Nokardiosis A43.1

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 15.06.2022

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Nocard 1888; Eppinger 1890;

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Rare, chronic granulomatous bacterial infectious disease caused by pathogens of the genus Nocardia (aeroactinomycetes).

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Gram-positive, aerobic rods (formerly assigned to fungi, like actinomycetes), which are widespread in the soil. Mainly Nocardia asteroides, also Nocardia brasiliensis, Nocardia madurae and Nocardia pelletieri. According to their natural occurrence in the soil, nocardia are exogenous infections.

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Worldwide, sporadically occurring; more frequent in the USA, very rare in Europe.

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Inoculation of the pathogen in the presence of wounds (skin nocardiosis, usually Nocardia brasiliensis) or by inhalation of the pathogen (pulmonary nocardiosis, usually Nocardia asteroides). Inoculation of contaminated material into the skin results in cutaneous nocardiosis. Inhalation of contaminated dust leads to pulmonary nocardiosis.

Person-to-person transmission does not occur.

Approximately 85% of affected patients are immunocompromised (HIV/AIDS, neoplasms, collagenoses, pre-existing chronic lung disease) - (Hémar V et al. 2018).

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Mostly occurring in immunosuppressed patients (Z.n. organ transplantation, HIV infection) or in severe underlying diseases (e.g. lupus erythematosus, systemic).

Clinical features
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Superficial form: Especially on the feet and hands, abscessing nodules are found in a chain-like arrangement along the lymphatic drainage area (sporotrichoid spread), occasionally mycetoma formation.

Lymphocutaneous form due to Nocardia asteroides.

Oculoglandular form with conjunctivitis and lymphadenopathy may result from smear infection. Most commonly caused by Nocardia brasiliensis.

Pulmonary and systemic form especially in immunocompromised patients (Uttamchandani RB et al. 1994).

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Non-specific granulation tissue with melting leukocytic abscesses. In older abscesses abundant foam cells at the edges. Nokardia cannot be stained in HE and Giemsa sections, but by means of Gram and Grocott staining. The abscesses contain clumped bacterial clusters, in which thin (about 1 µm thick) fibrous structures with branches reminiscent of spider webs are present at the edges. In contrast to actinomycosis, drusen are always missing.

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Pathogen detection in pus or sputum. The cultural detection is possible on universal culture media or media for tuberculosis diagnostics (e.g. Löwenstein-Jensen medium).

Differential diagnosis
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Rapid diagnosis and combined surgical and chemotherapeutic procedures are crucial for survival rates!

Internal therapy
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Antibiosis after antibiogram. 1st choice are sulfonamides like sulfadiazine (e.g. Sulfadiazine Heyl) 4-8-12g/day or cotrimoxazole (e.g. Cotrimox Wolff). Long-term treatment until several weeks after healing is important to avoid recurrence.

Alternatively (used more and more frequently due to increasing resistance of the pathogens) imipenem/cilastatin (e.g. Zienam 4 g/day) in combination with amikacin (e.g. Biklin 1 g/day) in maximum dosages can be considered.

Good results have also been described with minocycline (e.g. Klinomycin 100 Filmtbl.) 2 times/day 100 mg p.o. as monotherapy or in combination with sulfonamides.

If necessary, other antibiotics depending on the resistance of the pathogen.

Operative therapie
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Operational rehabilitation and drainage.

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Good for cutaneous form. In pulmonary and systemic form: lethal outcome in 50% of cases. Tendency to relapse.

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  1. Dorman SE et al (2002) Nocardia infection in chronic granulomatous disease. Clin Infect Dis 35: 390-394
  2. Eppinger H (1890) On a new pathogenic Cladothrix and a pseudotuberculosis (Cladothrichica) caused by it. Beitr Path Anat 9: 287-328.
  3. Gutiérrez C et al (2020) Nocardia cyriacigeorgica infection in AIDS patient. Rev Chilena Infectol 37: 322-326.

  4. Hémar V et al (2018) Retrospective analysis of nocardiosis in a general hospital from 1998 to 2017. Med Mal Infect 48: 516-525.
  5. Kandi V (2015) Human nocardia infections: a review of pulmonary nocardiosis. Cureus 7:e304.
  6. Maraki S et al (2003) Lymphocutaneous nocardiosis due to Nocardia brasiliensis. Diagn Microbiol Infect Dis 47: 341-344.
  7. Naka W et al (1995) Unusually located lymphocutaneous nocardiosis caused by nocardia brasiliensis. Br J Dermatol 132: 609-613.
  8. Nocard E (1888) Note sur la maladie des boeufs de la Guadaloupe. Ann Inst Pasteur 2: 293-302.
  9. Pintado V et al (2003) Nocardial infection in patients infected with the human immunodeficiency virus. Clin Microbiol Infect 9: 716-720.
  10. Rees W et al (1994) Primary cutaneus nocardia farcinica infection after cardiac transplantation. Deutsch Med Wochenschrift 119: 1276-1280
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  12. Saubolle MA et al (2003) Nocardiosis: review of clinical and laboratory experience. J Clin Microbiol 41: 4497-4501.
  13. Uttamchandani RB et al (1994) Nocardiosis in 30 patients with advanced human immunodeficiency virus infection: clinical features and outcome. Clin Infect Dis 18: 348-53


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Last updated on: 15.06.2022