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Year : 2009  |  Volume : 52  |  Issue : 2  |  Page : 294-295
A case of mixed pulmonary infection by nocardia and Mycobacterium tuberculosis


Department of Microbiology, Peoples College of Medical Sciences, Peoples Hospital, Karond Bypass Road, Bhanpur, Bhopal - 462 010, Madhya Pradesh, India

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How to cite this article:
Chaudhury RC, Aher AR, Rastogi V, Prabhu TK. A case of mixed pulmonary infection by nocardia and Mycobacterium tuberculosis. Indian J Pathol Microbiol 2009;52:294-5

How to cite this URL:
Chaudhury RC, Aher AR, Rastogi V, Prabhu TK. A case of mixed pulmonary infection by nocardia and Mycobacterium tuberculosis. Indian J Pathol Microbiol [serial online] 2009 [cited 2020 Apr 8];52:294-5. Available from: http://www.ijpmonline.org/text.asp?2009/52/2/294/48961


Sir,

We are reporting a case of mixed pulmonary infection due to Mycobacterium tuberculosis and Nocardia species. Nocardia is gram-positive actinomycete. Nocardia species can be found as saprophytes in the soil. [1] Nocardia presents as an important human pathogen. Nocardia asteroids complex are opportunistic pathogens especially infecting immunocompromised patients with impaired cell-mediated immunity. It has been reported in patients receiving cancer chemotherapy, corticosteroids, post-transplant or immunosuppressants and immunosuppressed human immunodeficiency virus-positive patients. Infection is acquired from the soil by the air-borne route.

A 45-year-old woman with the complication of a lump in the right breast since 8-9 months, gradually increasing in size, was admitted to the hospital. The patient also had a complaint of cough for 3 months. Investigation revealed that the patient had ductal adenocarcinoma of the breast. X-ray of the chest showed pneumonic condensation in the right upper lung. Liver function and renal function tests were normal. Sputum Gram stain showed a Gram-positive branching filament with coccoid elements suggestive of Nocardia species [Figure 1]. Conventional Ziehl Neelsen (ZN) staining for acid fast bacilli (AFB) was negative. However, modified ZN staining [2] using 1% sulfuric acid showed acid fast branching filaments. Multiple sputum specimens were examined and routine culture was set up along with Lowenstein-Jensen (LJ) medium. Blood agar revealed dry whitish to tan colonies, which on modified ZN staining showed acid fast branching filamentous bacteria while ZN staining from colonies on LJ medium showed AFB suggestive of M. tuberculosis .

This case illustrates the importance of the investigation of Nocardia along with Mycobacterial infection. An immunosuppressed patient suspected of having tuberculosis should also be considered for the possibility of non-Mycobacterial species when acid fast organisms are observed in specimens, particularly when a modified ZN stain is used. [3] Few cases have been reported for the mixed infection by Nocardia and M. tuberculosis . [4],[5] There were very few cases reported in India having mixed pulmonary infection. Gupta et al. [4] recovered 2.9% cases of N. asteroids among 209 cases of pulmonary tuberculosis. A microbiologist should process the respiratory tract specimens not only for Mycobacteria but should also be alert to the fact that organisms such as Nocardia may cause pulmonary infection, especially in immunosuppressed patients. Because mixed infection is very rare, no treatment strategy has been established. The combined therapy using cotrimoxazole, clarithromycin and antituberculous drugs was found to be effective in some studies. [5]

 
   References Top

1.Lerner PI. Nocardia species. In: Mandell GI, Bennette JE, Dolin R, editors. Mandell, Douglas and Bennette's principles and practice of infectious diseases. 4 th ed. New York: Churchill Livingstone; 1995. p. 2273-80.  Back to cited text no. 1    
2.Duguid JP. Staining methods. In: Colle JG, Duguid JP, Fraser AG, Marmion BP, editors. Mackie and McCartney practical medical microbiology. 13 th ed. Edinburgh: Churchill Livingstone; 1989. p. 46-9.  Back to cited text no. 2    
3.Rasheed MU, Belay G. Nocardiosis in HIV seropositive clinically ­suspected pulmonary tuberculosis patients. Trop Doct 2008;38:34-5.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Gupta ML, Grover PS, Bharadwaj BK. Nocardia associated with ­pulmonary tuberculosis. J Commun D 1991;23:157-9.  Back to cited text no. 4    
5.Shimokubo T, Ashtani J, Ihi T, Higa T, Kumamoto K. A case of mixed infection by Nocardia asteroides and Mycobacterium tuberculosis . Nihon Kokyuki Gakkai Zasshi 2002;40:703-7.  Back to cited text no. 5    

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Correspondence Address:
Reshmi Chanda Chaudhury
Department of Microbiology, Peoples College of Medical Science and Research Centre, Bhanpur bypass Road, Bhopal - 462 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.48961

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