Letter to the Editor
Disseminated nocardiosis secondary to Nocardia otitidiscaviarum infection with fatal outcome
Nocardiosis diseminada de evolución fatal por Nocardia otitidiscaviarum
María Paniagua-Garcíaa,b,
, Zaira R. Palacios-Baenaa, María Dolores del Toro Lópeza
Corresponding author
a Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Virgen Macarena. Departamento de Medicina de la Universidad de Sevilla. Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
b Unidad Clínica de Medicina Interna, Hospital Universitario Virgen Macarena, Sevilla, Spain
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Palacios-Baena, María Dolores del Toro López" "autores" => array:3 [ 0 => array:4 [ "nombre" => "María" "apellidos" => "Paniagua-García" "email" => array:1 [ 0 => "maria.paniagua89@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Zaira R." 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Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad Clínica de Medicina Interna, Hospital Universitario Virgen Macarena, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding auhthor." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nocardiosis diseminada <span class="elsevierStyleItalic">de evolución fatal por Nocardia otitidiscaviarum</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 863 "Ancho" => 900 "Tamanyo" => 81247 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT scan image (lung window) showing empyema, lung nodules and fluid collections.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Nocardia</span> genus is a ubiquitous group of environmental bacteria that are transmitted by inhalation, direct inoculation or intake. <span class="elsevierStyleItalic">Nocardia</span> spp. is usually an opportunistic pathogen,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> especially affecting immunocompromised patients however, immunocompetent infections have been described in up to a third of cases.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Pulmonary nocardiosis<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,3</span></a> is the most common form of presentation, followed by the central nervous system (CNS).<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Due to slow bacterial growth, nocardiosis is difficult to diagnose. Serological tests are not yet available for clinical use, while Gram staining may be useful. Although CNS is primarily affected through hematogenous dissemination, <span class="elsevierStyleItalic">Nocardia</span> spp. is barely isolated in blood cultures.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report a case of disseminated nocardiosis in a 57-year-old male with a history of arterial hypertension, type 2 diabetes mellitus, dyslipidaemia, chronic obstructive pulmonary disease and revascularized ischaemic heart disease. The patient was not undergoing steroid treatment or other immunosuppressive treatment.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Two months earlier, the patient was admitted to hospital due to an increase in his basal dyspnoea and fever, showing pleural effusion on the chest radiograph in the lower half of the right hemithorax. Chest computed tomography (CT) showed no evidence of neoplastic disease or consolidation imaging. Thoracentesis was performed, obtaining 1000<span class="elsevierStyleHsp" style=""></span>cc of clear pleural fluid, meeting exudate criteria and negative culture. The patient evolved favourably and was discharged with a diagnosis of decompensated heart failure caused by respiratory infection.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient came again for persistent dyspnoea and fever. He presented with erythema, oedema and pain in the right costal area where thoracentesis had been performed. A chest CT scan was repeated, which revealed extensive right pleural effusion with diffuse thickening of the pleural layers, suggestive of empyema (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In addition, 2 fluid collections were seen in the right hemithorax (one extrapleural intrathoracic and another in the thoracic wall muscles) and multiple lung nodular images (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">A pleural drainage catheter was placed and both collections were drained. Pleural fluid of purulent characteristics was obtained, isolating <span class="elsevierStyleItalic">Nocardia otitidiscaviarum</span> sensitive to amikacin, trimethoprim/sulfamethoxazole (TMP-SMX) and linezolid in the cultures. No neoplastic cells were observed in the pleural fluid cytology. Treatment with intravenous TMP-SMX was initiated, but the clinical course was unfavourable, with fever and progressive respiratory failure. Four days later, the patient began with a low arousal level and left hemiparesis, evidencing multiple hypodense nodular lesions in the cranial CT, compatible with brain abscesses, with ring-shaped uptake. Given the clinical context, an hematogenous dissemination of <span class="elsevierStyleItalic">N. otitidiscaviarum</span> was suspected. Linezolid was added to the treatment, given its high capacity for cerebral penetration, and dexamethasone treatment was initiated. No treatment with amikacin was initiated due to its low lung and CNS diffusion capacity and the risk of nephrotoxicity. The patient continued with torpid evolution and finally died a few days later due to refractory respiratory failure. No cultures of the skin lesions were obtained.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Nocardiosis treatment<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> should be individualized, with sulfamides being the antimicrobial agents of choice, despite their bacteriostatic activity. Alternative treatment includes amikacin, carbapenems, ceftriaxone, cefotaxime, tetracyclines, quinolones, linezolid and amoxicillin-clavulanic acid. For most cases, initial combination therapy is recommended. In patients with CNS involvement, drugs with good penetration should be included, such as TMP-SMX and ceftriaxone, and in the case of severe nocardiosis, a third agent such as linezolid should be added. It is recommended to maintain the combination treatment until the antimicrobial susceptibility profile is available and until the patient shows clinical improvement and can subsequently simplify to monotherapy. As for the duration of treatment, it is usually prolonged to minimize the risk of relapse.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, we report a case of disseminated nocardiosis with pulmonary, cerebral and cutaneous involvement, with fatal outcome, and which we consider of special clinical interest when developing in an immunocompetent patient who only had diabetes mellitus as a triggering factor. A high index of suspicion, especially in weakened and comorbid patients, with adequate sampling for culture, can help early diagnosis, adequate treatment and mortality reduction.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Paniagua-García M, Palacios-Baena ZR, del Toro López MD. Nocardiosis diseminada por <span class="elsevierStyleItalic">Nocardia otitidiscaviarum</span> de evolución fatal. 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