Presentation
History
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Generalized nocardiosis
- In patients with cutaneous disease, elicit history of trauma at the site of mycetoma (eg, scrape from thorn), firm subcutaneous abscesses (eg, cat scratch, insect bite, open cut), and/or cervical adenitis (eg, dental injury). Signs of infection tracking along lymph node chains or a draining sinus may be present.
- Slowly progressive joint swelling and pain, with or without fever, may occur, resulting in Nocardia septic arthritis if the trauma was deep (eg, puncture from rooster's claw).
- The pulmonary course begins with nonspecific complaints, including fever (night sweats), malaise, chest or abdominal pain (may be sudden onset), persistent cough (rarely hemoptysis), and anorexia.
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Disseminated nocardiosis
- If dissemination occurs from a pulmonary infection, a constellation of acute and chronic symptoms develops, ranging from headache to obtundation (CNS), pyuria (kidneys), and right upper abdominal pain (liver). CNS infection may have no signs or symptoms or may present with focal neurological deficits, seizures, and coma.
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Children at risk for nocardiosis as an opportunistic infection include patients with the following:
- Lymphoreticular neoplasms
- Chronic pulmonary disorders (most notably alveolar proteinosis)
- Prolonged corticosteroid usage
- Systemic lupus erythematosus
- Severe asthma
- Chronic granulomatous disease
- Children with acquired immune deficiency syndrome (AIDS)
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Patients undergoing transplant for the following are at risk:
- Renal
- Cardiac
- Liver
- Bone marrow
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Physical
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Subcutaneous abscesses are palpable at the site of trauma and generally feel firmer than fluctuant. Contiguous lymph nodes may indicate infection tracking along lymphatics.
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A lung examination may reveal diffuse or localized abnormal breath sounds.
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Mild-to-severe respiratory distress that progresses to respiratory failure may occur.
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Disseminated miliary appearance can occur with diffuse organ abscesses that mimic miliary tuberculosis.
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Clinical manifestations may include the following:
- Bronchopneumonia
- Lobar pneumonia
- Necrotizing pneumonia
- Persistent meningitis
- Cerebral abscesses
- Peritonitis
- Intra-abdominal abscesses
- Hematogenous endophthalmitis
- Sinusitis
- Endocarditis
- Aortitis
- Mediastinitis
- Pyelonephritic abscesses
- Septic arthritis
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Causes
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Nocardia are usually found in soil and dust, and infection results from inoculation of a wound or inhalation. Person-to-person transmission has not been reported, and Nocardia are not commensal in humans or animals.
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Nosocomial cases have been reported. In some cases, N asteroides were detected in the dust and air of the hospital unit.
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