Nocardiosis A Diagnosis of Consideration in Immunocompromised Patients

Ranjit Sah1, Priyatam Khadka1, Shusila Khadka1, Bharat Mani Pokharel1, Jeevan Bahadur Sherchand2, Keshab Parajuli1, Niranjan Prasad
Shah1, Shyam Kumar Mishra1, Sangita Sharma1, Dibya Singh Shah3 Hari Prasad Kattel1, Ramesh Basnet1,, Basista Rijal1
1.Department of Microbiology, Tribhuvan University and Teaching Hospital (TUTH) Institute of Medicine, Kathmandu Nepal.
2. Public Health Research Laboratory, Tribhuvan University Institute of Medicine, Kathmandu Nepal.
3. Department of Medicine (Nephrology), Tribhuvan University and Teaching Hospital (TUTH) Institute of Medicine, Kathmandu Nepal.

Result
Background
Nocardia is an uncommon pathogen in immunocompetent
patients; however, it can occur as a significant
opportunistic
pathogen
in
immunocompromised
individuals1,2,3. In this report, we describe a case of
subcutaneous nocardiosis in a 60 year old male patient
admitted in nephrology ward TUTH, Nepal on December
24, 2015 who was a diagnosed case of nephrotic
syndrome and was on steroid therapy, presented with
swelling on right thigh which was not improving for 12
days of hospital admission.

Culture of pus sample on blood agar plate with growth of Nocardia

after 72 hours incubation

Method
Pus from sub-cutaneous abscess was received for Gram
stain which revealed plenty of pus cells, with gram
variable, branching, filamentous bacteria without any
other bacterial structure. On the background of
filamentous bacteria on Gram stain Ziehl-Neelsen (ZN)
and
Modified Ziehl-Neelsen stain4 was performed.
Culture was done aerobically on blood and MacConkey
agar and anaerobically in Robertson cooked meat media
and incubated at 37C. After growth of organism Gram
stain, catalase test, urea hydrolysis test and antibiotic
sensitivity test by Kirby Bauer method was done
following standard protocol2

Gram stain of pus revealed plenty of pus cells with gram

variable branching filamentous bacteria . ZN stain revealed
no bacilli whereas modified ZN stain revealed numerous
acid fast branching filamentous organism with beaded
appearance. On culture there was no growth at 24 hours of
incubation and no turbidity in Robertson cooked meat
media. But on further incubation, chalky white, adherent
colonies were seen after 48 hours of incubation in blood
agar. On prolonged incubation, the colonies became
yellowish and had molar tooth appearance. These colonies
were catalase and urea hydrolysis test positive. There was
no growth on MacConkey agar and no growth after
subculture from Robertson cooked meat media which was
incubated anaerobically. On antibiotic susceptibility testing
the organism was sensitive to cotrimoxazole, cefixime,
meropenem, imipenem, amikacin and ceftriaxone . So
patient was treated with cotrimoxazole for one month and he
improved.
Thus, Nocardia species was identified in pus sample by
staining and aerobic culture

Conclusion
Nocardia colonies on gram staining showing gram
variable structure

Diagnosis of Nocardial infection is often cumbersome,

resulting at times a wrong initial clinical diagnosis such as
cancer and other bacterial infection (e.g. tuberculosis).
Therefore it is important to consider Nocardial infection in
the differential diagnosis of chronic subcutaneous infection

Keywords: Nocardia, Nocardiosis, immunocompromised

References

Modified ZN stain of pus sample showing acid-fast

filamentous structure of Nocardia sp.
Antibiotic susceptibility testing of Nocardia

1.Coney R. Mahon 5th edition text book of diagnostic

microbiology
2.Ana C Guerra et. al. Disseminated Nocardiosis : A
successful blind strategy of treatment in a HIV infected
patient case reports in Infectious disease hindwai Publishing
corporation volume 2015, Article ID 260640, 4 pages
3.Sh Ghaesami et al. disseminated Nocardiosis in an
immunocompromised child with unknown cause IJMS 2002
VOL 27 No. 32.
4.Bailey and Scotts diagnostic microbiology 12th edition