Nocardiosis

Disease Overview

Nocardiosis is an infectious pulmonary disease characterized by abscesses in the lungs. These abscesses may extend through the chest wall. The infection is spread through the body via the bloodstream by a microorganism called Nocardia asteroides.

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Synonyms

• Lung Nocardiosis

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Signs & Symptoms

Most cases of nocardiosis begin as pulmonary infections that develop into lung abscesses. Symptoms may include chest pain, cough, bloody sputum, sweats, chills, weakness, lack of appetite, weight loss and difficult or labored breathing. Nocardiosis symptoms are similar to those of pneumonia and tuberculosis.

The infection may spread through the bloodstream resulting in abscesses in the brain, where they are very serious indeed, or less frequently and less seriously, in the kidney, intestines or other organs. Approximately one-third of reported cases develop brain abscesses if left untreated or if treatment is delayed. Symptoms associated with brain abscesses may include severe headache and focal, sensory and motor disturbances.

Skin abscesses occur in approximately one-third of all cases of nocardiosis, and are usually found scattered across the hand, chest wall and buttocks. In patients whose immune system is suppressed due to HIV infection or to corticosteroid or cytotoxic drugs, ulcerative colitis, malignancy of the lymph system or a variety of other diseases, progression of the disease can be very rapid.

Nocardiosis may last from several months to years. It is essential that the infection be diagnosed and differentiated from tuberculosis and pneumonia.

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Causes

Nocardiosis is caused by Nocardia asteroides, a bacterium that is carried up into the air from the ground and may be inhaled. Other species of the same family of bacteria such as Nocardia brasiliensis, Nocardia caviae, and Nocardia farcinica, are also known to cause disease. The organism usually enters the body through the lungs or, more rarely, through the gastrointestinal tract or the skin.

People whose immune systems are not functioning properly (immunocompromised) are at risk for nocardial infections. People whose immune systems are functioning properly but who are taking immunosuppressive drugs as part of the routine for organ transplantation are at greater than normal risk as well.

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Affected populations

Nocardiosis occurs worldwide. Those affected tend to be older adults, and males are more often affected than are females.

In the USA, about 500 to 1,000 new cases of nocardiosis are diagnosed each year.

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Disorders with Similar Symptoms

Symptoms of the following disorders can be similar to those of Nocardiosis. Comparisons may be useful for a differential diagnosis:

Actinomycosis is a chronic infectious disease characterized by draining sinuses. The microorganisms which cause Acitnomycosis are often found on the gums, tonsils and teeth. Actinomycosis most commonly affects adult males. The most common entry into the body for the infecting microorganism is through decayed teeth. Pulmonary or abdominal disease may also occur due to this infection. The infection causes small abscesses which spread to adjoining tissue. The abdominal form of the infection produces symptoms of pain, fever, vomiting, diarrhea or constipation and emaciation. There may be an abdominal mass with signs of intestinal obstruction, and draining pus may develop in the abdominal wall. In the thoracic form of the infection, lung infection may resemble tuberculosis with chest pain, fever and a cough with sputum.

Tuberculosis (TB) is an acute or chronic bacterial infection found most commonly in the lungs. The infection is spread like a cold, mainly through airborne droplets breathed into the air by a person infected with TB. In the lungs these tubercules produce breathing impairment, coughing and release of sputum. Tuberculosis may also affect the kidneys, bones, lymph nodes, and membranes surrounding the brain. Initial symptoms include fever, loss of appetite, weight loss, weakness, and dry cough. In later stages, symptoms may include blood in the sputum. (For more information on this disorder, choose “Tuberculosis” as your search term in the Rare Disease Database.)

Pneumonia is a common bacterial infection of the lungs. Onset is sudden, and usually presents itself as fever and shaking chills. Symptoms may include fever, pain or difficulty in breathing, cough and the production of sputum. Fever rises rapidly, sometimes to 105 degrees F. There may also be nausea, vomiting and a general feeling of ill health. Initially there may be a dry cough that later worsens and produces blood-streaked sputum. (For more information on this disorder, choose “Pneumonia” as your search term in the Rare Disease Database.)

