The Findings of Pulmonary Nocardiosis on Chest High Resolution Computed Tomography

Objectives: Pulmonary nocardiosis is a rare opportunistic infection that is often encountered in immunocompromised patients, in particular those with human immunodeficiency virus (HIV) infection and in solid organ transplant recipients. As the number of immunocompromised patients increase, it is expected that the number of patients with pulmonary nocardiosis will increase. The aim of this study is to review the chest HRCT findings of patients with confirmed pulmonary nocardiosis and to review the imaging features of pulmonary nocardiosis in the literature. Methods: We searched the electronic database of the Royal Hospital, Muscat, Oman for patients with a diagnosis of pulmonary nocardiosis between January 2006 and January 2019. Nine patients with pulmonary nocardiosis were identified, but three patients were excluded as no chest HRCT images were available. Patient clinical presentation was recorded and chest HRCT images were retrospectively reviewed. Results: The six patients enrolled in the study were male, aged between 29 and 49 years. Three patients were immunocompromised, two of whom had undergone a renal transplant. The main HRCT findings were cavitary nodules/masses, non-cavitary nodules/masses, septal thickening, centrilobular nodules, ground glass opacities, consolidation, pleural effusion, pleural thickening, enlarged lymph nodes and necrotic lymph nodes. Conclusion: Pulmonary nocardiosis has various findings on chest CT. Most common are pulmonary nodules and masses. Awareness of these findings can help radiologists to suggest the diagnosis in the appropriate clinical settings. Keywords: Nodules; Masses; Lung Infections; Opportunistic Pathogen; Pulmonary Nocardiosis; Computed Tomography.

Case report: pulmonary nocardiosis caused by Nocardia exalbida in an immunocompetent patient

Background Nocardiosis is known as an opportunistic infection in immunocompromised hosts, but it occasionally has been reported in immunocompetent patient. The Nocardia exalbida is first-reported in 2006 from Japan, and a few cases of have been reported in only immunocompromised host, and the characteristic is still unclear. We herein describe the first case of pulmonary nocardiosis caused by N. exalbida in an immunocompetent patient. Case presentation A77 -year-old Japanese man was admitted to our hospital on November 2, 2018. He was a lifelong non-smoker with no childhood history of respiratory disease. He had a medical history of dyslipidemia. One month before this admission fevers, sputum, mild cough were developed and he was evaluated in a clinic near our hospital. His diagnosis was community acquired pneumonia within his right middle lobe. He was treated with ceftriaxone 1 g/day intravenously for a week, however his symptoms relapsed a few days later. So, the physician retried ceftriaxone for another 3 days, but his symptoms did not improve. He was referred to our hospital. He was treated with sitafloxacin as an outpatient for a week, however his symptoms got worse. The chest CT showed consolidation and atelectasis in his right middle lobe. Low density area was scattered in consolidation, and right pleural effusion was observed. The patient was diagnosed with pulmonary abscess and he was admitted. Administration of piperacillin/tazobactam improved his condition. We switched antibiotics to amoxicillin/clavulanate, and he was discharged. After 2 weeks, he relapsed and was admitted again. After administration of piperacillin/tazobactam for 3 weeks, we perform bronchoscopy and Nocardia species were cultured from samples of the bronchial wash. The isolates were identified as N. exalbida using 16S rRNA gene sequencing. We prescribed Trimethoprim / Sulfamethoxazole (TMP/SMX) for 4 months. Then we switched to minocycline for renal dysfunction caused from TMP-SMX for 1 more month. After 5 months therapy, Consolidation on CT disappeared, and Nocardiosis was cured. Conclusion we reported the first case of pulmonary nocardiosis caused by N. exalbida in an immunocompetent patient. N. exalbida infection might be associated with a good response to treatment.