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Revista da Sociedade Brasileira de Medicina Tropical

versão impressa ISSN 0037-8682versão On-line ISSN 1678-9849

Rev. Soc. Bras. Med. Trop. vol.52  Uberaba  2019  Epub 06-Jun-2019

http://dx.doi.org/10.1590/0037-8682-0485-2018 

Images in Infectious Diseases

Cerebral and mediastinal abscesses caused by Nocardia asiatica in an hiv-infected patient

Francisco Kennedy Scofoni Faleiros de Azevedo1 

Valéria Dutra2 

Francisco José Dutra Souto1 
http://orcid.org/0000-0001-7985-6781

1Departamento de Clínica Médica, Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil.

2Hospital Veterinário e Laboratório de Microbiologia Veterinária e Biologia Molecular, Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil.


We herein describe the case of a 40-year-old woman in the Central-West region of Brazil with a nine-year history of HIV infection, who was receiving stavudine, lamivudine, and efavirenz. She had a CD4 T lymphocyte count of 42/mm3, CD8 T lymphocyte count of 642/mm3, and her most recent viral load was 6,275 copies/mL. She presented with mediastinal and cerebral manifestations, characterized by a left hemithoracic tumor, left pleural effusion, evolving hypoesthesia in the phalanges of the right hand, headache, presence of a left thoracic collection, and a hypodense left parieto-temporal lesion on computed tomography, caused by Nocardia asiatica. The patient recovered after treatment with sulfamethoxazole/trimethoprim, ceftriaxone, and amikacin; thoracotomy; and drainage of the extensive thoracic collection. Nocardiosis is an uncommon infection that occurs in immunocompromised individuals, such as HIV-positive patients, patients with oncological diseases, or those receiving immunosuppressive drugs1,2.

Analysis of pleural and cerebral secretions detected Nocardia spp., a Gram-positive (Figure A), filamentous, strictly aerobic, partially alcohol- and acid-resistant bacterium (Figure B). The laboratory identification of Nocardia spp. is difficult as it is often confused with mycobacteria2. N. asiatica was also identified by direct microscopic examination with 20% potassium hydroxide (Figure C). Sequencing of the 1376 bp 16S rRNA from this isolate (GenBank accession no. KF562729) revealed 100% identity with that of the N. asiatica strain DSM 44668 (GenBank accession no. GQ217495). Furthermore, phylogenetic analysis showed the formation of a clade with N. asiatica, emphasizing the importance of genotypic analysis for the diagnosis of nocardiosis3.

FIGURE A: Presence of Gram-positive filamentous bacteria (Nocardia spp) on Gram staining. 

FIGURE B: Presence of partially alcohol and acid resistant filamentous bacteria (Nocardia spp) on Ziehl-Neelsen staining. 

FIGURE C: Presence of filamentous bacteria (Nocardia spp), identified by direct microscopic examination with 20% potassium hydroxide. 

REFERENCES

1. Steinbrink J, Leavens J, Kauffman CA, Miceli MH. Manifestations and outcomes of nocardia infections: Comparison of immunocompromised and nonimmunocompromised adult patients. Medicine (Baltimore). 2018;97(40):e12436. [ Links ]

2. Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ Jr. Clinical and laboratory features of theNocardia spp. based on current molecular taxonomy. Clin Microbiol Rev. 2006;19(2):259-82. [ Links ]

3. Conville PS, Brown-Elliott BA, Smith T, Zelazny AM. The complexities of Nocardia taxonomy and identification. J Clin Microbiol. 2017;56(1).pi:e01419-17. [ Links ]

Financial Support: This research had financial support from the Brazilian National Council for Scientific and Technological Development (CNPq), a federal agency for research support, through a research incentive grant for Francisco José Dutra Souto.

Recebido: 12 de Novembro de 2018; Aceito: 14 de Fevereiro de 2019

Corresponding author: Dr. Francisco Kennedy Scofoni Faleiros de Azevedo. e-mail:fksfazevedo@gmail.com

Conflict of Interest: The authors declare that there is no conflict of interest.

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License