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Letters to the Editors

Pulmonary Abscess Caused by Nocardia beijingensis: The Second Report of Human Infection

Chu, Reann Wai-Po MBChB, FHKAM (Paediatrics); Lung, David MBBS; Wong, Sik-Nin MBBS, FRCPCH

Author Information
The Pediatric Infectious Disease Journal: June 2008 - Volume 27 - Issue 6 - p 572-573
doi: 10.1097/INF.0b013e31816ffbfc
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To the Editors:

Nocardia is a ubiquitous Gram-positive actinomycetes that can cause local suppuration or systemic infection in humans and animals. At least 16 species of Nocardia are known to cause human infections. Beaman et al1 reported that 80–90% of human nocardiosis in the United States were caused by Nocardia asteroids, and the rest were caused by Nocardia brasiliensis, Nocardia farcinica, Nocardia nova, and Nocardia transvalensis. A recent Belgium series by Wauters et al2 showed that the commonly identified species were Nocardia farcinica (44%), Nocardia nova (22%), Nocardia brasiliensis (7%), Nocardia abscessus (6%), and Nocardia paucivorans (2%). Nocardiosis is typically regarded as an opportunistic infection in immunocompromised patients. In 1997, Mok et al3 described nocardiosis in 6 systemic lupus erythematosus (SLE) patients, and identified 26 other cases in their literature search. In a search for novel actinomycetes, Wang et al4 first isolated Nocardia beijingensis from soil in China in 2001. Kageyama et al5 reported this new species in human infectious samples in 2004. We report a 13-year-old girl with SLE who suffered pulmonary nocardiosis caused by N. beijingensis.

Our patient presented at age 11 years with fever, generalized skin rash, pancytopenia, positive SLE serology, and diffuse proliferative glomerulonephritis on renal biopsy. She remitted after a full 2-year course of intravenous cyclophosphamide and oral prednisolone. Her nephritis relapsed 1 year later and she needed reinduction with high-dose prednisolone and mycophenolate mofetil. She developed fever, dyspnea, and left lung consolidation on chest radiography. Bronchoscopy was performed and the bronchoalveolar lavage fluid was plated on blood agar and chocolate agar. An organism was isolated within 3 days. It produced chalky white, doom-shaped, small and rough colonies. They were Gram-positive rod-shaped organisms producing aerial hyphae. The organism grew in lysosome and was modified Ziehl-Neelson stain positive. The preliminary identification was Nocardia species. The 16s rRNA gene was sequenced with Microseq 500 (ABI 310, Applied Biosystems). The sequence of the 16s rRNA gene was compared by performing a sequence database search using BLAST (Basic Local Alignment and Search Tool). BLAST search revealed that this strain of Nocardia was most similar to N. beijingensis (Accession number from AB094639 to AB094656).

The infection progressed to massive lung abscess evident on computerized tomography of thorax (Fig. 1). Despite that, she was treated successfully with intravenous meropenem for 4 weeks, followed by oral cotrimoxazole for 1 year. Repeat computed tomography scan showed complete resolution of her lung abscess.

FIGURE 1.
FIGURE 1.:
Computed tomography scan of thorax (lung window with intravenous contrast) showing patchy ground-glass attenuation in both lungs. There was massive left lower lobe consolidation and a cavitatory lesion with a fluid level inside.

To our best knowledge, this is the second report of human infection caused by N. beijingensis. It is believed that N. beijingensis is widely distributed in the South-East Asia, including China, Japan, and Thailand.4 It may be an underreported pathogen since first identified in 2001. Although classically antibiotic therapy and surgical drainage were regarded as the mainstay of treatment for suppurative nocardia infections, this case illustrated that conservative treatment may be equally effective.

Reann Wai-Po Chu, MBChB, FHKAM (Paediatrics)

Department of Paediatrics and Adolescent Medicine

David Lung, MBBS

Department of Clinical Pathology

Sik-Nin Wong, MBBS, FRCPCH

Department of Paediatrics and Adolescent Medicine

Tuen Mun Hospital

Hong Kong Special Administration

Region China

REFERENCES

1.Beaman BL, Burnside J, Edwards B, Causey Wl. Nocardial infections in the United States 1972–1974. J Infect Dis. 1976;134:286–289.
2.Wauters G, Avesani V, Charlier J. Distribution of nocardia species in clinical samples and their routine rapid identification in the laboratory. J Clin Microbiol. 2005;43:2624–2628.
3.Mok CC, Yuen KY, Lau CS. Nocardiosis in systemic lupus erythematosus. Semin Arth Rheum. 1997;26:675–683.
4.Wang L, Zhang Y, Lu Z, et al. Nocardia beijingensis sp. nov., a novel isolate from soil. Int J Syst Evol Microbiol. 2001;51:1783–1788.
5.Kageyama A, Poonwan N, Yazawa K, Mikami Y, Nishimura K. Nocardia beijingensis, is a pathogenic bacterium to humans: The first infectious cases in Thailand and Japan. Mycopathologia. 2004;157:155–161.
© 2008 Lippincott Williams & Wilkins, Inc.