Nocardia infections among immunomodulated inflammatory bowel disease patients: A review

Abstract

Human nocardiosis, caused by Nocardia spp., an ubiquitous soil-borne bacteria, is a rare granulomatous disease close related to immune dysfunctions. Clinically can occur as an acute life-threatening disease, with lung, brain and skin being commonly affected. The infection was classically diagnosed in HIV infected persons, organ transplanted recipients and long term corticosteroid treated patients. Currently the widespread use of immunomodulators and immunossupressors in the treatment of inflammatory diseases changed this scenario. Our purpose is to review all published cases of nocardiosis in immunomodulated patients due to inflammatory diseases and describe clinical and laboratory findings. We reviewed the literature concerning human cases of nocardiosis published between 1980 and 2014 in peer reviewed journals. Eleven cases of nocardiosis associated with anti-tumor necrosis factor (TNF) prescription (9 related with infliximab and 2 with adalimumab) were identified; 7 patients had inflammatory bowel disease (IBD), 4 had rheumatological conditions; nocardia infection presented as cutaneous involvement in 3 patients, lung disease in 4 patients, hepatic in one and disseminated disease in 3 patients. From the 10 cases described in IBD patients 7 were associated with anti-TNF and 3 with steroids and azathioprine. In conclusion, nocardiosis requires high levels of clinical suspicion and experience of laboratory staff, in order to establish a timely diagnosis and by doing so avoid worst outcomes. Treatment for long periods tailored by the susceptibility of the isolated species whenever possible is essential. The safety of restarting immunomodulators or anti-TNF after the disease or the value of prophylaxis with cotrimoxazole is still debated.

Diagnosis of severe respiratory infections in immunocompromised patients

“…Specific risk factors have been reported for pneumonia due to Nocardia, Neisseria, Rhodococcus, and Q fever (Coxiella burnetii). Nocardiosis is associated with hematological and solid malignancies, high-dose steroid therapy, and TNFα antagonist therapy [25]. Risk factors for N. meningitidis infection are nasopharyngeal carriage and complement deficiencies [26].…”

Central nervous system nocardiosis in Queensland

“…Newer immunosuppressive therapies such as monoclonal antibodies may also be a risk factor for infection and several cases of CNS nocardiosis have been reported in the setting of monoclonal antibodies. [25–28] The concomitant use of multiple agents and corticosteroids in particular makes direct attribution of risk difficult. However, given the increasing number of individuals being placed on novel agents, this is an area which warrants further scrutiny.…”

Pulmonary co-infection with nocardia species and nontuberculous mycobacteria mimicking miliary tuberculosis in a patient with Crohn’s disease under combined immunosuppressive therapy

“…Nocardiosis is a rare and life-threatening opportunistic infection in immunocompromised hosts caused by ubiquitous soil-born, acid-resistant, Gram-positive bacteria. Originally usually diagnosed in HIV-positive patients, reports of Nocardia infection in IBD patients were summarized and presented by Abreu et al in 2015 [2]. The authors identified 11 cases of nocardiosis in patients with anti-TNF-α therapy, of which 7 patients had IBD.…”

“…Nocardiosis and infection with atypical mycobacteria have been described in HIV-positive patients with substantial immunodeficiency. Only a few cases of nocardiosis in IBD patients have been reported [2]. We describe the first case of pulmonary co-infection with Nocardia spp.…”