Nocardia infection in renal transplant recipient: diagnostic and therapeutic considerations

Santamaria Saber, L.T.; Figueiredo, J.F.C.; Santos, S.B.; Levy, C.E.; Reis, M.A.; Ferraz, A.S.

doi:10.1590/S0036-46651993000500006

Abstracts

In the present report the authors discuss the diagnostic difficulties, therapeutic measures and the clinical course of Nocardia infection which occurred among renal transplant recipients at the University Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (UH-FRP), from 1968 to 1991. Among 500 individuals submitted to renal transplant, 9 patients developed Nocardiosis at varying times after transplant (two months to over two years). All the patients had pulmonary involvement and their most common symptoms were fever, cough and pleural pain. Dissemination of the process is common and three patients presented cutaneous abscesses, four CNS involvement and one had pericarditis due to Nocardia. The diagnostic is quite difficult since there is no specific clinical picture, concomitant infections are frequent and the microorganism presents slow growth in culture (ranging from four to forty days, in our experience). In this report, three cases were only diagnosed by necropsy. The treatment of choice is a combination of Sulfamethoxazole and Trimethoprim (SMX-TMP). In the present series, overall mortality was 77% (7 cases) and in five of the patients who died the diagnosis was late. All the patients who had CNS involvement died.

Renal transplant; Nocardia infection

Foram analisados retrospectivamente 500 prontuários de pacientes transplantados renais no período de 1968 a 1991, sendo identificados 9 casos de Nocardiose; 7 do sexo masculino e 2 do sexo feminino. A idade mediana destes pacientes foi de 33 anos e a infecção ocorreu nos primeiros 6 meses em 6 pacientes, havendo relação direta com pulsoterapia em apenas um paciente. Manifestações pulmonares ocorreram em 100% dos casos, sendo que os sintomas mais frequentes foram febre, tosse e dor pleural. As alterações radiológicas observadas compreenderam infiltrados nodulares em 55% e abcessos em 22% dos casos. Houve disseminação para a pele em 3 pacientes, para o SNC em 4 pacientes, e 1 paciente apresentou, além de comprometimento pulmonar, pericardite por Nocardia. Em nossa casuística o diagnóstico foi post-mortem em 30% dos casos e a mortalidade foi de 77%. Km 3 pacientes, cujo diagnóstico foi precoce, houve resposta satisfatória ao tratamento instituído. As infecções por Nocardia apresentam bom prognóstico quando diagnosticadas a tempo, sendo portanto necessário um alto grau de suspeição, principalmente em pacientes imunossuprimidos com acometimento pulmonar, neurológico ou cutâneo.

ORIGINAL ARTICLES

Nocardia infection in renal transplant recipient: diagnostic and therapeutic considerations

Infecção por Nocardia cm transplante renal: considerações diagnósticas e terapêuticas

L.T. Santamaria Saber^II; J.F.C. Figueiredo^III; S.B. Santos^II; C.E. Levy^III; M.A. Reis^IV; A.S. Ferraz^I,II,(¹ Address for correspondence: Agenor Spallini Ferraz, MD ⁾

^ICNPq Investigator

^IIDepartment of Surgery and Renal Transplant Unit, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil

^IIIDepartment of Internal Medicine and Laboratory of Microbiology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil

^IVDepartment of General Pathology, Faculty of Medicine of Triângulo Mineiro, Uberaba (MG), Brazil

^{Address for correspondence} Address for correspondence: Agenor Spallini Ferraz, MD

SUMMARY

In the present report the authors discuss the diagnostic difficulties, therapeutic measures and the clinical course of Nocardia infection which occurred among renal transplant recipients at the University Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (UH-FRP), from 1968 to 1991.

Among 500 individuals submitted to renal transplant, 9 patients developed Nocardiosis at varying times after transplant (two months to over two years). All the patients had pulmonary involvement and their most common symptoms were fever, cough and pleural pain.

Dissemination of the process is common and three patients presented cutaneous abscesses, four CNS involvement and one had pericarditis due to Nocardia.

The diagnostic is quite difficult since there is no specific clinical picture, concomitant infections are frequent and the microorganism presents slow growth in culture (ranging from four to forty days, in our experience). In this report, three cases were only diagnosed by necropsy.

The treatment of choice is a combination of Sulfamethoxazole and Trimethoprim (SMX-TMP).

In the present series, overall mortality was 77% (7 cases) and in five of the patients who died the diagnosis was late. All the patients who had CNS involvement died.

