CME INDIA Case Presentation by Dr Nishith Kumar, Pulmonologist, Ranchi.

CME INDIA Case Study:

  • 46yr/Male, old history of Bilateral Bronchiectasis
  • with c/o Cough, Chest Pain, Fever, Malaise & progressive breathlessness for last 3 weeks…

Breathlessness for 3 weeks - scan

  • Total Serum IgE, CBC, LFT, KFT – WNL
  • HIV – Negative
  • Sputum MTB CBNAAT – Negative
  • SpO2 – 84% on Room Air
  • Temp 102 deg F

Breathlessness for 3 weeks - scan

CT guided Pus Aspiration done from peripherally situated necrotic lung parenchyma

Pus bacterial culture – sterile, GeneXpert – MTB not detected

Breathlessness for 3 weeks - scan

Breathlessness for 3 weeks - scan

Aspirated Pus 1% AFB Stain


Can you think of a Spot diagnosis?

Dr Noni G Singha,Dibrugarh

Pulmonary Nocardiosis

Dr V P Youmash, Assistant Professor, KAPV Medical College: Nocardiosis?

Dr Manoj Saini, MD Medicine & Dy Physician to President: Actinomycosis or Nocardiosis may be.

Dr T R Hem Kumar, Diabetologist, Bengaluru: Nocardia.

Dr Dhiraj: Nocardia! Sir? d/d Actinomyces.

Dr Pawan: Aspergillus.

Dr Gaurabh Gupta, New Delhi: Nocardia.

Dr Nishith Kumar, Pulmonologist, Ranchi: * Final Diagnosis: Pulmonary Nocardiosis *😃


CME INDIA Learning Points

(By Dr Nishith Kumar, Pulmonologist, Ranchi)

  • Nocardiosis is a neglected tropical disease. Unless suspected, diagnosis can be easily missed resulting in increased morbidity and mortality. That’s why early recognition & effective therapy is very important to achieve successful outcomes.
  • Although nocardiosis typically occurs in patients with immunosuppressive conditions, infection may occasionally develop in immunocompetent patients as well. People having COPD, Bronchiectasis, Pulmonary Alveolar Proteinosis etc. or those on immunosuppressive therapy are susceptible for developing Pulmonary Nocardiosis.
  • Nocardial infections are transmitted either by inhalation, ingestion, or inoculation; inhalation is considered the most common route. It has been broadly classified as pulmonary, central nervous system, cutaneous, or disseminated nocardiosis depending on the location
  • The radiological manifestations of pulmonary nocardiosis are infiltration, ground‐glass shadow, cavity, and pleural effusion.
  • Clinical symptoms and signs are subtle and nonspecific & many a time mimics other common infection especially Pulmonary Tuberculosis.
  • Whenever suspected adequate sample (Sputum/Pus/BAL etc.) should be submitted for microbiological evaluation. On Gram stain, Nocardia appears as thin (<1 μm in diameter) and long bacilli with right-angle branching and with tiny noncontiguous gram-positive beads of varying sizes.
  • 1%AFB stain may show filamentous acid-fast bacilli.
  • TMP–SMX is the first‐line treatment for pulmonary nocardiosis. Treatment varies between 6-12months. However, in severe disease initial combination drug therapy is recommended.


CME INDIA Tail Piece

Breathlessness for 3 weeks - scan

Quick Scan

  • An opportunistic infection
  •  An aerobic actinomycetes
  • Gram positive branching filamentous bacteria
  • Weakly acid fast (1% H2So4)
  • First isolated by Edmond Nocard in the year 1888
  • Present ubiquitously in the soil/water/organic matter.
  • Not a normal commensal of the human body.

Clinical manifestations

  • Disseminated Nocardiosis
  • 50% of pulmonary nocardiosis have evidence of dissemination
  • 20% of disseminated nocardiosis can occur without pulmonary involvement
  • Localized nocardiosis
  • Pulmonary (Most common)
  • Isolated CNS
  • Isolated cutaneous (Cellulitis, lymphocutaneous, actinomycetoma)
  • Ophthalmic involvement (keratitis, endophthalmitis)

Imaging characteristics

A great mimicker. Can have a plethora of imaging findings.

  • Most common CT findings
    • Consolidation (with or without breakdown)
    • Nodules (Solitary or multiple). May also cavitate
    • Masses (Solitary or multiple)
  • Less common CT findings
    • Pleural thickening / effusion (10-30%)
    • Mediastinal lymphadenopathy (10%)
    • Chest wall invasion
    • Crazy paving appearance (Case reports)
    • Bronchiectasis

Direct Smear examination

  • Gram positive beaded filaments
  • Acid fast (weak)

Culture

  • Grow on most fungal and mycobacterial media
  • Need 2-8 weeks for isolation
  • Laboratory should be intimated prior whenever nocardiosis is suspected so as to maximize the likelihood of isolation
  • Drug sensitivity testing – Several methods (Microbroth dilution testing)

Treatment

  • Trimethoprim Sulphamethoxazole:
  • First drug of choice
  • Dose- Trimethoprim 5-10 mg/kg/day and sulpha 25-50 mg/kg/day
  • Resistance common in N.otitidiscaviarum, N.Nova and N. farcinica
  • Linezolid:
  • All isolates are susceptible
  • Long term side effects are a major problem (cytopenias, peripheral neuropathy, optic neuropathy, metabolic acidosis)

Duration of Treatment:

  • Immunocompetent:
    • Pulmonary: 6-12 months
    • CNS: 12 months
    • Isolated cutaneous: 2 months
  • Immunosuppressed:
    • At least 12 months
    • (maintenance treatment may be needed in patients who remain to be immunosuppressed)


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