Pulmonary And Extrapulmonary Tuberculosis Along With Pulmonary Nocardiosis In A Patient With Human Immunodeficiency Virus Infection
Correspondence Address :
Dr.V.Anil Kumar MD (Microbiology) Clinical Assistant Professor Department of Microbiology Amrita Institute of Medical Sciences Ponekara, Kochi,Kerala India: 682041. vanilkumar@aims.amrita.edu Office:0484 2801234 (Extn : 8010,8015] Mob: 09037401413
A 53 year old male presented with respiratory symptoms, low grade intermittent fever, anorexia, diarrhoea and weight loss of 5 months duration. Chest X-ray showed bilateral upper and mid-zone non-homogenous opacity and right lower zone homogenous opacity with hilar enlargement, while USG abdomen revealed a peripancreatic mass. The serology of HIV-1 was positive by enzyme linked immunosorbent assay (ELISA) and western blot. The patient was diagnosed with pulmonary and extrapulmonary tuberculosis along with concomitant pulmonary nocardiosis.
Tuberculosis; nocardia; human immunodeficiency virus.
INYRODUCTION Nocardia most commonly affects patients with COPD or patients who are immuno suppressed. (1)
In a reported series, 60% 90% of the patients had some underlying immunosuppressive condition such as chronic steroid use, solid-organ transplantation, lymphoreticular malignancy, chronic granulomatous disease (CGD), or human immunodeficiency virus (HIV) infection.(2)
Nocardia asteroides is the predominant species and the one which is most commonly associated with disseminated disease. The typical sites of dissemination include the lungs, skin, brain, and the musculoskeletal system. The less-common sites include the pericardium, kidney, adrenal glands, eye, spleen, and the liver. There are occasional reports of nocardiosis in patients with HIV infection. (3)
Tuberculosis also has more or less the same type of involvement, but with a higher prevalence in our population. Tuberculosis has reached epidemic proportions in HIV patients in India. Concomitant pulmonary tuberculosis and nocardiosis in an HIV patient have rarely been reported through autopsy studies nor have they shown the presence of coinfection in HIV patients dying of pulmonary tuberculosis. (4)
We present here, a rare case of pulmonary and extrapulmonary tuberculosis with pulmonary nocardiosis in an HIV patient.
A 53 year old male presented with productive cough with moderate amount of mucopurulent expectoration, low grade intermittent fever, anorexia, diarrhoea and weight loss of 5 months duration. There was no history of sexual promiscuity or intravenous drug abuse. He gave a history of blood transfusion 7 years ago. The physical examination revealed a thinly built individual with a pulse rate of 80/minute and a blood pressure of 120/80 mm of Hg. There was no pallor, icterus, cyanosis, finger clubbing or pedal oedema. The inguinal lymph nodes were palpable. The examination of the respiratory system revealed bilateral infra-clavicular, mammary and infra-axillary crackles. The examinations of other systems were not contributory. The haemoglobin concentration was 10 gm% and the total leucocyte count was 9500/mm3, with the differential count showing 70% polymorphs, 22% lymphocytes and 8% mixed population cells. The renal function was deranged with S. creatinine- 1.6mg/dl and S.urea -56mg/dl. The liver function test also showed significant hepatic damage with serum levels of bilirubin -1.3mg/dl, aspartate aminotransferase- 105 IU/L, alanine aminotransferase- 78 IU/L and alkaline- phosphatase 154IU/l. The frontal radiograph of the chest showed bilateral upper and mid-zone non-homogenous opacity and right lower zone homogenous opacity with hilar enlargement (Table/Fig 1). Three consecutive morning samples of sputum were positive for acid fast bacilli (AFB). The gram staining of the pus which was aspirated under ultrasonographic (USG) guidance from the lung nodule revealed a gram positive branching filamentous organism (Table/Fig 2) resembling nocardia, which was also 1% acid fast (Table/Fig 3). USG of the abdomen showed a peripancreatic mass which on aspiration showed AFB (Table/Fig 4). The HIV-1 antibody was positive by enzyme linked immunosorbent assay (ELISA) and western blot. All specimens were cultured on blood agar plates, brain-heart infusion agar, blood-chocolate plates and Lowenstein Jensen (LJ) slants. Nocardia grew from pus which was aspirated from the lung nodule, on blood agar, brain heart infusion and chocoloate agar plates and was it identified as Nocardia asteroides by using manual standard methods. Mycobacterial cultures of the pus which was aspirated from the peripancreatic mass and sputum were positive for M. tuberculosis. but those from the pus which was aspirated from the lung nodule were negative for M. tuberculosis. The patient was started on a therapy with co-trimoxazole and anti tubercular drugs. Blood cultures grew an extended spectrum beta lactamase producing E.coli on the fourth day, but unfortunately the patient’s condition worsened in spite of starting on culture sensitive antibiotics. He expired on the fifth day due to hepatorenal failure, subsequent to uncontrolled Gram negative sepsis.
