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Pulmonary Nocardiosis in Immunocompetetent Host: Unusual Response FREE TO VIEW

Saurabh Kansal, MS; Amrit Pal Kansal, MD; Gopal Chawla, MD; Kamal Deep, MD
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Government Medical College, Patiala, India

Chest. 2014;146(4_MeetingAbstracts):154A. doi:10.1378/chest.1989352
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SESSION TITLE: Infectious Disease Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary nocardiosis (PN) is an infrequent and severe infection due to Nocardia spp., microorganisms that may behave both as opportunists and as primary pathogens. The risk of pulmonary or disseminated disease is more in persons with deficient cell mediated immunity.Pleural involvement is common in pulmonary nocardiosis and was detected in 36% of the cases using computed tomography of chest.Pleural involvement in nocardiosis is rarely documented in India.Diagnosis is extremely difficult because nocardiosis is not well known by clinicians and the culture of Nocardia is not easy (it is important to inform biologists that Nocardia should be checked for). Dissemination of the bacteria is also possible and worsens the prognosis.

CASE PRESENTATION: A 38 year old labourer presented with chief complaints of progressive breathlessness which increased from grade I to grade III over a period of one month, chest pain and mild dry cough for last 10 days. CXR revealed homogenous opacity left side pushing mediastinal structures to the other side. CECT chest showed left sided massive effusion with complete collapse of ipsilateral lung along with mediastinal lymphadenopathy. Intercostal chest tube drainage was done and around 6 liters of fluid drained over a period of 6 days. The patient was non reactive to HIV, non-diabetic and was not on any other medication and there was no other finding suggestive of immunosupression. LBC(liquid based cytology) and MGG(May Gruenwald giemsa) smear of pleural fluid showed features those of pleural effusion due to nocardiosis.The pleural fluid grew Nocardia after 2weeks of culture on Sabourauds dextrose agar at 37 °C. Patient started on trimethoprim-sulfamethaxazole and oral steroids. The patient responded well to treatment.

DISCUSSION: Nocardiosis is an acute, sub-acute or chronic infectious disease that occurs in cutaneous, pulmonary and disseminated forms. Pulmonary nocardiasis is usually in form of pneumonitis and is mostly seen in immunocompromised patients. Pulmonary nocardiasis in form of massive unilateral pleural effusion in immunocompetant host without underlying pneumonitis is a rare condition.

CONCLUSIONS: In nocardiosis, pleural involvement occurs through direct spread from the chest wall or the lung parenchyma and pleural fluid may be the only source of diagnosis.Pulmonary nocardiosis mimics pulmonary tuberculosis in both clinical symptoms, being chronic in nature and radiological characteristics, and it is often wrongly treated with anti-tuberculosis drugs.The similarity of the radioclinical appearance between tuberculosis and nocardiosis demands that a search is made for the latter on all HIV positive patients and in negative cases a search for Koch's bacillus and empirical antibiotic therapy ought to have a spectrum of activity that would include nocardia.

Reference #1: Singh M, Sandhu RS, Randhawa HS, Kallan BM Prevalence of pulmonary nocardiosis in a tuberculosis hospital in Amritsar, Punjab.Indian J Chest Dis Allied Sci. 2000;42(4):325-39

Reference #2: Minero MV, Marin M, Cercenado E, et al. Nocardiosis as the turn of the century. Medicine 2009; 88: 250-261

DISCLOSURE: The following authors have nothing to disclose: Saurabh Kansal, Amrit Pal Kansal, Gopal Chawla, Kamal Deep

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