Nocardiosis in a Patient with Acute Necrotizing Pancreatitis. aCn A Simple Microscope Specimen Save a Patient’s Life? A Case Report

Abstract

Objective: A 50-year-old immunocompetent patient was hospitalized following an episode of acute necrotizing pancreatitis. Piperacillin/tazobactam was administered empirically. Despite continuous IV antibiotic therapy, on the 20th day of treatment the patient required urgent laparotomy. A swab sample was collected and subsequent Vancomycin with Amikacin administered empirically.Design: Despite administration of intensive treatment, general clinical condition of the patient deteriorated. The question was, why we experienced ineffectiveness of conservative treatment, as well as of subsequent surgical procedures? Was the microbiological specimen taken incorrectly? Why was it difficult to identify bacteria constituting the etiological infection source?Results: What is emphasized in our article is the significance of proper collection of a specimen and gathering an appropriate clinical history. What also needs to be taken into account in severe acute pancreatitis is perhaps allowing for longer bacterial culture growth. Conclusion:In this case, the infection was caused by a past injury with the previously undiagnosed etiological factor, i.e. Nocardia spp., challenging both current diagnosis and treatment, which ultimately resulted in severe necrotizing pancreatitis. This indicates the importance of a microbiologist for diagnosis and treatment.Keywords: Nocardiosis; Nocardia spp; Acute pancreatitis; Pancreatic abscess; Necrotizing pancreatitis Case ReportA 50-year-old patient was admitted due to increasing abdominal pain accompanied with nausea and vomiting. Prior to admission the patient developed discomfort in the epigastric region which was accompanied by nausea. In the evening, the patient's general condition deteriorated as persistent pain appeared together with vomiting with no relief. The pain increased significantly, the patient vomited several times, was weak, and it was more difficult to maintain logical contact with him. On admission blood pressure was 160/90, pulse 115 beats/ min., saturation 97%, tachypnea (24 breaths/min.). Laboratory results presented glycaemia 221 mg/dl, CRP 6.5 mg/dl, serum amylase 722 U/l and a slight anemia with Hb 13.3 g/dl.His medical history revealed cholecystectomy, stable angina pectoris, type 2 diabetes, hypertension. The patient was continued on betaxolol, ramipril, torasamide, rosuvastatin, fenofibrate, trimetazidine, and metformin. He did not report any allergies, had not been smoking for several years, and used nicotine substitutes only periodically. He did not consume alcohol.The patient was classified as risk group 2 due to diabetes, obesity, and hospitalization within the last 12 months. Other risk factors were dismissed by the patient.On admission the patient was conscious and oriented to time, place, and person. On examination type I obesity was observed with BMI 32.5, blood pressure 160/90, pulse 115 beats/min., body temperature 36.8°C, saturation 97%. The abdomen was soft, distended, tender in the epigastric region, negative peritoneal signs, slow peristalsis,...

Review of Infectious Etiology of Acute Pancreatitis

“…Sporadic cases of AP due to gastrointestinal bacteria like Campylobacter jejuni [ 35 , 36 ], Yersinia enterocolitica [ 37 , 38 ], Yersinia pseudotuberculosis [ 38 ], Brucella [ 39 ], and Nocardia [ 40 ] have been reported in the literature [ 6 ].…”

Comment on a Primary Cutaneous Nocardiosis of the Hand

“…Nocardia species are identified using conventional test and molecular methods that phenotypic tests are laborious, time-consuming, expensive and need to expertise technicians while molecular methods such as direct sequencing of the hsp65 (using pair primers of TB11: 5′-ACCAACGATGGTGTGTCCAT-3′ and TB12: 5′-CTTGTCGAACCGCATACCCT-3′) and 16S rRNA (whit primers 27f (5′-AGAGTTTGATCMTGGCTCAG-3′ and 1525r (5′-AAGGAGGTGWTCCARCC-3′) and PCR-RFLP are reliable, accurate and rapid for identification of nocardial infections especially in emergency cases for example in nocardial disseminated infections that necessary to urgent identifying Nocardia spp. before death of patients [ 3 ][ 4 ][ 5 ]. Based on the literatures, antimicrobial drug susceptibility of Nocardia species are different.…”