|Year : 2010 | Volume
| Issue : 4 | Page : 390-392
A fatal case of empyema thoracis by Nocardia farcinica in an immunocompromised patient
MV Parande1, RS Shinde1, BG Mantur1, AM Parande1, MR Chandrashekhar1, PS Aralikatti2, E Palled3
1 Department of Microbiology, Belgaum Institute of Medical Sciences, Belgaum - 590 001, Karnataka, India
2 Department of Surgery, Belgaum Institute of Medical Sciences, Belgaum - 590 001, Karnataka, India
3 Department of Radiology, Belgaum Institute of Medical Sciences, Belgaum - 590 001, Karnataka, India
|Date of Submission||11-Mar-2010|
|Date of Acceptance||14-Jul-2010|
|Date of Web Publication||20-Oct-2010|
M V Parande
Department of Microbiology, Belgaum Institute of Medical Sciences, Belgaum - 590 001, Karnataka
Source of Support: None, Conflict of Interest: None
Empyema thoracis by Nocardia farcinica infection is uncommon. Here we report a rare and fatal infection in a 27-year-old HIV- seropositive male who presented with cough, expectoration, and breathlessness. Nocardia farcinica was isolated from sputum and pus from the pleural cavity. Confirmation of the isolate and minimum inhibitory concentrations (MIC) for various antibiotics was done at the Aerobic Actinomycetes Reference Laboratory, Centres for Disease Control and Prevention (CDC), Atlanta. Patient was treated with suitable antibiotics and antiretroviral drugs in spite of which he eventually succumbed to the disease.
Keywords: Empyema thoracis, Nocardia farcinica, immunocompromised
|How to cite this article:|
Parande M V, Shinde R S, Mantur B G, Parande A M, Chandrashekhar M R, Aralikatti P S, Palled E. A fatal case of empyema thoracis by Nocardia farcinica in an immunocompromised patient. Indian J Med Microbiol 2010;28:390-2
|How to cite this URL:|
Parande M V, Shinde R S, Mantur B G, Parande A M, Chandrashekhar M R, Aralikatti P S, Palled E. A fatal case of empyema thoracis by Nocardia farcinica in an immunocompromised patient. Indian J Med Microbiol [serial online] 2010 [cited 2019 Mar 26];28:390-2. Available from: http://www.ijmm.org/text.asp?2010/28/4/390/71831
| ~ Introduction|| |
Members of Nocardiaceae are Gram-positive weakly acid-fast filamentous saprophytic organisms, which form branching hyphae in living tissues and in culture media. Nocardia farcinica infections are rare and life-threatening. It can cause a variety of clinical presentations including localized diseases and disseminated infections especially in immunocompromised patients such as HIV disease, neoplasia, recipients of organ transplants, those receiving corticosteroids and chemotherapeutic agents.  Clinical diagnosis of nocardial infections and identification to species level is difficult. In addition to this, the organism is usually resistant to multiple antimicrobial agents especially broad-spectrum cephalosporins, which might make treatment of the infection difficult.  In the world literature, very few cases of empyema thoracis caused by Nocardia species are reported. ,, To the best of our knowledge, this is the second reported case and first reported fatal case of empyema thoracis caused by N. farcinica.
| ~ Case Report|| |
A 27-year-old male farmer was admitted to our hospital on 02.March, 2009 with history of cough with expectoration and discharging wound on the left side of the chest from last five months. Sputum was mucopurulent, foul smelling without blood. Patient had associated loss of appetite and weight. There was no history of similar complaints in the past or no family history of tuberculosis.
On physical examination at admission, patient was poorly built and nourished. Oral examination showed extensive oropharyngeal candidiasis. Body temperature was 100.4°F and respiratory rate was 28/min. On local examination a tender discharging sinus was present in the right midaxillary region. On auscultation, breath sounds were reduced on the right side of the chest. Other systems like CNS, CVS and per-abdominal examinations were apparently normal.
Laboratory evaluation revealed Hb 10.6 mg/dl and leukocyte count 6800/dl, differential counts were within normal limits and random blood glucose was 114 mg/dl. Patient's serum was reactive for HIV-1 antibodies and CD4 count was 156/dl (FACSCalibur TM Flow Cytometer, Becton Dickinson). Chest radiograph showed right lower middle lobe infiltrates with pleural effusion. A provisional diagnosis of HIV infection with empyema thoracis was made. Employing strict aseptic precautions, under local anaesthesia an intercostal drainage tube was inserted in the right 5 th intercostal space in the midaxillary line. Pus was drained and sent to the microbiology laboratory along with sputum sample for Gram stain, Ziehl-Neelsen (ZN) stain, culture and antibiotic sensitivity testing.
