Abstract: Nocardiosis is a common opportunistic infection in the immunocompromised and in patients with chronic debilitating diseases,e.g continuous ambulatory peritoneal dialysis (CAPD) patients. Primary abdominal nocardiosis is rare and is indeed a very rare infection in immunocompetent persons. Only two cases have been reported in immunocompetent patients so far and this may be third case to the best of our knowledge and first in India. About 11 cases have been reported in CAPD patients and AIDS patients.We report a case of Nocardiosis in an immunocompetent young female who presented with an abdomino-pelvic mass masquerading as carcinoma ovary.After initial resistance to various antibiotics, she responded to intraperitoneal and oral linezolid and oral ciprofloxacin.
Key Words: Nocardiosis; CAPD patients, Trimethoprim-sulfamethoxazole (TMP-SMX); Amikacin; Intraperitoneal.
Introduction: Nocardia is an aerobic, gram positive, partially acid fast bacterium that characteristically produces a mycelium that often fragments into bacillary and coccoid elements.(1,2) Nocardiosis is an acute, subacute or chronic infectious disease that occurs as cutaneous, pulmonary and disseminated forms that may involve any organ (mainly brain and meninges).(1,2) Nocardia is found worldwide as an ubiquitous saprophyte in soil ,decaying organic matter and water.(1,2)
The main risk factors for nocardiosis are a weakened immune system, chronic lung disease, chronic steroid therapy, peritoneal dialysis, cancer, AIDS and bone marrow transplantation.(1- 3)
Primary abdominal nocardiosis is a very rare infection usually seen in CAPD patients or in immunocompromised patients. To the best of our knowledge 11 such cases have been reported so far in the literature (eight in CAPD, three in AIDS patients). (4,5).
In immunocompetent persons, only two cases have been reported in the literature(6,7) to the best of our knowledge and this probably represents the third case in world and the first in India.
Case Report:
A 32 years old young parous female presented with the complaints of mass per abdomen, pain abdomen and dyspeptic symptoms of one month’s duration.
On examination there was a vague abdominal mass in the umbilical and the epigastric region and bilateral adnexal masses (6×5×5 cms) with restricted mobility.
Ultrasound Colour Doppler scan showed bilateral adnexal masses with increased vascularity and low Pulsatality Index and Resistance Index, omental thickening with increased vascularity and pelvic and para-aortic lymph node enlargement with minimal ascites. The CA-125 was 141 u\ml. The chest x-ray was normal.
A clinical diagnosis of carcinoma ovary was made and she was taken up for exploratory laparotomy. Intraoperatively, the omentum appeared ‘caked up’ and was apparently infiltrating the anterior abdominal wall. There were bilateral ovarian tumors with hydrosalpinx, tumor deposits over the intestines and peritoneum and enlarged pelvic and para-aortic lymph nodes with minimal ascites.
Total abdominal hysterectomy, bilateral salpingo-oophorectomy, total omentectomy, tumor debulking with partial excision of anterior and posterior rectus sheath and pelvic and para-aortic lymph node dissection was carried out. The abdomen was closed with a prolene mesh.
The histopathology of the surgical specimens revealed nocardiosis (acid fast) involving the ovaries, tubes and omentum. (Figure 1, Figure 2).
Figure 1: Colonies of Nocardia in omentum
Figure 2: High power view of a Nocardia colony
She started developing ascites on the fifteenth postoperative day which gradually became massive. She was initially started on oral minocycline 200mg BID which was continued for three weeks as there was no response she was then started on oral trimethoprim-sulfamethoxazole (TMP-SMX) BID, and Inj. Amikacin 750 mg OD intravenously. This treatment was continued for three months with regular ascitic tapping. However, there was no improvement with increasing ascites and associated weight loss. Computed tomography scan at this time revealed only loculated ascites in the abdomen and pelvis.
Ascitic fluid culture and sensitivity was done at this juncture, which grew nocardia that was sensitive to linezolid and ciprofloxacin. Direct intraperitoneal Linezolid injection 600mg (direct prick with 18 G needle under local anaesthesia) into the ascitic fluid twice a week with oral linezolid 600mg BID, and oral ciprofloxacin 500 mg BID, was started.
The intraperitoneal route was decided as she didn’t have response to intravenous amikacin even though sensitive.
After about three weeks of such treatment her ascites started reducing and by 7-8 weeks, it had completely disappeared. She was continued on oral linezolid and ciprofloxacin for a total of six months. At six month’s follow up, she is free of disease and well.
