Scientific letter
Bacteremia by Nocardia farcinica
Bacteriemia por Nocardia farcinica
Laura Rodríguez Fernández
, Javier Miguel Martín Guerra, Inmaculada Gil González
Corresponding author
Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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They belong to the order of Actinomycetales, but unlike Actinomyces, they are partially acid-alcohol fast. They are considered environmental saprophytes, so they do not form part of the human or animal commensal flora. It is transmitted to humans mainly by inhalation or by traumatic inoculation through the skin and mucosa.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 77-year-old man, ex-smoker of 40 packs/year up to 3 years earlier, with a history of high-risk chronic obstructive pulmonary disease (COPD), exacerbation phenotype with emphysema, in regular treatment with aclidinium bromide, salmeterol and fluticasone. He presented with a 4-day history of dyspnoea, cough with purulent expectoration and fever. Physical examination revealed the presence of crackles in the lower third of the right hemithorax. Lab tests showed the presence of 23<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3<span class="elsevierStyleHsp" style=""></span></span>mm<span class="elsevierStyleSup">–3</span> white blood cells with neutrophilia, <span class="elsevierStyleSmallCaps">C</span> reactive protein (CRP) of 150<span class="elsevierStyleHsp" style=""></span>mg/l (normal value [NV] up to 5<span class="elsevierStyleHsp" style=""></span>mg/l) and procalcitonin of 1.04<span class="elsevierStyleHsp" style=""></span>ng/ml (NV up to 0.5<span class="elsevierStyleHsp" style=""></span>ng/ml). The radiograph showed a consolidation in the right lower lobe. Blood cultures were taken and empirical treatment with levofloxacin was started with the diagnosis of community-acquired pneumonia. Nocardia farcinica isolates were detected in the blood culture. In accordance with the diagnosis of <span class="elsevierStyleItalic">N. farcinica</span> bacteraemia secondary to pulmonary foci, treatment with trimethoprim-sulfamethoxazole (TPM-SMX), imipenem (1<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h IV) and amikacin 15<span class="elsevierStyleHsp" style=""></span>mg/kg/12<span class="elsevierStyleHsp" style=""></span>h IV) was initiated, with resolution of bacteraemia in 4 weeks. Subsequently, sequential treatment with ciprofloxacin, linezolid and TPM-SMX was prescribed for an additional 20 weeks, with no recurrences during follow-up.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Nocardiosis is a rare, life-threatening opportunistic infection that can cause localized or disseminated disease. The main risk factor for its development is cell immunosuppression; however, cases have been described in immunocompetent patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Suffering from chronic lung disease with an underlying immunosuppression is the most common clinical setting in <span class="elsevierStyleItalic">Nocardia</span> spp. infections. Within it, COPD in patients with chronic exposure to corticosteroids is the most described association in the medical literature.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The microbiological diagnosis of <span class="elsevierStyleItalic">Nocardia</span> spp. is difficult, despite its isolation in most of the media used, due to its slow growth. Its clear growth disadvantage when cultured together with other microorganisms, as occurs in respiratory samples, further complicates its isolation.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Unlike other subspecies of <span class="elsevierStyleItalic">Nocardia</span>, <span class="elsevierStyleItalic">N. farcinica</span> has a special predisposition for central nervous system (CNS) involvement and specific drug susceptibility patterns. Usually, it presents sensitivity to imipenem, fluoroquinolones, amikacin and TMP-SMX.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The choice of antimicrobial regimen is determined by the severity of the condition and the affected structures. The duration of treatment is not well defined, although it is true that it is recommended for at least 6 months, which can be extended if there is CNS involvement, although in their recent study, Lebeaux et al. pointed to reducing the regimen duration to 120 days.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">To date, 2 cases of <span class="elsevierStyleItalic">Nocardia asteroides</span> bacteraemia, both associated with patients with central venous catheter<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> have been reported. However, we report the first case of <span class="elsevierStyleItalic">N. farcinica</span> bacteraemia secondary to pulmonary foci. However, this exceptionality could be due to underdiagnosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Given the limited clinical experience in the treatment of <span class="elsevierStyleItalic">Nocardia</span> spp. bacteraemia, we believe that the inherent severity of bacteraemia warrants treatment for at least 6 months and with 3 active drugs, as it occurs in other serious conditions, such as CNS infection.</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: Rodríguez Fernández L, Martín Guerra JM, Gil González I. Bacteriemia por <span class="elsevierStyleItalic">Nocardia farcinica</span>. Med Clin (Barc). 2020;154:521.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and laboratory features of the <span class="elsevierStyleItalic">Nocardia</span> spp. based on current molecular taxonomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. Brown-Elliott" 1 => "J.M. Brown" 2 => "P.S. Conville" 3 => "R.J. 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González García" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "An Med Interna" "fecha" => "2004" "volumen" => "21" "paginaInicial" => "554" "paginaFinal" => "556" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15538907" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcome and treatment of nocardiosis after solid organ transplantation: new insights from a European study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Lebeaux" 1 => "R. Freund" 2 => "C. van Delden" 3 => "H. Guillot" 4 => "S.D. Marbus" 5 => "M. Matignon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/cid/cix124" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2017" "volumen" => "64" "paginaInicial" => "1396" "paginaFinal" => "1405" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28329348" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Central venous catheter-associated Nocardia bacteremia: an unusual manifestation of nocardiosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D. Kontoyiannis" 1 => "K. Jacobson" 2 => "E. Whimbey" 3 => "K. Rolston" 4 => "I.I. Raad" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/313941" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2000" "volumen" => "31" "paginaInicial" => "617" "paginaFinal" => "618" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10987735" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015400000012/v1_202006190827/S238702062030190X/v1_202006190827/en/main.assets" "Apartado" => array:4 [ "identificador" => "43311" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015400000012/v1_202006190827/S238702062030190X/v1_202006190827/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702062030190X?idApp=UINPBA00004N" ]
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