Direct Gram staining of the pus and sputum samples revealed plenty of pus cells with Gram-positive thin branching, rarely beaded filamentous structures. ZN staining and modified acid-fast staining were performed using 1% H 2 SO 4 as decolourizer. The modified acid-fast staining showed acid-fast thin branching beaded filamentous structures [Figure 1].
|Figure 1: Modified ZN stain of sputum sample showing pus-cells with acid-fast filamentous structures (×1000)|
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Samples were inoculated on blood agar, MacConkey's agar, Lowenstein-Jensen (LJ) medium, Sabouraud's Dextrose agar (SDA), thioglycollate broth and incubated aerobically at 37°C. After 72 h of incubation, small, dry, wrinkled, yellowish white colonies appeared on blood agar and SDA. Examination of the colonies under 10× objective revealed branching hyphae on and into the surface of the medium (substrate mycelium) and hyphae growing away from the agar surface (aerial mycelium) [Figure 2]. Colonies were seen on the LJ medium after nine days of incubation. Gram stain, ZN stain and modified ZN stain of the colonies revealed similar findings. The same organism was isolated from a repeat sample collected from the patient. The isolate was identified as N. farcinica on the basis of equal growth at 35 and 45°C; opacification on Middlebrook 7H10 agar; lack of arylsulfatase and resistance to gentamicin, tobramycin, erythromycin and cefotaxime., Antimicrobial susceptibility test was done by Kirby Bauer disc diffusion method. The isolate was sensitive to amoxicillin-clavulanic acid, trimethoprim / sulphamethoxazole, amikacin, ciprofloxacin, imipenem, linezolid and resistant to penicillin, ampicillin, gentamicin, tobramycin, erythromycin, cefotaxime, ceftriaxone and vancomycin.
|Figure 2: Colonies of N. farcinica on SDA showing fine, intertwining, branched filaments with delicate aerial hyphae (×10)|
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Isolate was sent to Aerobic Actinomycetes Reference Laboratory, CDC, Atlanta, USA (CDC sample code no. 2009010677), where identification of isolate was confirmed as N. farcinica and MIC for different antibiotics was done by broth micro-dilution method, according to Clinical and Laboratory Standards Institute (CLSI) guidelines  [Table 1].
|Table 1: Minimum inhibitory concentrations of various antibiotics against N. farcinica|
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Based on antibiotic susceptibility pattern, patient was started on amikacin and trimethoprim/sulphamethoxazole intravenously along with antiretroviral therapy (ART) at the ART centre. The patient showed initial clinical improvement, but later he developed extensive pulmonary infection, which was evident on repeat chest radiograph. However, patient's health continued to deteriorate and he eventually succumbed to the disease on August 22, 2009.
| ~ Discussion|| |
Nocardia species is a soil saprophyte found worldwide and its infection is acquired from natural sources.  In our case, patient was a farmer by occupation so respiratory route is the most probable route of transmission. Suppression of cellular immunity and chronic granulomatous disease are important risk factors for Nocardia infection.  In a recent retrospective review of 53 cases of N. farcinica infections, 85% of the patients had predisposing factors. 
The incidence of nocardial infections in human and animal populations is not known. Several reports indicate that such infections are under-diagnosed and incidence of infections is apparently increasing. Because of its controversial status N. farcinica was not mentioned in the literature for some years, so its relative frequency among clinical nocardial isolates is difficult to determine and may vary geographically.  In a study from USA, N. farcinica was reported to constitute 19% of 200 isolates and 60.3% of 131 isolates in a study from Germany. 
Pulmonary infection via inhalation of contaminated airborne dust particles may be subclinical or transient or may provoke an acute or chronic granulomatous process mimicking staphylococcal or fungal pneumonia, tuberculosis or carcinoma.  Nocardia organisms have tendency to disseminate haematogenously from the primary site of infection usually to the lungs, brain, kidney, joints, bones and eyes.  Among the very few reported cases of empyema thoracis, cough, progressive dyspnoea and pleuritic chest pain were the presenting complaints. Our case presented with a chief complaint of discharging sinus of long duration which is an unusual presentation.
In our case, the Gram stain finding of gram-positive filamentous organisms was further identified as Nocardia by modified ZN staining. Hence modified ZN staining is a simple, rapid and cost-effective method for identification of Nocardia, which can be performed on all suspected clinical samples in any routine Microbiology laboratory.
A case of idiopathic thrombocytopenic purpura with pyothorax caused by N. farcinica is the only reported case to the best of our knowledge which recovered after antibiotic treatment.  In our case, in spite of treatment with appropriate antibiotics and antiretroviral drugs, patient succumbed to the disease. The fatality could be due to delay in the diagnosis as patient reported late to the hospital and also his immunocompromised state.
Misinterpretation of findings as contaminants and difficulties in determining the precise species can delay the start of appropriate antibiotic therapy. Because of aggressiveness and tendency of N. farcinica infections to disseminate and resistance of the organism to antibiotics, such a delay can have serious consequences. 
In conclusion, we advocate high index of suspicion for Nocardia in immunocompromised state with respiratory infections because of increase in the incidence of such cases. Active effort is to be made to collect appropriate samples and modified ZN staining to be done for all such samples. Routine microbiology laboratory should attempt to isolate and identify Nocardia up to species level, and in vitro antibiotics susceptibility testing should be done because N. farcinica is usually resistant to multiple antimicrobial agents.
| ~ Acknowledgment|| |
The authors gratefully acknowledge Gerald J. Pelligrini, Microbiologist, Aerobic Actinomycetes Reference Laboratory CDC, Atlanta, USA, for confirming the identification of the isolate and performing the MIC of various antibiotics.
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[Figure 1], [Figure 2]
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