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First Report of Nocardia asiatica Presenting as an Anterior Mediastinal Mass in a Patient with Myasthenia Gravis: A Case Report and Review of the Literature

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      Abstract

      The spectrum of infections with Nocardia spp. is heterogeneous. It has classically been associated with lung, brain, or skin involvement. We describe an unusual presentation of Nocardia asiatica (N. asiatica) in an Iraqi patient with myasthenia gravis suffering from a disseminated infection and presenting with an anterior mediastinal cystic mass. N. asiatica has only been three times described outside Japan and Thailand, and the rarity of this entity deserves this communication.

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      Most cited references 23

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      Nocardiosis: updated clinical review and experience at a tertiary center.

      Nocardiosis is a rare opportunistic disease that affects mainly patients with deficient cell-mediated immunity, such as those with acquired immunodeficiency syndrome (AIDS) or transplant recipients. Pulmonary disease is the most common presentation in immunosuppressed patients and approximately one-third have a disseminated disease. Primary cutaneous nocardiosis is more frequently observed in immunocompetent patients with direct inoculation of the organism through professional exposure. The diagnosis can be challenging, as signs and symptoms are not specific and a high index of clinical of suspicion is necessary. Although gram stain, modified acid-fast stain, and cultures remain as the standard diagnostic tools, novel molecular techniques have changed the taxonomy of these organisms and, in some instances, have facilitated their identification. The disease has a marked tendency to recur and a high morbidity and mortality rate in immunosuppressed patients. Treatment is usually prolonged and an associated antibiotic treatment is preferred for severe disease. Although sulfonamides in combination with other antibiotics are still the treatment of choice, other associations such as imipenem plus amikacin are preferred in some centers. Linezolid is a useful alternative therapeutic agent due to its oral availability and activity against most of the isolates studied. Twenty-eight cases of nocardiosis were diagnosed at our center between January 1989 and April 2009. We report the epidemiologic characteristics of Nocardia spp. observed in our institution and discuss the risk factors, clinical features, diagnosis, and management of the disease.
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        Antimicrobial-resistant nocardia isolates, United States, 1995-2004.

        We conducted a 10-year retrospective evaluation of the epidemiology and identification of Nocardia isolates submitted to the Centers for Disease Control and Prevention for antimicrobial susceptibility testing. The species most commonly identified were N. nova (28%), N. brasiliensis (14%), and N. farcinica (14%). Of 765 isolates submitted, 61% were resistant to sulfamethoxazole and 42% were resistant to trimethoprim-sulfamethoxazole.
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          Determination of antimicrobial susceptibility patterns of Nocardia spp. from clinical specimens by Etest.

          Susceptibilities to 11 antimicrobial agents were determined by Etest for 93 Nocardia isolates from clinical specimens and 15 type strains belonging to different Nocardia spp. All isolates were susceptible to trimethoprim-sulphamethoxazole, amikacin and linezolid, but susceptibilities of the various Nocardia spp. to beta-lactams, aminoglycosides, ciprofloxacin and clarithromycin varied markedly. Overall, there was a good correlation between the drug resistance patterns and the species identification established by conventional phenotypic tests and 16S rDNA sequencing. Among the different species encountered, Nocardia farcinica and Nocardia brasiliensis displayed the most multiresistant profiles, with resistance to imipenem occurring mainly among isolates of N. brasiliensis and Nocardia abscessus. The species variability in susceptibility profiles and the numerous recent taxonomic changes means that in-vitro susceptibility tests may be a complementary tool for the identification of Nocardia isolates from human clinical specimens. Further studies on a larger number of species from more diverse geographical sources, including species that are found less commonly among clinical isolates, are required to validate and extend the results.
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            Author and article information

            Affiliations
            1Division of Infectious Diseases, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El Solh, Beirut 1107 2020, Lebanon
            2Department of Pathology & Laboratory Medicine, American University of Beirut Medical Center, Beirut 11072020, Lebanon
            3Division of Pulmonary and Intensive Care medicine, American University of Beirut Medical Center, Beirut 11072020, Lebanon
            4Division of Cardiology, American University of Beirut Medical Center, Beirut 11072020, Lebanon
            Author notes

            Academic Editors: T. Shibata and K. Yeboah-Antwi

            Journal
            Case Rep Infect Dis
            Case Rep Infect Dis
            CRIM.ID
            Case Reports in Infectious Diseases
            Hindawi Publishing Corporation
            2090-6625
            2090-6633
            2012
            16 July 2012
            : 2012
            3403161
            22844621
            10.1155/2012/325767
            Copyright © 2012 Rima I. El-Herte et al.

            This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

            Categories
            Case Report

            Infectious disease & Microbiology

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