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Diagnosis

Physical examination usually reveals decreased breath sounds in the lungs and crackles or rales in the infected lung. Cultures of the sputum and/or the fluid in the lungs will prove positive for the Norcardia bacteria. Chest X-rays, CT scans and viewing the lungs through an optical filament (bronchoscopy) can confirm the diagnosis and determine whether abscesses are present.

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Standard Therapies

Treatment

Nocardia organisms are usually resistant to penicillin. Sulfonamide drugs may be prescribed. However, since most cases respond slowly, treatment with sulfonamide drugs must be continued for several months. Trimethoprim-sulfamethoxazole is often prescribed for immunosuppressed patients. Recurrent infection is common.

Other drugs sometimes prescribed are Imipenem and cilastatin (Primaxin), Meropenem (Merrem IV), Cefotaxime (Claforan), Ceftriaxone (Rocephin) ampicillin, minocycline, and amikacin. Without treatment the disease can be fatal, so proper and prompt diagnosis is essential.

If infection occurs and spreads, surgery may be needed to remove and/or drain the infected areas.

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Clinical Trials and Studies

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.

For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:

Tollfree: (800) 411-1222

TTY: (866) 411-1010

Email: [email protected]

For information about clinical trials sponsored by private sources, contact:

www.centerwatch.com

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References

TEXTBOOKS

Beers MH, Berkow R, eds. The Merck Manual, 17th ed. Whitehouse Station, NJ: Merck Research Laboratories; 1999:1159.

Bullock WE. Nocardiosis. In: Bennett JC, Plum F, eds. Cecil Textbook of Medicine. 20th ed. W.B. Saunders Co., Philadelphia, PA; 1996:1676-77.

Lerner PI. Nocardiosis. In: Mandell GL, Bennett JE, Dolan R, eds. Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 4th ed. Churchill Livingstone Inc. New York, NY; 1995:2273-80.

REVIEW ARTICLES

Wang AW, D’Cruz M, Leung M. Primary cutaneous nocardiosis of the hand: a case report and literature review. Hand Surg. 2002;7:155-57.

Kumar K, Jimenez V. Pulmonary nocardiosis after bone marrow transplantation successfully treated with doxycycline. Int J Infect Dis. 2001;5:222-24.

JOURNAL ARTICLES

Singh NP, Goyal R, Manchanda V, et al. Disseminated nocardiosis in an immunocompetent child. Ann Trop Paediatr. 2003;23:75-78.

Umansky F, Nocardial cerebral abscess: report of three cases and review of the current neurosurgical management. Neurol Res. 2003;25:27-30.

Acar T, Arshad M. Nocardia asteroides cerebral abscess in a renal transplant recipient: short report. Acta Chir Belg. 2002;102:470-71.

Corazza M, Ligrone L, Libanore M, et al. Primary cervicofacial nocardiosis due to nocardia asteroides in an adult immunocompetent patient. Acta Derm Venereol. 2002;82:391-92.

Wellinghausen N, Pietzcker T, Kern VW, et al. Expanded spectrum of Nocardia species causing clinical nocardiosis detected by molecular methods. Int J med Microbiol. 2002;292:277-82.

Torres HA, Reddy BT, Raad II, et al. Nocardiosis in cancer patients. Medicine (Baltimore). 2002;81:388-97.

Lee GY, Daniel RT, Brophy BP, et al. Surgical treatment of nocardial brain abscesses. Neurosurgery. 2002;51:668-71; 671-72.

Lick S, Duarte A. Of mycetomas and men. Chest. 2002;121:5-6.

FROM THE INTERNET

Parsons C. Pulmonary nocardiosis. MedlinePlus. Medical Encyclopedia. Update Date: 7/30/2002. 3pp.

www.nlm.nih.gov/medlineplus/ency/article/000083.htm

Nocardiosis. Centers for Disease Control and Prevention. DBMD. Last reviewed: March 7, 2003

www.cdc.gov/ncidod/dbmd/diseaseinfo/nocardiosis_t.htm

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