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VOLUME 23 , ISSUE 10 ( October, 2019 ) > List of Articles

Original Article

Pulmonary Nocardiosis Presenting as Exacerbation of Chronic Pulmonary Disease

Roopa Kancherla, Ramanathan Palaniappan Ramanathan, Bobbe Appalaraju, Srinivas Rajagopala

Citation Information : Kancherla R, Ramanathan RP, Appalaraju B, Rajagopala S. Pulmonary Nocardiosis Presenting as Exacerbation of Chronic Pulmonary Disease. Indian J Crit Care Med 2019; 23 (10):467-474.

DOI: 10.5005/jp-journals-10071-23270

License: CC BY-NC 4.0

Published Online: 01-04-2019

Copyright Statement:  Copyright © 2019; The Author(s).


Background: Pulmonary nocardiosis (PN) occurs in chronic pulmonary disease (CPD) in the absence of traditional risk factors. Clinical features that differentiate bacterial exacerbations (AE-CPDb) from PN-related exacerbations (AE-CPDPN) are not well described. Objectives: To describe a series of AE-CPDPN without traditional risk factors and compare clinical features, radiology and outcomes with age, gender and CLD-type matched AE-CPDb. Materials and methods: Single-center retrospective review and case-control study. Results: AE-CPDPN had longer duration of symptoms and more leukocytosis at hospitalization. AE-CPDb patients were sicker with more chronic respiratory failure (OR 33.3, p = 0.01), cardiac disease and pulmonary hypertension (OR 6.2, p = 0.008) at diagnosis. More patients with AE-CPDb were discharged on domiciliary oxygen (OR 5.27, p = 0.01). On logistic regression, AE-CPDPN was independently associated with mechanical ventilation (OR 22.3, p = 0.01), length of hospital stay (median difference, 4 days, p = 0.016) but not to hospital mortality. 22.7% of AE-CPDPN died. Respiratory failure requiring oxygen, NIPPV or mechanical ventilation was associated with mortality in AE-CPDPN. Conclusion: PN is a rare cause of AE-CPD and can be suspected by longer symptom duration, more leukocytosis, consolidation and cavitation. AE-CPDPN is associated with longer hospital stay and mechanical ventilation. Respiratory failure is associated with mortality in AE-CPDPN. Key messages: Pulmonary nocardiosis can present in advanced chronic lung disease as an exacerbation in the absence of traditional risk factors like immunosuppression. Bronchiectasis, followed by chronic obstructive pulmonary disease are the most common chronic lung disease risk factors. Pulmonary nocardiosis is a rare cause of acute exacerbation of chronic pulmonary disease (CPD). Compared to exacerbations of CPD due to bacterial infections, nocardiosis-related exacerbations (CPDPN) were independently related to need for mechanical ventilation and length of hospital stay. Respiratory failure requiring oxygen, noninvasive ventilation and mechanical ventilation are associated with mortality in AE-CPDPN.

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  1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease: 2018 Report. 2018. Accessed 20/7/2018.
  2. Ko FW, Chan KP, Hui DS, Goddard JR, Shaw JG, Reid DW, et al. Acute exacerbation of COPD. Respirology. 2016;21(7):1152–1165.
  3. Menendez R, Cordero PJ, Santos M, Gobernado M, Marco V. Pulmonary infection with Nocardia species: a report of 10 cases and review. Eur Respir J. 1997;10(7):1542–1546.
  4. Garcia-Bellmunt L, Sibila O, Solanes I, Sanchez-Reus F, Plaza V. Pulmonary nocardiosis in patients with COPD: characteristics and prognostic factors. Arch Bronconeumol. 2012;48(8):280–285.
  5. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA). 2018. Accessed 20-7-2018.
  6. Travis WD, Costabel U, Hansell DM, King TE Jr, Lynch DA, Nicholson AG, et al. An official American Thoracic Society/European Respiratory Society statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med. 2013;188(6):733–748.
  7. Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, et al. Standardisation of spirometry. Eur Respir J. 2005;26(2):319–338.
  8. Lerner PI. Nocardiosis. Clin Infect Dis. 1996;22(6):891–903.
  9. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93(3):391–398.
  10. Ambrosioni J, Lew D, Garbino J. Nocardiosis: updated clinical review and experience at a tertiary center. Infection. 2010;38(2):89–97.
  11. Lederman ER, Crum NF. A case series and focused review of nocardiosis: clinical and microbiologic aspects. Medicine (Baltimore). 2004;83(5):300–313.
  12. Beaman BL, Beaman L. Nocardia species: host-parasite relationships. Clin Microbiol Rev. 1994;7(2):213–264.
  13. Riviere F, Billhot M, Soler C, Vaylet F, Margery J. Pulmonary nocardiosis in immunocompetent patients: can COPD be the only risk factor? Eur Respir Rev. 2011;20(121):210–212.
  14. Aide MA, Lourenco SS, Marchiori E, Zanetti G, Mondino PJ. Pulmonary nocardiosis in a patient with chronic obstructive pulmonary disease and bronchiectasis. J Bras Pneumol. 2008;34(11):985–988.
  15. Anderson M, Kuzniar TJ. Pulmonary nocardiosis in a patient with chronic obstructive pulmonary disease–case report and literature review. Pneumonol Alergol Pol. 2012;80(6):565–569.
  16. Castellana G, Grimaldi A, Castellana M, Farina C, Castellana G. Pulmonary nocardiosis in chronic obstructive pulmonary disease: A new clinical challenge. Respir Med Case Rep. 2016;18:14–21.
  17. Khare V, Gupta P, Himanshu D, Kumar D. Emergence of co-trimoxazole resistant Nocardia brasiliensis causing fatal pneumonia. BMJ Case Rep. 2013;2013.
  18. Franssen F. The semantics of COPD exacerbations. 2017. Accessed 20-7-2018.
  19. Valdezate S, Garrido N, Carrasco G, Medina-Pascual MJ, Villalon P, Navarro AM, et al. Epidemiology and susceptibility to antimicrobial agents of the main Nocardia species in Spain. J Antimicrob Chemother. 2017;72(3):754–761.
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