Nocardia infection in renal transplant recipient: diagnostic and therapeutic considerations

Abstract

In the present report the authors discuss the diagnostic difficulties, therapeutic measures and the clinical course of Nocardia infection which occurred among renal transplant recipients at the University Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (UH-FRP), from 1968 to 1991. Among 500 individuals submitted to renal transplant, 9 patients developed Nocardiosis at varying times after transplant (two months to over two years). All the patients had pulmonary involvement and their most common symptoms were fever, cough and pleural pain. Dissemination of the process is common and three patients presented cutaneous abscesses, four CNS involvement and one had pericarditis due to Nocardia. The diagnostic is quite difficult since there is no specific clinical picture, concomitant infections are frequent and the microorganism presents slow growth in culture (ranging from four to forty days, in our experience). In this report, three cases were only diagnosed by necropsy. The treatment of choice is a combination of Sulfamethoxazole and Trimethoprim (SMX-TMP). In the present series, overall mortality was 77% (7 cases) and in five of the patients who died the diagnosis was late. All the patients who had CNS involvement died.

Molecular Identification of Nocardia Isolates from Clinical Samples and an Overview of Human Nocardiosis in Brazil

“…The only large series of nocardial infections occurred from 1978 to 1998 and was reported by Chedid and co-workers [41]. Solid organ transplantation was the most common underlying condition before the advent of effective medical therapy, which included the introduction of cyclosporine and prophylaxis with TMP-SMZ [5], [42], [43], [44]. Batista and co-workers [45] found only one case of nocardiosis among 1046 kidney and 708 liver transplants patients registered in four Brazilian centers in different geographical areas from 2001 to 2006.…”

Nocardial infections: report of 22 cases

“…In Germany the predominant species identified is N. farcinica (60.3%) 29 . In Japan 303 cases of nocardiosis were diagnosed showing that most were caused by N. asteroides complex (72.3%), being N. farcinica the predominant species (81 strains) followed by N. asteroides (72 strains) and N. brasiliensis (66 strains) 17 ; while in France 66.7% of isolates were N. asteroides and 23.8% were N. farcinica 6. In Brazil the reported lung infections were caused by N. asteroides complex 25,27 . This is the largest series of nocardial infections in Brazil since we published the first two pulmonary cases 25 which are included in the present series (patients 1 and 2).…”

The pleural space and organ transplantation.

“…Several cases of Nocardia pneumonia with pleural involvement have been described (113)(114)(115)(116)(117). Most have occurred within the first 4 mo after transplantation and/or with treatment for graft rejection (113,114,117).…”

“…Most have occurred within the first 4 mo after transplantation and/or with treatment for graft rejection (113,114,117). Chest radiographs revealed isolated pleural effusions (114) or effusions associated with pulmonary infiltrates (114,116,117).…”