Indian Journal of Pathology and Microbiology

CASE REPORT
Year
: 2016  |  Volume : 59  |  Issue : 2  |  Page : 240--242

Pleuropulmonary nocardiosis due to Nocardia otitidiscaviarum in a debilitated host


R Deepa, S Thasneem Banu, G Jayalakshmi, J Durdana Parveen 
 Institute of Microbiology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India

Correspondence Address:
R Deepa
Senior Assistant Professor, Institute of Microbiology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai - 600 003, Tamil Nadu
India

Abstract

Nocardia otitidiscaviarum is a rare cause of pulmonary nocardiosis. We present a case of pulmonary nocardiosis with pleural involvement in an adolescent with rheumatic heart disease and congestive cardiac failure presenting with right lower lobe consolidation and pleural effusion. Direct gram-stain of pleural fluid showed pus cells with Gram-positive filamentous branching bacilli. Empiric treatment with parenteral ceftriaxone and supportive therapy for cardiac failure was initiated. Pleural fluid culture yielded growth of N. otitidiscaviarum at 72 h. Antibiotic susceptibility testing showed resistance to cephalosporins. The patient expired due to congestive cardiac failure on the 5th day.



How to cite this article:
Deepa R, Banu S T, Jayalakshmi G, Parveen J D. Pleuropulmonary nocardiosis due to Nocardia otitidiscaviarum in a debilitated host.Indian J Pathol Microbiol 2016;59:240-242


How to cite this URL:
Deepa R, Banu S T, Jayalakshmi G, Parveen J D. Pleuropulmonary nocardiosis due to Nocardia otitidiscaviarum in a debilitated host. Indian J Pathol Microbiol [serial online] 2016 [cited 2020 Feb 26 ];59:240-242
Available from: http://www.ijpmonline.org/text.asp?2016/59/2/240/182011


Full Text

 Introduction



Nocardiae are soil borne actinomycetes having a worldwide distribution. They belong to the family Corynebacteriaceae, order Actinomycetales. The genus Nocardia contains more than 50 species characterized by phenotypic and molecular methods. Infection is acquired from inhalation of airborne spores or mycelial fragments from environmental sources.[1]

Nocardia otitidiscaviarum causes primary cutaneous, lymphocutaneous, and pulmonary infections in immunocompromised as well as immunocompetent patients.[1] It is less reported than other nocardiae (3%), probably due to reduced pathogenicity, the low prevalence in soil or under reporting.[2] Pleural involvement is also rarely reported. This case of pleuropulmonary nocardiosis is reported to emphasise that N. otitidiscaviarum a rare isolate can cause a severe infection in a debilitated host.

 Case Report



A 14-year-old girl presented with difficulty in breathing, cough with expectoration, right sided chest pain, low-grade intermittent fever for 10 days and pedal edema, with decreased urine output for 1 month. She was a known case of rheumatic heart disease with mitral stenosis and was treated by closed mitral commissurotomy 3 years back. She had no history of diabetes mellitus or tuberculosis. On examination, the patient was conscious, poorly built, and febrile with signs of congestive cardiac failure. Respiratory system examination revealed right lower lobe consolidation with pleural effusion. The patient was started on oxygen, parenteral frusemide, deriphylline, digoxin and paracetamol.

Biochemical investigations revealed normal blood sugar levels and liver function tests. Serum creatinine and blood urea levels were elevated. Hemogram showed a total leukocyte count of 39,500 cells/cumm, with relative neutrophilia, erythrocyte sedimentation rate - 36 mm/1 h, Hb - 8.1 g/dl. Pleural fluid analysis showed protein 3.8 g%, sugar 28 mg/dl, lactate dehydrogenase 258 units suggestive of an exudate. Antibodies to HIV 1 and 2 were negative.

Chest X-ray showed opacity in the right lower zone. Computed tomography (CT) confirmed right lower lobe consolidation and right sided pleural effusion. Thoracentesis yielded 50 ml of yellow, mildly turbid pleural fluid. Empiric antibiotic therapy with intravenous ceftriaxone was started after obtaining blood and sputum samples for bacterial and fungal culture.

Cytological analysis of pleural fluid showed intense inflammatory cells with infiltration of polymorphs and scattered mesothelial cells in an eosinophilic proteinaceous background. Direct gram-stain of pleural fluid showed plenty of pus cells and Gram-positive delicate branching filamentous bacteria which were partially acid-fast with modified Ziehl–Neelsen staining with 1% sulphuric acid [Figure 1]. Preliminary report of Nocardial infection was given.{Figure 1}

The culture of pleural fluid on Sabouraud's Dextrose agar without antibiotics at 37°C at 72 h of incubation yielded dry white colonies [Figure 2]. Blood agar plate showed nonhemolytic dry white irregular colonies which on gram-stain revealed delicate filamentous branching Gram-positive bacilli which were also partially acid fast stain with 1% sulfuric acid. The colonies{Figure 2}

were catalase positive, urease, and nitrate reduction test positive, gelatin hydrolysis test, and Citrate utilization test negative. Xanthine and hypoxanthine hydrolysis was not performed

due to the non-availability of the media.

