MD Nexus

Nocardiosis

Epidemiology

Risk Factors

General Comments

  • In a Literature Review of >1,000 Cases, Approximately 64% of Nocardia Cases were Immunocompromised (Clin Microbiol Rev, 1994) [MEDLINE]

Defect in T-Cell Mediated Immunity

  • General Comments
    • Defect in T-Cell Mediated Immunity is Main Risk Factor for Nocardia Infection
  • Clinical Types of Defects in T-Cell Mediated Immunity
    • Corticosteroid Use (see Corticosteroids)
    • Cushing Syndrome (see Cushing Syndrome)
    • Diabetes Mellitus (see Diabetes Mellitus)
    • Hematopoietic Cell Transplant (HSCT) (see Hematopoietic Cell Transplant)
    • Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) (see Human Immunodeficiency Virus)
      • Especially with CD4 Count is <100 Cells/mm3)
    • Lymphoreticular Malignancy
    • Malignancy
      • Especially Following Chemotherapy and/or Glucocorticoid Therapy
    • Solid Organ Transplant
      • Liver Transplant (see Liver Transplant)
        • In Organ Transplant Patients, History of Cytomegalovirus, Receipt of High-Dose Glucocorticoids, and High Calcineurin Inhibitor Levels were Indepednent Risk Factors for Nocardiosis (Clin Infect Dis, 2007)[MEDLINE]
      • Renal Transplant (see Renal Transplant) (Transpl Infect Dis, 2011) [MEDLINE]
        • In Organ Transplant Patients, History of Cytomegalovirus, Receipt of High-Dose Glucocorticoids, and High Calcineurin Inhibitor Levels were Indepednent Risk Factors for Nocardiosis (Clin Infect Dis, 2007)[MEDLINE]

Granulocyte Defect

Immunoglobulin Defect

  • General Comments
    • Immunoglobulin Defect is a Lesser Risk Factor for Nocardiosis

Other

Microbiology

Nocardia Species

Taxonomy

Origin

Features

Physiology

Clinical Manifestations

Pulmonary Manifestations

Segmental or Lobar Pneumonia (see Pneumonia)

  • Epidemiology
    • Symptoms May Be Present for Weeks Prior to Presentation
    • Immunosuppressed Patients May Have Fulminant Presentation
  • Diagnostic
    • Sputum Gram Stain/Culture and Sensitivity (see Sputum Culture): although Nocardia frequently colonizes the respiratory tract, culturing the organism from sputum is highly predictive of infection
    • Bronchoscopy (see Bronchoscopy)
      • Useful to Obtain DIagnostic Specimens (and Rule Out Any Component of Endobronchial Disease)
  • Clinical
  • Treatment
    • Early Treatment May Prevent Cavitation and Dissemination

Solitary or Multiple Lung Nodules Which May Cavitate (see Lung Nodule or Mass and Cystic-Cavitary Lung Lesions)

Endobronchial Lesions (with/without Pneumonia)

  • Epidemiology
    • Case Reports of Endobronchial Nocardiosis (Eur Respir J, 1994) [MEDLINE] (Mt Sinai J Med, 2006) [MEDLINE]
  • Diagnosis
  • Clinical
    • XXXX

Lung Abscess (see Lung Abscess)

  • Epidemiology
    • Occurs in Some Cases
  • Diagnosis
    • Suppurative (Non-Granulomatous)

Interstitial Pneumonia/Miliary Infiltrates (see Interstitial Lung Disease)

  • Epidemiology
    • Interstitial Pneumonia Occurs in Some Cases

Pleural Effusion (see Pleural Effusion-Exudate)

  • Epidemiology
    • Pleural Effusion Occurs in 50% of Nocardia Cases (Almost Always in Association with Parenchymal Infiltrates)
  • Diagnosis
    • Pleural Fluid
      • Appearance: ranges from serous fluid to frank pus
      • Aerobic Culture: culture may be positive or negative (grows slowly, may take up to 3 weeks to grow out)

Disseminated Nocardiosis

General Comments

  • Disseminated Nocardiosis is Defined as 2 Noncontiguous Anatomic Sites of Involvement Which May or May Not Include a Pulmonary Focus (Clin Infect Dis, 1996) [MEDLINE]
    • Nocardia Can Disseminate from a Pulmonary or Cutaneous Focus to Almost Any Organ (Medicine-Baltimore, 1998) [MEDLINE] (Medicine-Baltimore, 2004) [MEDLINE]
    • Although Dissemination is Presumed to Result from Hematogenous Spread, Identifying Nocardia in Blood Cultures is Uncommon Due, in Part, to the Fastidious Nature of the Organism (Medicine-Baltimore, 1998) [MEDLINE]
      • To Maximize the Yield for Recovery of Nocardia, Blood Cultures Should Be Incubated for Approximately 4 wks
  • In Cases Where the Original Focus of Nocardia Infection Cannot Be Ascertained, it is Presumed that Resolved Pulmonary or Cutaneous Disease was the Original Source

