Nocardiosis

Nocardiosis General Information

Nocardiosis infections can be local or disseminated, caused by a fungus-like bacteria called nocardia brasiliensis or nocardia asteroides are very rare diseases affecting especially the lungs (leading to a pulmonary type) and secondly the soft tissues, brain or other organs. These bacteria often live in the soil. When it affects the whole body we name it systemic. It develops mostly in men who present a weakness of the immune system. Left untreated it can cause death. This immune system weakening may be caused by different forms of cancer or by immunosuppressive medications or steroids. In children, the main cause may be represented by a transplantation of bone marrow, cytoxic chemotherapy or a treatment with glucocorticoids that lasted for too long. These are the risks of getting a disseminated Nocardiosis (when the bacteria is inhaled and leads to sepsis or poisoning of the blood). A very high mortality rate (over 70%) is met in patients affected by a brain infection; in the other cases, this rate is somewhere under 40% even if the adequate treatment is prescribed and followed properly. This suppurative infection can have different forms: acute, subacute and chronic. It can decrease in gravity or as well can go even more serious in a short time. The reason of getting infected with this disease may be a simple cut, scratch or wound that appears when someone is working outside the house (e.g. gardening). This skin infection occurs in various different forms and is known as cutaneous Nocardiosis.

Nocardiosis Symptoms

Symptoms depend all the time on the type of the infection. The organisms that cause Nocardiosis are found in the soil and they usually transmit through inhalation from the dust in the environment. When working with soil in farming, field works or landscaping the risk is even higher. A less common way of transmission is through abrasions or puncture wounds. In the first step, the bacteria infects the pulmonary areas causing pneumonia, but it can also spread to other parts of the body. These complications often develop in the brain or skin. When affecting the airways and the lungs, the main signs of Nocardiosis are: shortness of breath, coughing with mucous or blood, chest pain, pulmonary insufficiency that makes the breathing harder and harder. At the surface of the skin causes lumps, swallowing of the lymph nodes, abscesses (skin sores) and skin rashes. But all these signs may be misinterpreted with other more common skin infections. If it gets in the whole body can provoke a general feeling of illness, fever that comes and goes continually or an excessive sweating while sleeping. Headache, seizures, mental states changes, lethargy, dizziness and confusion are the most common symptoms of a nervous system infection. When reaching to the gastrointestinal system, the bacteria lead to a swallowing of the spleen and liver, nausea and vomiting and weight loss. The complications that develop from Nocardiosis are many and result as secondary conditions, being very hard to distinguish them as complications. They include mycetoma, pneumonia, gram positive bacilli or granuloma (intracranial abscess).

Nocardiosis Treatment

The number of immunocompromised persons has increased in the last few years so that the number of cases is also higher than it was a couple of years ago, although Nocardiosis is not a very common disease. In the case of a pulmonary infection, the spreading occurs through primary cutaneous affections (contaminated wounds) or inhalation. For a management of protracted antimicrobial therapies the expertise by a specialist in infectious diseases is highly recommended. Very important is also the site of the infection that may be thoracic or pulmonary so a consultation by a neurosurgeon is the most appropriate thing to do. A diagnosis on Nocardiosis may be difficult to put because identifying it by discharge or culture of sputum may be challenging. Diagnosing this disease requires almost all the time a typical clinical picture used in combination with special staining techniques. Owing to the fact that nocardiae are weakly acid-fast organisms they can be seen only by modifying Ziehl Neelsen stains. If there is a need to identify the species, the clinical laboratory holds routine cultures.Occasionally, using chest X-rays it can easily be observed if there is an infection of the pleura because it shows abscesses, interstitial or fluffy infiltrations or nodules. Lumbar puncture is very often used in brain infections caused by meningitis because it reveals increased opening pressure or other nonspecific changes. In a brain infection it is absolutely necessarily to monitor the patient for respiratory abnormalities or low levels of consciousness, including also any other signs of an increased intracranial pressure. It is necessarily to auscultate a patient’s lungs every day if he or she suffers of a pulmonary infection.

Another way of detecting Nocardiosis is analyzing the cerebrospinal liquid that might discover a low protein level and number of white blood cells or a high concentration of glucose in comparison with serum glucose. What it is very worrying is that more than 30% of nocardial infections are discovered only after the death of the patient, at the postmortem examination. What a doctor will always recommend is a therapy based on a high sulfa dose. Bactrim (timethoprim-sulfamethoxazole) or sulfadiazine is given intravenously. The period of treatment lasts for six months or may be longer and includes high doses of sulfonamides in combination with co-trimoxazole. There may be patients who do not respond to this kind of treatment so that other medications should be used, for example minocycline, ampicillin or erythromycin may be added. A new therapy with drugs that shows really good effects is based on amikacin, sulfonamide or ceftriaxone. During drug treatments, doctors may recommend surgical excision of necrotic tissues or drainage of abscesses. If the patient presents the acute phase of Nocardiosis, he must have as much bed rest as possible. If his or hers health state gets better, the activity can increase. Nocardiosis is not transmitted from a person to another one so that it does not require any isolation. Patients with CNS or AIDS need to be closely monitored because a relapse can occur a few years after the therapy.