Discussion:
In the general population nocardiosis is a rare infection but is a common opportunistic infection in immunocompromised hosts. Primary abdominal nocardiosis is a rare infection. The review of literature shows eight cases in CAPD patients and three cases in AIDS patients.(4,5)
In immunocompetent persons only two cases have been reported. The first was a 11-year-old Sudanese girl who presented with liver and renal abscesses that were treated successfully with oral trimethoprim-sulfamethoxazole and parenteral amikacin.(6) The second case presented as a pancreatic abscess in a 76 year old male and was cured with intravenous amikacin when treatment with trimethoprim-sulfamethoxazole failed.(7) Peritonitis caused by nocardiosis in CAPD patients has been reported and treated successfully with intraperitoneal trimethoprim-sulfamethoxazole and /or amikacin.(4,8,9) Our case presented as an abdomino-pelvic mass. The probable source of infection could be the intra uterine Copper T device which she had 3-4 years back. The most commonly recommended therapy for nocardiosis is TMP-SMX and amikacin.(1,2) The present case did not respond to these antibiotics but responded well to linezolid therapy which had been tried successfully in one case previously.(1) We wish to highlight that abdomino-pelvic nocardiosis can simulate malignancy very closely at presentation and preoperatively, and is an eminently treatable condition.
References:
1. Greenfield AR Nocardiosis. (eMedicine Infectious Diseases Website). Oct-14, 2008. Available at http://www.emedicine.medscape.com/article/224123- overview. Accessed Feb 11, 2010.
2. Filice AG. Nocardiosis. In: Braunwald E et al. (eds) Harrison’s-Principles of Internal Medicine, 15th edition. McGraw Hill Companies. pp. 1006-1008.
3. Ortiz MA, Rabagliati R, Machuca E. Successful Treatment of Nocardia asteroids Peritonitis in a Patient Undergoing Automated Peritoneal Dialysis and Receiving Immuno-suppressive Therapy. Adv Perit Dial. 2005;21:66- 68.
4. Li SY, Yu KW, Yang WC et al. Nocardia Peritonitis — a Case Report and Literature Review. Peritl Dial Int. 2008;28(5):544-547.
5. John MA, Madiba TE, Mahabeer P et al. Disseminated nocardiosis masquerading as abdominal tuberculosis. S Afr J Surg. 2004;42(1):17-19.
6. Salfield SAW, Duerden BI, Dickson JA et al. Abdominal nocardiosis in a Sudanese girl. Eur J Pediatr.1983;140(2):135-137.
7. Meiers B, Metzger U, Maller F et al. Successful Treatment of a Pancreatic Nocardia asteroids Abscess with Amikacin and Surgical Drainage. Antimicrob Agents Chemother. 1986;29(1):150-151.
8. Lopes JO, Alves SH, Benevenga JP et al. Nocardia asteroides peritonitis during continuous ambulatory peritoneal dialysis. Rev Inst Med Trop Sao Paulo. 1993;35(4):377-9.
9. Chu KH, Fung KS, Tsang WK et al. Nocardia Peritonitis: Satisfactory Response to Intraperitoneal Trimethoprim-Sulfamethoxazole. Perit Dial Int. 2003;23(2):197– 199.
Key Words: Nocardiosis; CAPD patients, Trimethoprim-sulfamethoxazole (TMP-SMX); Amikacin; Intraperitoneal.
Introduction: Nocardia is an aerobic, gram positive, partially acid fast bacterium that characteristically produces a mycelium that often fragments into bacillary and coccoid elements.(1,2) Nocardiosis is an acute, subacute or chronic infectious disease that occurs as cutaneous, pulmonary and disseminated forms that may involve any organ (mainly brain and meninges).(1,2) Nocardia is found worldwide as an ubiquitous saprophyte in soil ,decaying organic matter and water.(1,2)
The main risk factors for nocardiosis are a weakened immune system, chronic lung disease, chronic steroid therapy, peritoneal dialysis, cancer, AIDS and bone marrow transplantation.(1- 3)
Primary abdominal nocardiosis is a very rare infection usually seen in CAPD patients or in immunocompromised patients. To the best of our knowledge 11 such cases have been reported so far in the literature (eight in CAPD, three in AIDS patients). (4,5).
In immunocompetent persons, only two cases have been reported in the literature(6,7) to the best of our knowledge and this probably represents the third case in world and the first in India.
Case Report:
A 32 years old young parous female presented with the complaints of mass per abdomen, pain abdomen and dyspeptic symptoms of one month’s duration.
On examination there was a vague abdominal mass in the umbilical and the epigastric region and bilateral adnexal masses (6×5×5 cms) with restricted mobility.
Ultrasound Colour Doppler scan showed bilateral adnexal masses with increased vascularity and low Pulsatality Index and Resistance Index, omental thickening with increased vascularity and pelvic and para-aortic lymph node enlargement with minimal ascites. The CA-125 was 141 u\ml. The chest x-ray was normal.
A clinical diagnosis of carcinoma ovary was made and she was taken up for exploratory laparotomy. Intraoperatively, the omentum appeared ‘caked up’ and was apparently infiltrating the anterior abdominal wall. There were bilateral ovarian tumors with hydrosalpinx, tumor deposits over the intestines and peritoneum and enlarged pelvic and para-aortic lymph nodes with minimal ascites.
