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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 5  |  Page : 34-36

A case report of Nocardia asiatica in a renal transplant recipient


Department of Microbiology, Apollo Hospitals, Bengaluru, Karnataka, India

Date of Submission05-Feb-2021
Date of Decision19-May-2021
Date of Acceptance22-May-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Devaraj Chandana
Apollo Hospitals, Bannerghatta Road, Bengaluru - 560 076, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_11_21

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  Abstract 


Nocardiosis is a life-threatening disease in solid organ transplant recipients. It is an uncommon but important infection in these patients. Nocardiosis is caused by a Gram-positive, weakly acid fast, branching filamentous aerobic bacteria belonging to the order Actinomycetales. It causes pulmonary and systemic infections in immunocompromised patients. The common species of Nocardia causing infections are Nocardia asteroids, Nocardia brasiliensis, Nocardia farscinica, and Nocardia nova. Here, we report a case of a 32-year-old female postrenal transplant recipient developing pulmonary nocardiosis by a rare species of Nocardia called Nocardia asiatica. A modified Ziehl–Neelsen stain using 1% H2SO4 in the endotracheal (ET) secretion revealed numerous acid fast branching filamentous organisms morphologically resembling Nocardia spp., and the culture grew Nocardia and it was confirmed as N. asiatica by MALDI TOF. Our patient had cytomegalovirus co-infection. The patient was started on trimethoprim-sulfamethoxazole. This case shows the importance of keeping nocardiosis as a differential diagnosis in immunocompromised patients.

Keywords: Nocardia asiatica, pulmonary nocardiosis, renal transplant


How to cite this article:
Chandana D, Jayasree S. A case report of Nocardia asiatica in a renal transplant recipient. Apollo Med 2021;18, Suppl S1:34-6

How to cite this URL:
Chandana D, Jayasree S. A case report of Nocardia asiatica in a renal transplant recipient. Apollo Med [serial online] 2021 [cited 2022 Sep 30];18, Suppl S1:34-6. Available from: https://apollomedicine.org/text.asp?2021/18/5/34/320554




  Introduction Top


Nocardia has been recognized as an increasing opportunistic pathogen in immunocompromised individuals. Pneumonia is one of the most common presentations in nocardiosis.[1] It causes pulmonary and systemic infections in immunocompromised patients.[2] Prognosis remains poor in immunocompromised patients and disseminated forms.[3] The common species of Nocardia causing infections are Nocardia asteroids, Nocardia brasiliensis, Nocardia farscinica, and Nocardia nova. This case shows the importance of keeping nocardiosis as a differential diagnosis. Here, we report a case of pulmonary nocardiosis in a renal transplant patient by a rare species Nocardia asiatica.


  Case Report Top


A 32-year-old female patient had underwent kidney transplantation in February 2018 from across-matched donor who was her mother. After 1 year of transplantation in February 2019, she presented with cough, dyspnea, expectoration, and breathlessness associated with fever of insidious onset for 4 days. Laboratory investigations revealed Hb% 7.3 g/dl, white blood cell count 31.4 × 109 cells/L, platelet count 407 × 109/L, serum creatinine 1.11 mg/dl, direct bilirubin 0.19 mg/dl, indirect bilirubin 0.44 mg/dl, aspartate aminotransaminase 8 U/L, alanine aminotransaminase 3 U/L, and CD4 counts 41 cells/μL. Microbiological investigations included Gram stain and Ziehl–Neelsen (ZN) stain which was done on endotracheal (ET) secretion. Gram stain showed the presence of slender, Gram-positive, branching filamentous bacilli. A modified ZN staining using 1% H2SO4 revealed numerous acid fast branching filamentous organisms morphologically resembling Nocardia spp. [Figure 1]. Culture on chocolate agar and blood agar for 48 h at 37°C under aerobic conditions revealed white, rough, and dry colonies. The culture grew Nocardia spp., which was confirmed as N. asiatica by MALDI TOF. A final diagnosis of pulmonary nocardiosis was then done. Antibiotic susceptibility testing was done by Kirby Bauer's disc diffusion method which was sensitive to azithromycin, cefotaxime, co-trimoxazole, ceftriaxone, imipenem, meropenem, and linezolid and resistant to levofloxacin.[4],[5] The patient was started on trimethoprim-sulfamethoxazole (Bactrim DS two tablets three times daily) and later meropenem (500 mg TID) was added as a second-line drug due to inadequate response. Acid fast stain, acid-fast bacteria culture, and Genexpert were negative. Chest X-ray revealed right lower lobe consolidation and pleural effusion on the right side [Figure 2]. Computed tomography revealed development of consolidation of posterior segment of the right upper lobe, middle lobe, and lower lobe segments. There was a co-infection with cytomegalovirus (CMV) in the patient, with the viral load being 7000 copies/ml. The patient was put on canciclovir to treat CMV. But, unfortunately, the patient expired on treatment.
Figure 1: Modified Ziehl–Neelsen stain showing Gram-positive branching filamentous bacilli