Key words: Renal transplant; Nocardia infection

RESUMO

Foram analisados retrospectivamente 500 prontuários de pacientes transplantados renais no período de 1968 a 1991, sendo identificados 9 casos de Nocardiose; 7 do sexo masculino e 2 do sexo feminino. A idade mediana destes pacientes foi de 33 anos e a infecção ocorreu nos primeiros 6 meses em 6 pacientes, havendo relação direta com pulsoterapia em apenas um paciente. Manifestações pulmonares ocorreram em 100% dos casos, sendo que os sintomas mais frequentes foram febre, tosse e dor pleural. As alterações radiológicas observadas compreenderam infiltrados nodulares em 55% e abcessos em 22% dos casos.

Houve disseminação para a pele em 3 pacientes, para o SNC em 4 pacientes, e 1 paciente apresentou, além de comprometimento pulmonar, pericardite por Nocardia.

Em nossa casuística o diagnóstico foi post-mortem em 30% dos casos e a mortalidade foi de 77%. Km 3 pacientes, cujo diagnóstico foi precoce, houve resposta satisfatória ao tratamento instituído.

As infecções por Nocardia apresentam bom prognóstico quando diagnosticadas a tempo, sendo portanto necessário um alto grau de suspeição, principalmente em pacientes imunossuprimidos com acometimento pulmonar, neurológico ou cutâneo.

Full text available only in PDF format.

Texto completo disponível apenas em PDF.

Recebido para publicação em 05/05/1993.

Aceito para publicação em 23/06/1993.

Unidade de Transplante Renal - Hospital das Clínicas-Campus - 14048-900 Ribeirão Preto, SP

1. AVRAM, M.M.; RAMACHANDRAN, N.S.; LIPNER, H.I. & CHERUBIN, C.E. - Persistent nocardemia following renal transplantation. J. Amer. med. Ass., 239: 2779-2780, 1978.
2. BEAMAN, B.L. - Nocardia in naturally acquired and experimental infections in animals. J. Hyg., 91: 393-419, 1983.
3. BENBOW, E.P. - Sulfonamide therapy in actinomycosis: two cases caused by aerobic partially acid-fast actinomyces. Amer. Rev. Tuberc., 49: 395-407, 1944.
4. COHEN, M.L.; WEISS, E.B. & MONACO, A.P. - Successful treatment of P. carinii and Nocardia asteroides in a renal transplant patient. Amer. J. Med., 50: 269-276, 1971.
5. CURRY, W.A. - Human nocardiosis. A clinical review with selected case reports. Arch. intern. Med., 140: 818-826, 1980.
6. FORBES, G.M.; HARVEY, A.H.; PHILPOTT-HOWARD, J.N.; O'GRADY, J.G.; JENSEN, R.D.; SAHATHEVAN, M.; CASEWELL, M.W. & WILLIAMS, R. - Nocardiosis in liver transplantation: variation in presentation, diagnosis and therapy. J. Infect., 20: 11-19, 1990.
7. HELLYAR, A.G. - Experience with Nocardia asteroides in renal transplant recipients. J. Hosp. Infect., 12: 13-18, 1988.
8. HILL JR, R.B.; ROWLANDS, D.T. & RIFKIND, D. - Infectious pulmonary disease in patients receiving immunosuppressive therapy for organ transplantation. New Engl. J. Med., 271: 1021-1027, 1964.
9. HOELPELMAN, I.M.; BAKKER, L.J.; JESSURUN, R.F.M.; ROZEMBERG-ARSKA, M. & VERHOEF, J. - Disseminated Nocardia asteroides infections complicating renal transplantation. Netherlands J. Med., 31: 175-182, 1987.
10. JACOB, E.T.; ZISKIND, Z.; NATIV, O. & SHABTAI, M. - Severe pulmonary nocardiosis in a kidney allograft recipient with a low immunological response. Israel J. med. Sci., 21: 613-616, 1985.
11. KONG, N.C.T.; MORAD, Z.; SULEIMAN, A.B.; CHEONG, I.K.S. & LAJIN, I. - Spectrum of nocardiosis in renal patients. Ann. Acad. Med., 19: 375-379, 1990.
12. KRICK, J.A.; STINSON, E.B. & REMINGTON, J.S. - Nocardia infection in heart transplant patients. Ann. intern. Med., 82: 18-26, 1975.
13. LEAKER, B.; HELLYAR, A.G.; NEILD, G.H.; RUDGE, C.; MANSELL, M. & THOMPSON, F.D. - Nocardia infection in a renal transplant unit. Transplant. Proc., 21: 2103-2104, 1989.
14. LOVETT, L.S.; HOUANG, E.T.; BURGE, S.; TURNER-WARWICK, M.; THOMPSOM, F.D.; HARRISON, A.R.; JOEKES, A.M. & PARKINSON, M.C. - An outbreak of Nocardia asteroides infection in a renal transplant unit. Amer. J. Med., 198: 123-135, 1981.
15. MOORE, G.S. & JACIOW, D.M. - Micology for the clinical laboratory. Virginia, Reston Publishing Company, 1979.
16. PALMER, D.L.; HARVEY, R.L. & WHEELER, J.K. - Diagnostic and therapeutic considerations in Nocardia asteroides infection. Medicine, 53: 391-401, 1974.
17. PETERSEN, E.A.; NASH, M.L.; MAMMANA, R.B. & COPELAND, J.G. - Minocycline treatment of pulmonary nocardiosis. J. Amer. med. Ass., 250: 930-932, 1983.
18. RABY, N.; FORBES, G. & WILLIAMS, R. - Nocardial infection in patients with liver transplants or chronic liver disease. Radiology, 174: 713-716, 1990.
19. REIS, M.A. - Causes of death in renal transplant recipients: a study of 102 autopsies from 1968 to 1991 in the University Hospital of Ribeirăo Preto. Ribeirăo Preto, 1992. (Master thesis presented to the Faculty of Medicine of Ribeirăo Preto, University of Săo Paulo).
20. RIFKIND, D.; MARCHIORO, T.L.; SCHNECK, S.A. & HILL JR, R.B. - Systemic fungal infections complicating renal transplantation and immunosuppressive therapy. Amer. J. Med., 43: 28-38, 1967.
21. RUEBUSH, T.K. & GOODMAN, J.S. - Nocardia asteroides bacteremia in a immunosuppressed renal transplant patient. Amer. J. clin. Path., 64: 537-539, 1975.
22. SIMON, H.B. - Mycobacterial and nocardial infections in the compromised host. In: RUBIN, R.H. & YOUNG, L.S. Clinical approach to infections in the compromised host. 2. ed. New York, Plenum Medical Book Company, 1988. Chapter 9, p. 221-251.
23. WILSON, J.P.; TURNER, H.R.; KIRCHNER, K.A. & CHAPMAN, S.W. - Nocardial infections in renal transplant recipients. Medicine, 68: 38-57, 1989.
24. YOGEV, R.; GREENSLAD, T.; FIRLIT, C.F. & LEWY,P. - Successfull treatment of Nocardia asteroides infection with amikacin. Pediatrics, 96: 771-773, 1980.