Total abdominal hysterectomy, bilateral salpingo-oophorectomy, total omentectomy, tumor debulking with partial excision of anterior and posterior rectus sheath and pelvic and para-aortic lymph node dissection was carried out. The abdomen was closed with a prolene mesh.
The histopathology of the surgical specimens revealed nocardiosis (acid fast) involving the ovaries, tubes and omentum. (Figure 1, Figure 2).
Figure 1: Colonies of Nocardia in omentum
Figure 2: High power view of a Nocardia colony
She started developing ascites on the fifteenth postoperative day which gradually became massive. She was initially started on oral minocycline 200mg BID which was continued for three weeks as there was no response she was then started on oral trimethoprim-sulfamethoxazole (TMP-SMX) BID, and Inj. Amikacin 750 mg OD intravenously. This treatment was continued for three months with regular ascitic tapping. However, there was no improvement with increasing ascites and associated weight loss. Computed tomography scan at this time revealed only loculated ascites in the abdomen and pelvis.
Ascitic fluid culture and sensitivity was done at this juncture, which grew nocardia that was sensitive to linezolid and ciprofloxacin. Direct intraperitoneal Linezolid injection 600mg (direct prick with 18 G needle under local anaesthesia) into the ascitic fluid twice a week with oral linezolid 600mg BID, and oral ciprofloxacin 500 mg BID, was started.
The intraperitoneal route was decided as she didn’t have response to intravenous amikacin even though sensitive.
After about three weeks of such treatment her ascites started reducing and by 7-8 weeks, it had completely disappeared. She was continued on oral linezolid and ciprofloxacin for a total of six months. At six month’s follow up, she is free of disease and well.
Discussion:
In the general population nocardiosis is a rare infection but is a common opportunistic infection in immunocompromised hosts. Primary abdominal nocardiosis is a rare infection. The review of literature shows eight cases in CAPD patients and three cases in AIDS patients.(4,5)
In immunocompetent persons only two cases have been reported. The first was a 11-year-old Sudanese girl who presented with liver and renal abscesses that were treated successfully with oral trimethoprim-sulfamethoxazole and parenteral amikacin.(6) The second case presented as a pancreatic abscess in a 76 year old male and was cured with intravenous amikacin when treatment with trimethoprim-sulfamethoxazole failed.(7) Peritonitis caused by nocardiosis in CAPD patients has been reported and treated successfully with intraperitoneal trimethoprim-sulfamethoxazole and /or amikacin.(4,8,9) Our case presented as an abdomino-pelvic mass. The probable source of infection could be the intra uterine Copper T device which she had 3-4 years back. The most commonly recommended therapy for nocardiosis is TMP-SMX and amikacin.(1,2) The present case did not respond to these antibiotics but responded well to linezolid therapy which had been tried successfully in one case previously.(1) We wish to highlight that abdomino-pelvic nocardiosis can simulate malignancy very closely at presentation and preoperatively, and is an eminently treatable condition.
References:
1. Greenfield AR Nocardiosis. (eMedicine Infectious Diseases Website). Oct-14, 2008. Available at http://www.emedicine.medscape.com/article/224123- overview. Accessed Feb 11, 2010.
2. Filice AG. Nocardiosis. In: Braunwald E et al. (eds) Harrison’s-Principles of Internal Medicine, 15th edition. McGraw Hill Companies. pp. 1006-1008.
3. Ortiz MA, Rabagliati R, Machuca E. Successful Treatment of Nocardia asteroids Peritonitis in a Patient Undergoing Automated Peritoneal Dialysis and Receiving Immuno-suppressive Therapy. Adv Perit Dial. 2005;21:66- 68.
4. Li SY, Yu KW, Yang WC et al. Nocardia Peritonitis — a Case Report and Literature Review. Peritl Dial Int. 2008;28(5):544-547.
5. John MA, Madiba TE, Mahabeer P et al. Disseminated nocardiosis masquerading as abdominal tuberculosis. S Afr J Surg. 2004;42(1):17-19.
6. Salfield SAW, Duerden BI, Dickson JA et al. Abdominal nocardiosis in a Sudanese girl. Eur J Pediatr.1983;140(2):135-137.
7. Meiers B, Metzger U, Maller F et al. Successful Treatment of a Pancreatic Nocardia asteroids Abscess with Amikacin and Surgical Drainage. Antimicrob Agents Chemother. 1986;29(1):150-151.
8. Lopes JO, Alves SH, Benevenga JP et al. Nocardia asteroides peritonitis during continuous ambulatory peritoneal dialysis. Rev Inst Med Trop Sao Paulo. 1993;35(4):377-9.
9. Chu KH, Fung KS, Tsang WK et al. Nocardia Peritonitis: Satisfactory Response to Intraperitoneal Trimethoprim-Sulfamethoxazole. Perit Dial Int. 2003;23(2):197– 199.