Cardiovascular Manifestations

  • Endocarditis (see xxxx)
    • Epidemiology
      • Especially Associated with Prosthetic Heart Valves

Dermatologic Manifestations

  • Clinical
    • Subcutaneous Skin Abscess with/without Sinus Tract (see Skin Abscess)
      • Diagnosis
        • Suppurative (Non-Granulomatous)

Endocrinologic Manifestations

  • Clinical
    • Adrenal Abscess (Diagn Microbiol Infect Dis, 1996) [MEDLINE]
    • Thyroiditis (J Clin Microbiol, 1999) [MEDLINE]

Gastrointestinal/Hepatic Manifestations

Hematologic Manifestations

Infectious Manifestations

  • Bacteremia (see Bacteremia)
    • Epidemiology
      • Nocardia Bacteremia Occurs Rarely (Int J Infect Dis, 2020) [MEDLINE]
        • Blood Cultures are the Positive in Only 38% of Cases (Int J Infect Dis, 2020) [MEDLINE]
      • In a Systematic Review of 138 Disseminated Nocardia Cases from 1999-2018, 81% of Patients were Immunocompromised (Int J Infect Dis, 2020) [MEDLINE]
        • Corticosteroids (49% of Cases)
        • Hematologic Malignancy (20% of Cases)
        • Solid Organ Transplant (20% of Cases)
        • Solid Organ Malignancy (19% of Cases)
        • Hematopoietic Stem Cell Transplant (15% of Cases)
        • Endovascular Device (29% of Cases)
    • Diagnosis
      • In a Literature Review of 36 Nocardia Bacteremia Cases, Approximately 30% of Cases Had Concomitant Bacteremia with Other Pathogens (Predominantly Gram-Negative Organisms) (Medicine-Baltimore, 1998) [MEDLINE]
    • Clinical
      • Pulmonary Infection is the Most Common Concurrent Site of Clinical Disease (67% of Cases) (Int J Infect Dis, 2020) [MEDLINE]
      • The Clinical Presentation and Risk Factors for Disseminated Nocardiosis are Similar to in Both Bacteremic and Non-Bacteremic Cases
        • The Only Unique Risk Factor for Nocardia Bacteremia is the Presence of an Endovascular Device (Medicine-Baltimore, 1998) [MEDLINE] (J Clin Pathol, 2004) [MEDLINE]
        • In One Study, 10/17 Cases of Nocardia Bacteremia in Cancer Patients were Associated with the Presence of a Central Venous Catheter (Emerg Infect Dis, 2011) [MEDLINE]
    • Prognosis
      • Nocardia Bacteremia is Associated with a High Mortality Rate (Int J Infect Dis, 2020) [MEDLINE]
        • Thirty-day all-cause mortality: 28%
        • Overall All-Cause Mortality Rate: 40%

Neurologic Manifestations

Ophthalmologic Manifestations

  • Clinical
    • Keratitis (see Keratitis) (Cornea, 2007)[MEDLINE] (Am J Ophthalmol, 2007) [MEDLINE]
      • Associated with Primary Infection Involving Direct Inoculation of Nocardia Organisms into the Eye
    • Endophthalmitis (see Endophthalmitis) (Am J Ophthalmol, 2007) [MEDLINE]
      • Associated with Primary Infection Involving Direct Inoculation of Nocardia Organisms into the Eye
      • Nocardia Endophthalmitis Following Cataract Surgery is Associated with Poor Visual Outcomes
    • Ocular Involvement

Otolaryngologic

  • Clinical
    • Sinusitis (see xxxx) (Clin Infect Dis, 1995) [MEDLINE]

Renal Manifestations

  • Clinical
    • XXXXXXX

Reproductive Manifestations

Rheumatologic/Orthopedic Manifestations

Other Manifestations

Prevention

Sulfamethoxazole-Trimethoprim (Bactrim, Septra) Prophylaxis (see Sulfamethoxazole-Trimethoprim)

Treatment

Antibiotics

Treatment of Choice

Alternative Antibiotics

Combination Therapy

Duration of Therapy

Drainage of Abscesses/Empyema

Prognosis

References

Epidemiology

Microbiology

Clinical Manifestations

Treatment