Chest Infections: Chest Infections I |

Pulmonary Infection by a Negative Acid-Fast Bacilli Nocardia cyriacigeorgica in a Patient With Bronchiectasis and Past History of Tuberculosis (TB) FREE TO VIEW

Mara Rubia Lima, MD; Eduardo Garcia, MD; Aline Siebeneichler, MD; Eduardo Everling; Patrícia Noguchi; Rafael Kiss; Bruno Hochhegger, MD; Everton Inamine, BScPharm; Spencer Camargo, MD; Bianca Schwengber, MD
Author and Funding Information

UFCSPA, Porto Alegre, Brazil

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A106. doi:10.1016/j.chest.2016.02.111
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SESSION TITLE: Chest Infections I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Nocardiosis is a rare lung infection caused by a Ziehl-Neelsen positive bacillus in immunocompromised hosts with multiple pulmonary cavitated nodules but also occurs in bronchiectasis cases making diagnosis more difficult.

CASE PRESENTATION: 05/11/2015 - 72-year-old non smoker man with asthenia, fever, weight loss, and night sweats for two months. No HIV infection, neoplasia or high-dose corticosteroid use. He takes omeprazole for gastritis and nasal fluticasone for rhinitis. Treated TB when 23 year old. Four years ago, right upper lobectomy due to bronchiectasis. 04/24/2015- culture of bronchial washing fluid obtained by fiberbronchoscopy positive for Aspergillus, starts itraconazole 400 mg/day. Axillary temperature 37.5 Celsius, Body Mass Index 17. Blood culture and serology negative for HIV and HCV. Negative acid-fast bacilli, fungi, and Gram staining sputum. 05/12/2015- Computed Tomography (CT) scan shows bronchiectasis, diffuse centrilobular opacities, consolidation, nodules with ground glass opacity. 05/15/2015- negative acid-fast bacilli, fungi and bacteria in bronchial washing fluid. Pneumocystis and Mycobacterium tuberculosis PCR: negative. No clinical improvement. 05/26/2015- CT-guided biopsy of the lung with negative results for bacteria, acid-fast bacilli, fungi and pneumocystis jirovecii; acute organizing pneumonia is identified, prednisone 40 mg/day is prescribed, and patient is discharged also taking itraconazole. 07/01/2015- readmitted and CT shows cavitation of the lung nodules. Prednisone and itraconazole suspended.07/03/2015- sample obtained by bronchoscopy shows no organism. 07/07/2015- videothoracoscopy collects lung sample with positive culture for Nocardia cyriacigeorgica by mass spectrometry. Patient starts sulfamethoxazole-trimethoprim and is discharged with tubular pleurostomia. In August, pleurostomy is closed, lung lesions improved, and treatment continued.

DISCUSSION: Despite no history of HIV infection, transplantation or neoplasia, this patient presents bronchiectasis, and received high doses of prednisone for a misdiagnosed organizing pneumonia. In Brazil, a country with high TB prevalence, repeated negative Ziehl-Neelsen staining and absence of cavitations make unlikely the diagnosis of TB and the suspicion of nocardiosis as well.

CONCLUSIONS: The lesson brought by this case is that nocardiosis may require invasive diagnostic procedures and should be considered more frequently, especially before prescribing systemic corticosteroids at high doses.

Reference #1: Wilson JW. Nocardiosis: updates and clinical overview. Mayo Clin Proc. 2012 Apr 87(4):403-7

Reference #2: Meharian P, Esfandiari E, Karimi MA, Memari B. Computed Tomography Features of Pulmonary Nocardiosis in Immunocompromised and Imunocompetent Patients. Pol J Radiol, 2015;80:13-17.

Reference #3: Aide MA, Lourenço SS, Marchiori E, Zanetti G, Mondino PJJ. Pulmonary nocardiosis in a patient with chronic obstructive pulmonary disease and bronchiectasis. J Bras Pneumol. 2008;34(11):985-988;

DISCLOSURE: The following authors have nothing to disclose: Mara Rubia Lima, Eduardo Garcia, Aline Siebeneichler, Eduardo Everling, Patrícia Noguchi, Rafael Kiss, Bruno Hochhegger, Everton Inamine, Spencer Camargo, Bianca Schwengber

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