Nocardia – Opportunistic chest infection in elderly: A case report
© Sanyal and Sabanathan; licensee BioMed Central Ltd. 2008
Received: 08 August 2008
Accepted: 21 August 2008
Published: 21 August 2008
In this rare case a non-immunocompromised patient with old Tuberculosis on low dose of steroids presents with opportunistic infection of a weakly aerobic gram positive acid fast, filamentous bacteria called Nocardia.
An 80 year old non-smoking white female presented with cough, shortness of breath and purulent sputum.
Initial antibiotics given were not helpful. Later microbial diagnosis was Nocardia in sputum sample which was uncommon in a non-immunocompromised. She responded to co-trimoxazole therapy.
Nocardia organism is filamentous gram positive rods. They are aerobic. Human pathogens infect by inhalation of airborne bacilli or the traumatic inoculation of organism into skin. Overall 80% present as invasive pulmonary infection, disseminated disease abscess; 20% present as cellulitis. Debilitated patients have a 45% mortality rate even with appropriate therapy.
In this report, we present a rare case of a non-immunocompromised patient with old Tuberculosis but she has been on low dose of steroids. Nocardia is a weakly aerobic gram positive acid fast, filamentous bacteria. They are an important opportunistic infection in elderly and immunocompromised affecting lung, brain and skin. Nocardiasis is sporadic and have higher incidence in the immunocompromised population. There is no age, race predilection . Pre-existing lung condition, in this of case of tuberculosis increase the risk of contracting the infection. Bronchiectasis is an important risk factor of Nocardia colonisation. The presentations are cough, fever and difficulties in breathing. The spread is sporadic, and are usually found in dust and soil. The use of Ziehl Neelson technique with a weaker acid concentration can result in identification of a variety of acid fast organisms . Generalised infection involves cutaneous joint and pulmonary cause. Further dissemination involves acute and chronic symptoms. There are no person to person transmission. Core diagnostic test include sputum culture and bronchoscopy.
Standard therapy is trimethoprim-sulphamethoxazole for 6 months to 1 year. Refractory case needs imipenem and amikacin. Nocardiais should be suspected in immunosuppressed patients.
Pulmonary bronchiectasis is difficult to diagnose, which delays its diagnosis and a high level of suspicion is required in patients with underlying chronic condition or chronic steroid use . Nocardia when involves the central nervous system leads to a poor prognosis, implies an early diagnosis and prompt treatment. Death occurs from sepsis, overwhelming pneumonia or brain abscess. Mortality is increased in disseminated disease involving 2 or more organs . Mortality is more in patients on corticosteroids or chemotherapy. Nocardiosis should be an important differential of any chronic pneumonia not responding to the antibiotic treatment.
Written consent has been obtained from the patient for submission of this manuscript and figures for publication. Funding was neither sought nor obtained.
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