Fatal pulmonary infection by trimethoprim-sulfamethoxazole resistant Nocardia otitidiscaviarum: report of two cases and review

Abstract

Introduction: Nocardia otitidiscaviarum is a rare cause of human infections, mostly causing cutaneous and lymphocutaneous infections of mild severity. We report two cases of fatal pulmonary infection caused by Nocardia otitidiscaviarum in elderly patients.
 Methodology: Case 1: A 70-year old woman presented with fever and cough with expectoration for a month. On physical examination, she had tachypnea and inspiratory crepitations in bilateral basal regions. Case 2: A 74-year old man presented with productive cough with foul smelling expectoration, fever and shortness of breath for one week. On examination, he had tachypnea, bilateral wheezing and inspiratory crepitations. In both cases, sputum was sent to microbiology laboratory. On direct microscopy Gram-positive, finely branching filaments were observed which were acid fast with 1% sulphuric acid. Chalky white opaque wrinkled colonies with musty basement type odour were seen on blood agar. Both patients were treated empirically with trimethoprim-sulfamethoxazole for Nocardia infection after notification of microscopy findings however both expired on Day 2 and Day 5 of admission, respectively. Both isolates were susceptible to amikacin, linezolid, ciprofloxacin and gentamicin. They were resistant to trimethoprim-sulfamethoxazole, ampicillin, amoxicillin-clavulanic acid, erythromycin, and imipenem. Based on biochemical identification and antimicrobial susceptibility pattern, the organism was identified as Nocardia otitidiscaviarum. The identification was confirmed using MALDI-TOF (Vitek MS, Biomerieux, France).
 Conclusion: Our report highlights the importance of early identification of Nocardia to species level to improve treatment outcomes especially in critically ill patients. Mass spectrometry can become an integral part of diagnostic algorithms for nocardiosis.

A fatal case of disseminated nocardiosis due to Nocardia otitidiscaviarum resistant to trimethoprim–sulfamethoxazole: case report and literature review

“…In our case, the isolated N. otitidiscaviarum was susceptible to Linezolid and Amikacin and was resistant to TMP-SMX, Ciprofloxacin, Imipenem, Cefepime, Cefoxitin, Amoxicillin-Clavulanic acid, Clarithromycin and Tobramycin. Seven cases were similarly reported with resistance to TMP-SMX [ 17 , 19 , 21 , 24 , 28 , 30 ] with four cases reported in immunocompetent patients [ 17 , 19 , 24 ], and one infecting a farmer [ 19 ], details of these studies are described in Table 4…”

“…Susceptible to Aminoglycosides, Beta-lactams and Carbapenem Levofloxacin + Vancomycin + Tobramycin Died Princess et al [ 21 ] 2018 51F On Corticosteroid therapy Resistant to: TMP-SMX, Amoxicillin, Clavulanate. Susceptible to: Amikacin, Ciprofloxacin, Linezolid, Imipenem and Ceftriaxone Azithromycin + Doxycycline à TMP-SMX + Imipenem Died Saksena et al [ 24 ] 2020 74M Immunocompetent Resistant to: Ampicillin, Amoxicillin-Clavulanate, Erythromycin, TMP-SMX and imipenem. SusceptibleTo: Amikacin, Linezolid, Ciprofloxacin, and Gentamicin Amoxicillin-Clavulanate + Azithromycin à TMP-SMX Died Saksena et al [ 24 ] 2020 74F Immunocompetent Resistant to: Ampicillin, Amoxicillin-Clavulanate, Erythromycin, TMP-SMX and imipenem.…”

“…Susceptible to: Amikacin, Ciprofloxacin, Linezolid, Imipenem and Ceftriaxone Azithromycin + Doxycycline à TMP-SMX + Imipenem Died Saksena et al [ 24 ] 2020 74M Immunocompetent Resistant to: Ampicillin, Amoxicillin-Clavulanate, Erythromycin, TMP-SMX and imipenem. SusceptibleTo: Amikacin, Linezolid, Ciprofloxacin, and Gentamicin Amoxicillin-Clavulanate + Azithromycin à TMP-SMX Died Saksena et al [ 24 ] 2020 74F Immunocompetent Resistant to: Ampicillin, Amoxicillin-Clavulanate, Erythromycin, TMP-SMX and imipenem. Susceptible to: Amikacin, Linezolid, Ciprofloxacin, and Gentamicin Meropenem + Colistin à TMP-SMX added Died M, male; F, female; TMP-SMX, trimethoprim–sulfamethoxazole; GCS, Glasgow coma scale …”

A Canine Case of Nocardia africana Infection Detected by Matrix-Assisted Laser Desorption Ionization—Time-of-Flight Mass Spectrometry

“…Treatment of nocardiosis usually requires long-term antibiotic administration. Trimethoprimsulfamethoxazole has long been used as first-line antibiotic therapy for nocardiosis, but resistance to this treatment has recently emerged [16]. In two previous reports of feline nocardiosis caused by N. africana, clinical signs were not controlled by treatment with trimethoprim-sulfamethoxazole [7,8].…”

Disseminated life threatening Nocardia otitidiscaviarum infection in a young female with newly diagnosed systemic lupus erythematosus, case report and review of literature

“… TMP-SMX x 6 months + Recovered [46] Praveen et al . , 2014 60/M Chronic obstructive pulmonary disease, trauma Subcutaneous, soft tissue Chest X-ray revealed increased bronchovascular markings in para-hilar region with emphysematous changes Amikacin + linezolid for 4 weeks then Oral linezolid for 8 weeks + Recovered [47] Douedi S et al 2020 56/M Diabetes Skin venous thrombosis of cephalic vein and abscess formation within the soft tissue of right axilla TMP-SMX for 3 months – Recovered [48] Scheelje Carabelli et al 2019 89/F Asthma, Bronchiectasis Lung right hydropneumothorax and areas of consolidation cotrimoxazole, amikacin, + imipenem + Died [49] Paniagua-García M et al 2019 57/M Diabetes mellitus, Chronic obstructive pulmonary disease Lung Brain Skin Right pleural effusion with diffuse thickening of the pleural layers, suggestive of empyema TMP-SMX Linezolid – Died [50] Saksena R et al 2020 70/F None Lung None described TMP-SMX – Died [51] Magalhães GM et al 2010 37/M None Hand osteolytic lesion on the hand bones TMP-SMX – Recovery [52] Yi-Chun Chen et al 2013 61/M Diabetes mellitus, Chronic liver disease Lung Pleural Effusion No detail available – Died [53] Yi-Chun Chen et al 2013 47/M Diabetes Mellitus Lung...…”