India has a very high prevalence of tuberculosis and infections in both healthy and compromised hosts are very common, whereas nocardia infections are rare among the normal population, with most infections occuring in immuno-compromised patients, showing pulmonary involvement predominantly. Nocardia spp. are common natural inhabitants of the soil throughout the world. Pulmonary nocardiosis is usually community acquired due to the direct inhalation of Nocardia spp. from contaminated soil, while a person-to-person transmission is rare. Tuberculosis also has a similar presentation, but extrapulmonary involvement is very common and a person to person transmission is the only way in which the disease spreads. N. asteroides may be a saprophyte in the skin and in the upper respiratory tract. Respiratory colonization can occur in a compromised host and can progress to tissue invasion and dissemination. (5),(6) Rosett and Hodges isolated Nocardia spp. from respiratory secretions from 36 patients, 19 of whom were free of the disease. (7) Most of those patients who had colonized Nocardia had obstructive pulmonary disease. The host resistance to infection with Nocardia spp. is thought to depend on functioning phagocytic cells. Neutrophils limit the spread of infection in the early stage of tissue invasion. (8) Activated macrophages and T-lymphocytes prevent dissemination and kill the bacteria. (9) The crucial role of cell-mediated immunity has been proved in experimental in vitro studies; thus, it is not surprising that the Nocardia spp. behaves as an opportunistic microorganism in an immunocompromised host. (9),(10) Patients who are infected by HIV are predisposed to a variety of common and uncommon pulmonary infections. Of the various species of nocardia that are pathogenic to men, N. asteroids is the most common. Most cases of nocardiosis present with non specific respiratory symptoms such as chronic cough, chest pain, dyspnoea and haemoptysis at presentation, which mimick tuberculosis. (11) About 5% of the patients with proven pulmonary tuberculosis were shown to have co-infection with nocardia. (12), (13) Chronic nocardiosis carries a mortality rate of 33% and acute disease shows a rate of 66-72%.(3),(13) With the incidence of concomitant pulmonary tuberculosis, the mortality increases. The chest radiological findings of pulmonary nocardiosis in advanced HIV infections include alveolar infiltration, cavitation, pleural effusion and reticulonodular pattern. (15) Nocardiosis presents at an advanced state of HIV infection and can be fatal. In an autopsy study by Lucas et.al, on 247 patients who died of HIV related illnesses, 10 (4%) patients were found to have nocardiosis and among those with AIDS defining illnesses, 5% were found to have this disease. Of 10 patients who were diagnosed to have nocardiosis, 4 had initially been misdiagnosed as having pulmonary tuberculosis. (4) In our case, despite the initial suspicion that the patient’s lung lesion represented the focus of tuberculous infection, a bacterial pathogen requiring different treatments was identified. More importantly, the search for acquired immune deficiency such as the HIV infection, should not be overlooked in patients with pulmonary and extra pulmonary tubercular infections. In India, the prevalence of nocardiosis as reported in 1973, was 4.6% among patients who were suspected to havetuberculosis. (11) Although nocardiosis resembles tuberculosis, the first line anti tubercular drugs have no roles to play in its treatment. (4) Therefore, it is important to establish a definitive diagnosis. It has been suggested that microscopic morphology can be suggestive enough to warrant empiric therapy for nocardiosis while awaiting the culture results, especially in seriously ill patients and in those with an impaired host defense system. (14)
In summary, two general conclusions can be made. Firstly, pulmonary nocardiosis is difficult to diagnose on the basis of clinical and radiological findings. Once pulmonary tuberculosis is diagnosed, co-infection with Nocardia is never suspected unless and until there is a high index of suspicion or when the patient does not recover after completing the course of anti tubercular chemotherapy. Microbiologists must be informed, in such cases, to include specific stains and cultures to investigate the presence of Nocardia spp. Secondly, cases with pulmonary and extrapulmonary tuberculosis along with pulmonary nocardiosis, with an HIV positive serology, are rare but not uncommon. So, any patient suffering from AIDS with pulmonary symptoms should be investigated for pulmonary tuberculosis and nocardiosis, while ruling out extrapulmonary tuberculosis.
: Mixed pulmonary infection in HIV
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