Address for correspondence:

Agenor Spallini Ferraz, MD

(1

) (Grant no. 502303/91-3)

Publication Dates

Publication in this collection
04 July 2006
Date of issue
Oct 1993

History

Accepted
23 June 1993
Received
05 May 1993

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. AVRAM, M.M.; RAMACHANDRAN, N.S.; LIPNER, H.I. & CHERUBIN, C.E. - Persistent nocardemia following renal transplantation. J. Amer. med. Ass., 239: 2779-2780, 1978.

[2] 2. BEAMAN, B.L. - Nocardia in naturally acquired and experimental infections in animals. J. Hyg., 91: 393-419, 1983.

[3] 3. BENBOW, E.P. - Sulfonamide therapy in actinomycosis: two cases caused by aerobic partially acid-fast actinomyces. Amer. Rev. Tuberc., 49: 395-407, 1944.

[4] 4. COHEN, M.L.; WEISS, E.B. & MONACO, A.P. - Successful treatment of P. carinii and Nocardia asteroides in a renal transplant patient. Amer. J. Med., 50: 269-276, 1971.

[5] 5. CURRY, W.A. - Human nocardiosis. A clinical review with selected case reports. Arch. intern. Med., 140: 818-826, 1980.

[6] 6. FORBES, G.M.; HARVEY, A.H.; PHILPOTT-HOWARD, J.N.; O'GRADY, J.G.; JENSEN, R.D.; SAHATHEVAN, M.; CASEWELL, M.W. & WILLIAMS, R. - Nocardiosis in liver transplantation: variation in presentation, diagnosis and therapy. J. Infect., 20: 11-19, 1990.

[7] 7. HELLYAR, A.G. - Experience with Nocardia asteroides in renal transplant recipients. J. Hosp. Infect., 12: 13-18, 1988.