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Figure 2: Chest X-ray showing right lower lobe consolidation and pleural effusion on the right side

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  Discussion Top


Nocardia is usually isolated from soil, dust, sand, decaying vegetation, fecal matter, and stagnant water.[3],[6] Incidence of nocardiosis in solid organ transplant recipients is about 0.6%, about 3.5% in lung transplant recipients, and around 0.2% in renal transplant recipients, In India, nocardiosis was reported in 1.4% renal transplant recipients.[7] Seven species have been associated with human disease. Nocardia asteroides is responsible for about 70% of infections caused by these organisms.[8] Pulmonary nocardiosis usually presents with dyspnea, chest pain, cough, fever, malaise, and anorexia. Usually, pulmonary nocardiosis mimics tuberculosis, pneumocytosis, invasive fungal disease, malignancy, and bacterial pneumonia. Hence, a high suspicion of nocardiosis should be kept as a differential diagnosis in immunosuppressed patients.[9]

The laboratory investigations of nocardiosis include Gram stain and modified acid fast stain. Nocardia spp., appear as Gram-positive, thin, branching, filamentous organisms. In modified acid fast stain, they are acid fast filamentous bacilli.[10] The chest radiographic findings include consolidations, large irregular nodules, masses, and interstitial patterns. Computed tomography also suggests cavitation, pulmonary nodules, pleural effusion, and chest wall involvement.[11] Because the culture of Nocardia is difficult and slow due to its fastidious nature and due to lack of serological tests, it is important to keep nocardiosis in the differential diagnosis. If sputum examination does not yield diagnosis, more invasive techniques such as bronchoscopy, needle aspiration, and open lung biopsy should be considered.[12] Mortality is higher in patients with disseminated nocardiosis. In pulmonary nocardiosis, mortality is about 40% and increases to 64% in disseminated nocardiosis and 100% in cerebronervous system involvement.[7] Even though there are many case reports of nocardia infection in a renal transplant recipients by various species,[13],[14] we could not find N. asiatica causing infection in renal transplant patients.[15] Our patient had both high tacrolimus levels and CMV infection apart from nocardia infection. Long-term maintenance therapy includes co-trimoxazole or doxycycline for immunocompromised patients.

Unfortunately, on treatment, the patient succumbed to the illness.

Here, we have analyzed 11 cases of nocardiosis by N. asiatica including the present case [Table 1]. This study reports pulmonary nocardiosis by N. asiatica in a renal transplant recipient for the first time in India.
Table 1: Nocardia asiatica infection reported in the literature

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A total of 66 cases of nocardiosis in renal transplant recipients from 49 articles were analyzed, which shows N. asteroides to be the most common agent with N. asiatica being not reported [Table 2].[16]
Table 2: Analysis of 66 renal transplant recipient cases with Nocardiosis

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  Conclusion Top


This was a case of pulmonary nocardiosis by a rare species of Nocardia called “N. asiatica” in a renal transplant recipient. Nocardiosis should be kept as a differential diagnosis of pneumonia especially in patients who are not responding to empiric treatment and when radiological features are atypical. Immunocompromised individuals such as renal transplant patients, human immunodeficiency virus infection, and long-term steroid therapy have the risk of developing nocardia infection. Microbiological evaluation is important for diagnosis, therefore bronchoalveolar lavage and ET secretion should be examined in patients with atypical pneumonia or with unusual response to empiric treatment. Nocardiosis presents with varying signs and symptoms in both immunocompetent and immunocompromised patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to acknowledge all laboratory staff who helped in isolating the organism.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kumar R, Chhina DK, Kaushal V, Mahajan R, Kaur H. Cytological diagnosis of pulmonary nocardiosis in an immunocompromised patient. Indian J Med Microbiol 2008;26:380-2.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Yaşar Z, Acat M, Onaran H, Ozgül MA, Fener N, Talay F, et al. An unusual case of pulmonary nocardiosis in immunocompetent patient. Case Rep Pulmonol 2014;2014:963482.  Back to cited text no. 2
    
