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Nocardiosis Clinical Presentation

  • Author: George Kurdgelashvili, MD; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Feb 16, 2016
 

History

Clinical manifestations of nocardiosis depend on the site of infection.[7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19]

Primary cutaneous nocardiosis may present as cutaneous infection, lymphocutaneous infection, or subcutaneous infection. Cutaneous nocardiosis generally manifests as either cellulitis or, more likely, single or multiple nontender erythematous nodule(s) at the site of traumatic inoculation. These nodules occasionally drain purulent material. Lymphocutaneous nocardiosis manifests as similar lesions accompanied by ascending regional lymphadenopathy. The lymphadenopathy may also occasionally drain purulent material. N brasiliensis is the most common cause of progressive cutaneous and lymphocutaneous (sporotrichoid) disease.

Nocardial species can cause mycetoma, a chronic, swollen, purulence-draining, subcutaneous infection of the extremities, typically encountered in tropical areas of the world, but also has been reported from the southern United States, Central and South Americas, and Australia. It is usually ascribed to N brasiliensis.[17, 20]

Postoperative wound infections due to Nocardia species are rare, but case clusters of nosocomial transmission have been described.

Traumatic inoculation nocardial arthritis has occurred but is rare. This presents as a subacute or chronic monarthritis, typically involving the knee.

Traumatic inoculation or postoperative nocardial keratitis has been well described in Asia and travelers returning from Asia.

Traumatic inoculation nocardial endophthalmitis has also occurred in rare instances.

Pulmonary disease is the predominant clinical finding in most patients with nocardiosis.[10, 18] Pulmonary nocardiosis may be acute, subacute, or chronic. Clinical manifestations include inflammatory endobronchial masses or localized or diffuse pneumonias, which may be accompanied by cavitation, abscess formation, pleural effusion, or empyema. Symptoms in patients with nocardiosis are indistinguishable from those in patients with similar pulmonary infections of other microbial etiology. Cough with sputum production and fever are the dominant symptoms. At least 40% of patients with disseminated nocardiosis have pulmonary infection; therefore, the clinical presentation may be dominated by the pulmonary symptoms.

Patients with nocardiosis may present with deep abscess at any site, particularly in the lower extremities or the CNS. In patients with extra-CNS abscesses, fever and local symptoms predominate. Up to 25% of reported nocardiosis cases (other than those involving mycetoma) involve the CNS. When occurring in isolation, CNS nocardiosis manifests as a slowly progressive mass lesion, with a host of specific neurologic findings related to the specific location of the abscess. CNS nocardiosis is detected in up to 44% of disseminated nocardial infections.[21] In two thirds of patients with CNS nocardiosis, clinical findings indicate abscess with or without meningitis, including fever, headache, stiff neck, and/or altered mental status.

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Physical

The physical findings of nocardiosis also vary based on the site of infection.

Patients with primary cutaneous nocardiosis present with cellulitis, cutaneous nodules, nodules with ascending lymphadenopathy, or with a mycetoma that is clinically indistinguishable from similar infections due to other pathogens.

Patients with pulmonary nocardiosis present with findings of pulmonary consolidation with or without evidence of pleural effusions.

The presentation of disseminated nocardiosis depends on the sites of infection. Pulmonary findings frequently predominate. Local findings associated with metastatic abscesses may be present at almost any site but are typically in the lower extremities. The combination of pneumonia and lower-extremity abscess is particularly suggestive of nocardiosis, although this is not seen exclusively in nocardiosis. Patients with brain abscess may present with altered mental status, personality changes, or various localizing neurologic findings. Patients with meningitis present with fever, altered consciousness, and meningismus.

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Causes

Pulmonary and disseminated nocardiosis are clearly associated with immunocompromising conditions, with approximately 60% of cases of nocardiosis other than mycetoma occurring in individuals with some compromise of host defense systems. Conditions associated with an increased risk of pulmonary and disseminated nocardiosis include the following:

  • Chronic pulmonary disease: Although pulmonary nocardiosis has been described in association with various chronic pulmonary diseases, patients with pulmonary alveolar proteinosis are at particular risk.
  • Alcoholism
  • Cirrhosis
  • Lymphoreticular malignancy
  • Solid-organ transplantation [22]
  • Bone marrow or stem cell transplantation, particularly allogeneic transplantation with subsequent graft versus host disease
  • Long-term corticosteroid use or Cushing syndrome
  • Systemic lupus erythematosus
  • Systemic vasculitis
  • Ulcerative colitis
  • Sarcoidosis
  • Renal failure
  • Whipple disease
  • Hypogammaglobulinemia
  • Treatment with anti–tumor necrosis factor antibody
  • HIV infection and AIDS: Nocardiosis in individuals with advanced HIV disease usually presents as a relentlessly progressive infiltrative pulmonary infection. The median CD4 count in patients infected with HIV who develop nocardiosis is approximately 50 cells/µL. [15]
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Contributor Information and Disclosures
Author