Antimicrobial susceptibility testing of the isolate was performed by Kirby-Bauer disc diffusion test. Inhibitory zones were recorded at 24-h intervals for 3 days.[3] The organism was found to be susceptible to gentamicin, ciprofloxacin, amikacin, trimethoprim- sulfamethoxazole, tetracycline, imipenem, and resistant to amoxicillin-clavulanate, cefotaxime, and ceftriaxone.

Direct gram-stain examination of sputum showed plenty of pus cells and occasional epithelial cells with few Gram-positive budding yeast cells with pseudohyphae. No acid-fast Bacilli were observed on Ziehl–Neelsen staining of sputum (using 1% and 20% sulphuric acid). The sputum culture showed scanty growth of non-albicans Candida spp. and other normal commensal flora. Bronchoscopic specimen could not be obtained due to the poor general condition of the patient. No pathogens were isolated in blood culture.

The patient's cardiac and renal function started deteriorating on the 3rd day. There was no clinical improvement of the patient, and she expired on the 5th day.

The organism was confirmed and speciated as N. otitidiscaviarum at the Mycology Division, PGIMER, Chandigarh by culture and molecular methods.

 Discussion



A literature search for recent reports showed that 1 of 35 Nocardial isolates recovered from pulmonary nocardiosis during a 5 years period from two tertiary hospitals in Australia was N. otitidiscaviarum.[4] A study on nocardiosis at a tertiary care hospital in North India reported that 1 of 12 Nocardial spp isolated from various specimens during a 2 year period was N. otitidiscaviarum.[5] This organism has also been identified as a causative agent in one of eight cases of pulmonary nocardiosis in a retrospective study in South India.[6]

Acute and subacute pulmonary nocardiosis has a poor prognosis as compared to the chronic form. A high level of clinical severity, comorbidity, and delay in starting antimicrobial therapy, misdiagnosis or delayed diagnosis are associated with poorer outcome.[7] Our patient too had an acute presentation with an underlying debilitating condition.

Pleural involvement in nocardiosis is reported to be detected in about 18% of patients by chest radiograph and in 36% of patients by CT scan.[7] Pleural involvement occurs due to direct spread from the chest wall and lung parenchyma resulting in pleural thickening, pleural effusion and empyema. The pleural fluid is often the only source of diagnosis.[8] Pleural involvement in N. otititdiscaviarum has been reported in an immunocompetent patient in South India.[9]

As neither the CT or chest radiography is pathognomonic of pulmonary nocardiosis, smear and culture of appropriate specimens remain the principal method of diagnosis. Sputum studies permit the diagnosis in half of the patients. Half of the patients required additional alternative specimens and bronchoscopic lavage.[5] In our patient, sputum culture and smear study was negative for Nocardia and bronchial specimens could not be obtained due to the poor general condition of the patient.

The presence of Nocardiae in normally sterile sites also increases the likelihood of the organism's role as an etiological agent.[10] Pelaez et al. reported a fatal case of pulmonary nocardiosis due to N. otititdiscaviarum, where repeated sputum and blood cultures were negative and the diagnosis was made by a pleural fluid tap.[2] This scenario was observed in our patient in whom growth of N. otitidiscaviarum from pleural fluid aided in the diagnosis.

Speciation of Nocardia is important because of the specific drug susceptibility patterns of various Nocardia species. N. otitidiscaviarum is biochemically distinct from other Nocardia species by its ability to hydrolyse both hypoxanthine and xanthine. This may be difficult in the routine diagnostic setting due to lack of commercial sources. Molecular testing may be necessary for confirmation of species.[10]

N. otitidiscaviarum is usually resistant to beta-lactams including broad-spectrum cephalosporins, amoxicillin, amoxicillin-clavulanic acid, and imipenem, but susceptible to amikacin, fluoroquinolones, and sulfonamides. For empirical therapy prior to the availability of susceptibility test results, a three-drug regimen consisting of TMP-SMX, amikacin, and either ceftriaxone or imipenem is recommended for patients with serious disease.[10]

 Conclusion



N. otitidiscaviarum is an emerging species of Nocardia capable of causing pulmonary infections with pleural involvement in a debilitated host. Nocardia spp are slow growing in culture and speciation requires a combination of biochemical and molecular diagnosis. In such a scenario, the direct gram-stain can provide a rapid diagnosis to help initiate empirical therapy.

Acknowledgment

The authors would like to thank Dr. Arunaloke Chakrabarti, Professor and Head, Department of Medical Microbiology, Centre of Advance Research in Medical Mycology, WHO Collaborating Centre, National Culture Collection of Pathogenic Fungi, Postgraduate Institute of Medical Education and Research, Chandigarh, for the speciation of Nocardia otitidiscaviarum isolate.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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