3.
Yaich S, Charfeddine K, Zaghdane S, El Aoud N, Masmoudi M, Kharrat M, et al. Pulmonary nocardiosis in a kidney transplant recipient: A case report and review of the literarture. J Transplant Technol Res 2011;1:101.  Back to cited text no. 3
    
4.
Lerner PI. Nocardiosis. Clin Infect Dis 1996;22:891-903.  Back to cited text no. 4
    
5.
Rajeswari AP, Prasad G, Vyasam RC, Ramesh BN, Sireesha G, Sam A, et al. Post renal transplant pulmonary nocardiosis – A case report. J NTR Univ Health Sci 2019;8:147-50.  Back to cited text no. 5
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6.
Hwang JH, Koh WJ, Suh GY, Chung MP, Kim H, Kwon OJ, et al. Pulmonary nocardiosis with multiple cavitary nodules in a HIV-negative immunocompromised patient. Intern Med 2004;43:852-4.  Back to cited text no. 6
    
7.
Martínez Tomás R, Menéndez Villanueva R, Reyes Calzada S, Santos Durantez M, Vallés Tarazona JM, Modesto Alapont M, et al. Pulmonary nocardiosis: Risk factors and outcomes. Respirology 2007;12:394-400.  Back to cited text no. 7
    
8.
Amatya R, Koirala R, Khanal B, Dhakal SS. Nocardia brasiliensis primary pulmonary nocardiosis with subcutaneous involvement in an immunocompetent patient. Indian J Med Microbiol 2011;29:68-70.  Back to cited text no. 8
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9.
Feigin DS. Nocardiosis of the lung: Chest radiographic findings in 21 cases. Radiology 1986;159:9-14.  Back to cited text no. 9
    
10.
Chopra C, Ahir GC, Chand, Jain PK. Pulmonary nocardiosis mimicking pulmonary tuberculosis. Indian J Tuberc 2001;48:211.  Back to cited text no. 10
    
11.
Kaswan KK, Vanikar AV, Feroz A, Patel HV, Gumber M, Trivedi HL. Nocardia infection in a renal transplant recipient. Saudi J Kidney Dis Transpl 2011;22:1203-4.  Back to cited text no. 11
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12.
Jorna T, Taylor J. Disseminated Nocardia infection in a renal transplant patient: The pitfalls of diagnosis and management. BMJ Case Rep. 2013;2013:bcr2012007276. doi: 10.1136/bcr-2012-007276.  Back to cited text no. 12
    
13.
Banerjee B, Gupta R, Varma M, Mukhopadhyay C, Shaw T. Disseminated nocardia asiatica infection in an immunocompromised individual: A rare entity needs careful vigilance. J Infect Public Health 2019;12:167-70.  Back to cited text no. 13
    
14.
Yu X, Han F, Wu J, He Q, Peng W, Wang Y, et al. Nocardia infection in kidney transplant recipients: Case report and analysis of 66 published cases. Transpl Infect Dis 2011;13:385-391.  Back to cited text no. 14
    
15.
Manikandan P, Bhaskar M, Revathi R, Anita R, Abarna Lakshmi LR, Narendran V. Isolation and antimicrobial susceptibility pattern of Nocardia among people with culture-proven ocular infections attending a tertiary care eye hospital in Tamilnadu, South India. Eye (Lond) 2007;21:1102-8.  Back to cited text no. 15
    
16.
National Committee for Clinical Laboratory Standards, Approved Standard, M2-A5. Performance Standard for Antimicrobial Disk Susceptibility Test. 5th ed. Villanova, PA: NCCLS; 1995.  Back to cited text no. 16
    


    Figures

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