Nocardial Infections in Bone Marrow Transplant Recipients

Abstract

Infections caused by Nocardia species have been infrequently described in bone marrow transplant (BMT) recipients. We reviewed six cases of nocardiosis occurring in our population of BMT recipients and the four cases previously reported in the literature. The rate of nocardial infection at our institution was 0.2% (1 of 554) among autologous BMT recipients and 1.7% (5 of 302) among allogeneic BMT recipients (odds ratio, 9.3 [95% confidence interval, 1.1-80.1]; P = .046). All 10 patients had received immunosuppressive medications, and all but one allogeneic BMT recipient had acute or chronic graft-vs.-host disease (GVHD). Four patients had extensive exposure to soil or dust before nocardiosis developed. Seventy percent of the patients died, but death was less often due to progressive nocardial infection than to complications of GVHD and associated invasive infection with Aspergillus species. Three patients had nocardiosis despite receiving prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMZ) on an intermittent basis two or three times a week. These data show that nocardial infection is an important if infrequent complication of bone marrow transplantation and is associated with a high rate of invasive fungal infection. TMP-SMZ prophylaxis given intermittently does not reliably protect against infection.

Nocardia in Solid Organ Transplant Recipients

“…In fact, nocardiosis appears to be a rare infection in children (105)(106)(107) (20,108). However, there are increasing reports of breakthrough infections by TMP-SMX-susceptible Nocardia isolates in patients taking TMP-SMX prophylaxis (11,13,14,19,34,46,69,(108)(109)(110), creating some doubt about the utility of this agent for prevention of nocardiosis (34) (13,14,109), though nocardiosis has also been reported despite daily TMP-SMX prophylaxis (46). Data are limited on which to base recommendations for secondary prophylaxis.…”

Nocardia cyriacigeorgica Septicemia

“…Hematogenous dissemination to the central nervous system, bone, joint, eyes, kidney, spleen, liver, thyroid, adrenal, heart, and/or prostate may occur (4, 10-12, 16), although central nervous system infection without apparent lung or skin involvement has commonly been reported (2,16). While nocardial infections may occur in individuals with intact immune systems, disease (particularly disseminated infection) is more commonly seen in patients with marked immunodeficiency such as those with bone marrow or solid-organ transplants, lymphoreticular malignancy, or AIDS or in the setting of chronic corticosteroid therapy (3,4,6,(10)(11)(12)16).…”

Pulmonary Nocardiosis Developed in a Hematopoietic Stem Cell Transplant Recipient with Bronchiolitis Obliterans

“…Patients with incomplete immune reconstitution following allogeneic HSCT are believed to have a significantly increased risk of nocardiosis. Reportedly, the overall incidence of nocardiosis in allogeneic HSCT recipients is 0.3 to 1.7% (16,17). In fact, among cancer patients who contracted nocardiosis, 31% of them were HSCT recipients (18).…”