[8] 8. HILL JR, R.B.; ROWLANDS, D.T. & RIFKIND, D. - Infectious pulmonary disease in patients receiving immunosuppressive therapy for organ transplantation. New Engl. J. Med., 271: 1021-1027, 1964.

[9] 9. HOELPELMAN, I.M.; BAKKER, L.J.; JESSURUN, R.F.M.; ROZEMBERG-ARSKA, M. & VERHOEF, J. - Disseminated Nocardia asteroides infections complicating renal transplantation. Netherlands J. Med., 31: 175-182, 1987.

[10] 10. JACOB, E.T.; ZISKIND, Z.; NATIV, O. & SHABTAI, M. - Severe pulmonary nocardiosis in a kidney allograft recipient with a low immunological response. Israel J. med. Sci., 21: 613-616, 1985.

[11] 11. KONG, N.C.T.; MORAD, Z.; SULEIMAN, A.B.; CHEONG, I.K.S. & LAJIN, I. - Spectrum of nocardiosis in renal patients. Ann. Acad. Med., 19: 375-379, 1990.

[12] 12. KRICK, J.A.; STINSON, E.B. & REMINGTON, J.S. - Nocardia infection in heart transplant patients. Ann. intern. Med., 82: 18-26, 1975.

[13] 13. LEAKER, B.; HELLYAR, A.G.; NEILD, G.H.; RUDGE, C.; MANSELL, M. & THOMPSON, F.D. - Nocardia infection in a renal transplant unit. Transplant. Proc., 21: 2103-2104, 1989.

[14] 14. LOVETT, L.S.; HOUANG, E.T.; BURGE, S.; TURNER-WARWICK, M.; THOMPSOM, F.D.; HARRISON, A.R.; JOEKES, A.M. & PARKINSON, M.C. - An outbreak of Nocardia asteroides infection in a renal transplant unit. Amer. J. Med., 198: 123-135, 1981.

[15] 15. MOORE, G.S. & JACIOW, D.M. - Micology for the clinical laboratory. Virginia, Reston Publishing Company, 1979.

[16] 16. PALMER, D.L.; HARVEY, R.L. & WHEELER, J.K. - Diagnostic and therapeutic considerations in Nocardia asteroides infection. Medicine, 53: 391-401, 1974.

[17] 17. PETERSEN, E.A.; NASH, M.L.; MAMMANA, R.B. & COPELAND, J.G. - Minocycline treatment of pulmonary nocardiosis. J. Amer. med. Ass., 250: 930-932, 1983.

[18] 18. RABY, N.; FORBES, G. & WILLIAMS, R. - Nocardial infection in patients with liver transplants or chronic liver disease. Radiology, 174: 713-716, 1990.

[19] 19. REIS, M.A. - Causes of death in renal transplant recipients: a study of 102 autopsies from 1968 to 1991 in the University Hospital of Ribeirăo Preto. Ribeirăo Preto, 1992. (Master thesis presented to the Faculty of Medicine of Ribeirăo Preto, University of Săo Paulo).

[20] 20. RIFKIND, D.; MARCHIORO, T.L.; SCHNECK, S.A. & HILL JR, R.B. - Systemic fungal infections complicating renal transplantation and immunosuppressive therapy. Amer. J. Med., 43: 28-38, 1967.

[21] 21. RUEBUSH, T.K. & GOODMAN, J.S. - Nocardia asteroides bacteremia in a immunosuppressed renal transplant patient. Amer. J. clin. Path., 64: 537-539, 1975.

[22] 22. SIMON, H.B. - Mycobacterial and nocardial infections in the compromised host. In: RUBIN, R.H. & YOUNG, L.S. Clinical approach to infections in the compromised host. 2. ed. New York, Plenum Medical Book Company, 1988. Chapter 9, p. 221-251.

[23] 23. WILSON, J.P.; TURNER, H.R.; KIRCHNER, K.A. & CHAPMAN, S.W. - Nocardial infections in renal transplant recipients. Medicine, 68: 38-57, 1989.

[24] 24. YOGEV, R.; GREENSLAD, T.; FIRLIT, C.F. & LEWY,P. - Successfull treatment of Nocardia asteroides infection with amikacin. Pediatrics, 96: 771-773, 1980.

Brasil

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Nocardia infection in renal transplant recipient: diagnostic and therapeutic considerations

Infecção por Nocardia cm transplante renal: considerações diagnósticas e terapêuticas

Abstracts

Publication Dates

History