George Kurdgelashvili, MD Clinical Associate Professor of Medicine, Department of Medicine, University of Oklahoma College of Medicine; Assistant Chief of Medical Service, Director of Diagnostic Center Clinic, Chair of Infection Prevention and Control Committee, Attending Physician, Infectious Diseases Section, Oklahoma City Veterans Affairs Medical Center

George Kurdgelashvili, MD is a member of the following medical societies: Infectious Diseases Society of America, HIV Medicine Association, Veterans Affairs Society of Practitioners in Infectious Diseases

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center

John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, Association of Subspecialty Professors, American Society for Microbiology, Infectious Diseases Society of America, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Thomas J Marrie, MD Dean of Faculty of Medicine, Dalhousie University Faculty of Medicine, Canada

Thomas J Marrie, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, Association of Medical Microbiology and Infectious Disease Canada, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

References
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  2. Euzeby Jean P. List of prokaryotic names with standing in nomenclature. www.bacterio.net/. Available at http://www.bacterio.net/-allnamesmr.html. Accessed: 11/20/2014.

  3. Beaman BL, Beaman L. Nocardia species: host-parasite relationships. Clin Microbiol Rev. 1994 Apr. 7(2):213-64. [Medline].

  4. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/nocardiosis/infection. Accessed: June 7, 2013.

  5. Smego RA Jr, Moeller MB, Gallis HA. Trimethoprim-sulfamethoxazole therapy for Nocardia infections. Arch Intern Med. 1983 Apr. 143(4):711-8. [Medline].

  6. Lavalard E, Guillard T, Baumard S, Grillon A, Brasme L, Rodríguez-Nava V, et al. Brain abscess due to Nocardia cyriacigeorgica simulating an ischemic stroke. Ann Biol Clin (Paris). 2013 Jun 1. 71(3):345-348. [Medline].

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  9. Filice GA. Nocardiosis in persons with human immunodeficiency virus infection, transplant recipients, and large, geographically defined populations. J Lab Clin Med. 2005 Mar. 145(3):156-62. [Medline].

  10. Hui CH, Au VW, Rowland K, Slavotinek JP, Gordon DL. Pulmonary nocardiosis re-visited: experience of 35 patients at diagnosis. Respir Med. 2003 Jun. 97(6):709-17. [Medline].

  11. Kilincer C, Hamamcioglu MK, Simsek O, et al. Nocardial brain abscess: review of clinical management. J Clin Neurosci. 2006 May. 13(4):481-5. [Medline].

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  14. Matulionyte R, Rohner P, Uckay I, et al. Secular trends of nocardia infection over 15 years in a tertiary care hospital. J Clin Pathol. 2004 Aug. 57(8):807-12. [Medline].

  15. Pintado V, Gomez-Mampaso E, Cobo J, et al. Nocardial infection in patients infected with the human immunodeficiency virus. Clin Microbiol Infect. 2003 Jul. 9(7):716-20. [Medline].

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  17. Pilsczek FH, Augenbraun M. Mycetoma fungal infection: multiple organisms as colonizers or pathogens?. Rev Soc Bras Med Trop. 2007 Jul-Aug. 40(4):463-5. [Medline].

  18. Martinez Tomas R, Menendez Villanueva R, Reyes Calzada S, et al. Pulmonary nocardiosis: risk factors and outcomes. Respirology. 2007 May. 12(3):394-400. [Medline].

  19. Rosman Y, Grossman E, Keller N, Thaler M, Eviatar T, Hoffman C, et al. Nocardiosis: A 15-year experience in a tertiary medical center in Israel. Eur J Intern Med. 2013 May 29. [Medline].

  20. Lerner PI. Nocardiosis. Clin Infect Dis. 1996 Jun. 22(6):891-903; quiz 904-5. [Medline].

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  22. Peleg AY, Husain S, Qureshi ZA, et al. Risk factors, clinical characteristics, and outcome of Nocardia infection in organ transplant recipients: a matched case-control study. Clin Infect Dis. 2007 May 15. 44(10):1307-14. [Medline].

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  24. Brown-Elliott BA, Biehle J, Conville PS, Cohen S, Saubolle M, Sussland D. Sulfonamide resistance in isolates of Nocardia spp. from a US multicenter survey. J Clin Microbiol. 2012 Mar. 50(3):670-2. [Medline].

  25. Minero MV, Marin M, Cercenado E, Rabadan PM, Bouza E, Munoz P. Nocardiosis at the turn of the century. Medicine (Baltimore). 2009 Jul. 88(4):250-61. [Medline].

 
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High-power microscopic appearance of Nocardia. Image courtesy of CDC.
Photomicrograph of tissue biopsy stained with Gomori methenamine silver demonstrating acute inflammatory response and organisms compatible with Nocardia.
Plain chest radiograph in a patient with nocardiosis. Image courtesy of Applied Radiology, Anderson Publishing, LTD.
Chest CT scan in a patient with pleuropulmonary nocardiosis. Image courtesy of Applied Radiology, Anderson Publishing, LTD.
Brain CT scan in a patient with nocardial brain abscess. Image courtesy of Applied Radiology, Anderson Publishing, LTD.
 
 
 
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