Fulminant Nocardiosis Due to a Multidrug-Resistant Isolate in a 12-Year-Old Immunocompetent Child

Abstract

Nocardiosis is a rare cause of infection that usually affects immunocompromised adult patients and might not be recognized by pediatricians. We report a fatal case of disseminated nocardiosis in a previously healthy child initially admitted for an abdominal mass with suspicion of a renal malignant tumor. The patient, originating from Mali without any medical history, displayed abdominal pain with progressive altered general status. Laboratory and imaging findings revealed lymphocytic meningitis and disseminated abscesses in the brain and the cerebellum and a large number of cystic lesions of the kidney. Despite being administered wide-spectrum antibiotics and antituberculous and antifungal therapies with an external ventricular drainage for intracranial hypertension, the patient died 6 days after his admission. spp was cultured from a renal biopsy and the cerebrospinal fluid. Species identification and antibiotic susceptibility were obtained later, revealing a multidrug-resistant isolate of the complex. This case reveals the difficulties of diagnosing nocardiosis, in particular in children not known to be immunocompromised, because we face multiple differential diagnoses and the importance of treating nocardiosis appropriately because of intrinsic resistance issues.

Nocardialung abscess in an immunocompetent adolescent

“…There are few documented cases of pulmonary nocardiosis affecting adult immunocompetent patients,7–9 and they are mostly associated with pulmonary chronic disease (such as bronchiectasis, chronic obstructive pulmonary disease or asthma) 10–13. There are also reports of previously healthy children having nocardiosis associated with pneumonia and pleural effusion, central nervous system infection and septic arthritis 14–17…”

Nocardia spp.: A Rare Cause of Pneumonia Globally

“…Most cases (60 to >80%) of nocardiosis occur in patients with severely impaired cellular immunity. 4,5,19,77 However, infections (sometimes fulminant and lethal) may occur in previously healthy hosts, 5,9,10,12,23,78 particularly in subtropical or tropical regions. 5,16 Nocardiosis is more common in males.…”

“…34,175 In one IC patient with brain abscesses and an intracranial aneurysm due to N. abscessus, a combination of antimicrobials and surgical resection of the aneurysm was curative. 183 Severe CNS disease may occur even in previously healthy children 9 and adults. 38,183,186,187 Nocardia paucivorans, which rarely causes diseases in humans, appears to have a predilection for CNS involvement and dissemination.…”

“…Infections caused by bacteria in the genus Nocardia (termed nocardiosis) may cause pneumonia and other infections, principally in immunosuppressed (IS) patients with severe impairments in cellular immunity. [1][2][3][4][5][6][7][8] However, nocardiosis may occasionally affect immunocompetent (IC) patients, 9,10 especially those with underlying pulmonary disease, 11,12 bronchiectasis, 10,13,14 diabetes mellitus, [15][16][17] or alcohol abuse. 16,18 Pulmonary nocardiosis may mimic communityacquired pneumonia, and this may be more common among individuals with agricultural or outdoor occupations in developing countries.…”

Systemic Nocardiosis as Unusual Clinical Onset of Late Advanced HIV Infection: A Case Report

“…Furthermore, cases of multi-drug resistance nocardiosis [9,10] and the epidemiology and drug susceptibility of less common Nocardia species have recently been described [11,12]. In HIV-positive patients pulmonary nocardiosis, the most common clinical presentation, has a low reported prevalence of 0.3% [13], and it is not considered an AIDSdefining disease.…”