. 2014; 7 (12): e12495. [DOI:10.5812/jjm.12495] [PMID] [PMCID]
21. Gupta S, Grant LM, Powers HR, et al. Invasive Nocardia Infections across Distinct Geographic Regions, United States. Emerg Infect Dis. 2023; 29 (12): 2417-25. [DOI:10.3201/eid2912.230673] [PMID] [PMCID]
22. Deshmukh A, Kurup R, Nair A, Sugathan A, Nath AB, Ramachandran A. Uncommon and Unusual Pathogen - A Case of Pulmonary and Cutaneous Nocardiosis. J Med Sci Clin Res. 2020; 8 (11): 521-5.
23. Singh A, Sandhu RS, Agnihotri R, Kumar R, Jain S, Singh S. Pulmonary Nocardiosis: Clinical Profile, Diagnosis, and Outcome in Patients Presenting as Suspected Tuberculosis. Lung India. 2020; 37 (4): 306-10.
24. Lerner PI. Nocardiosis. Clin Infect Dis. 1996; 22 (6): 891-905. [DOI:10.1093/clinids/22.6.891] [PMID]
25. Georghiou PR, Blacklock ZM. Infection with Nocardia species in Queensland. A review of 102 clinical isolates. Med J Aust. 1992; 156 (10): 692-7. [DOI:10.5694/j.1326-5377.1992.tb121509.x] [PMID]
26. Gutiérrez C, Céspedes A, Legarraga P, Morales P, Chanqueo L. Infection by Nocardia cyriacigeorgica in a patient with HIV infection in the AIDS stage. Rev Chil Infectol. 2020; 37 (3): 322-6. [DOI:10.4067/s0716-10182020000300322] [PMID]
27. Manoharan H, Selvarajan S, Sridharan KS, Sekar U. Pulmonary Infections Caused by Emerging Pathogenic Species of Nocardia. Case Rep Infect Dis. 2019; 5184386. [DOI:10.1155/2019/5184386] [PMID] [PMCID]
28. Udhe KB, Pathak S, McCullum I, Jannat-Khah DP, Shadommy SV, Dykewicz CA, et al. Antimicrobial-Resistant Nocardia Isolates, United States, 1995-2004. Clin Infect Dis. 2010; 51 (12): 1445-8. [DOI:10.1086/657399] [PMID]
29. Weng SS, Zhang HY, Ai JW, Gao Y, Liu YY, Xu B, et al. Rapid Detection of Nocardia by Next-Generation Sequencing. Front Cell Infect Microbiol. 2020; 10: 13. [DOI:10.3389/fcimb.2020.00013] [PMID] [PMCID]
30. Lafont E, Conan PL, Rodriguez-Nava V, Lebeaux D. Invasive Nocardiosis: Disease Presentation, Diagnosis and Treatment - Old Questions, New Answers? Infect Drug Resist. 2020; 13: 4601-13. [DOI:10.2147/IDR.S249761] [PMID] [PMCID]
Add your comments about this article : Your username or Email:
CAPTCHA
Send email to the article author

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.