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      A Rare Case of Drug-Resistant Nocardia transvalensis Infection in a Renal Transplant Patient

      case-report

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          Abstract

          Nocardia transvalensis is a rare species of Nocardia and is known to be a drug-resistant organism. Multiple cases have been reported of Nocardia species causing opportunistic infections in immunocompromised hosts. To our knowledge, we report the first case of successfully treated drug-resistant Nocardia transvalensis causing pulmonary nocardiosis in a renal transplant patient. Our case validates the importance of prompt identification of Nocardia species and their drug sensitivities to improve clinical outcomes and reduce mortality.

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          Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy.

          Barbara Brown-Elliott, June Brown, Patricia S Conville … (2006)
          The recent explosion of newly described species of Nocardia results from the impact in the last decade of newer molecular technology, including PCR restriction enzyme analysis and 16S rRNA sequencing. These molecular techniques have revolutionized the identification of the nocardiae by providing rapid and accurate identification of recognized nocardiae and, at the same time, revealing new species and a number of yet-to-be-described species. There are currently more than 30 species of nocardiae of human clinical significance, with the majority of isolates being N. nova complex, N. abscessus, N. transvalensis complex, N. farcinica, N. asteroides type VI (N. cyriacigeorgica), and N. brasiliensis. These species cause a wide variety of diseases and have variable drug susceptibilities. Accurate identification often requires referral to a reference laboratory with molecular capabilities, as many newer species are genetically distinct from established species yet have few or no distinguishing phenotypic characteristics. Correct identification is important in deciding the clinical relevance of a species and in the clinical management and treatment of patients with nocardial disease. This review characterizes the currently known pathogenic species of Nocardia, including clinical disease, drug susceptibility, and methods of identification.
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            Nocardia species: host-parasite relationships.

            B Beaman, L. Beaman (1994)
            The nocardiae are bacteria belonging to the aerobic actinomycetes. They are an important part of the normal soil microflora worldwide. The type species, Nocardia asteroides, and N. brasiliensis, N. farcinica, N. otitidiscaviarum, N. nova, and N. transvalensis cause a variety of diseases in both normal and immunocompromised humans and animals. The mechanisms of pathogenesis are complex, not fully understood, and include the capacity to evade or neutralize the myriad microbicidal activities of the host. The relative virulence of N. asteroides correlates with the ability to inhibit phagosome-lysosome fusion in phagocytes; to neutralize phagosomal acidification; to detoxify the microbicidal products of oxidative metabolism; to modify phagocyte function; to grow within phagocytic cells; and to attach to, penetrate, and grow within host cells. Both activated macrophages and immunologically specific T lymphocytes constitute the major mechanisms for host resistance to nocardial infection, whereas B lymphocytes and humoral immunity do not appear to be as important in protecting the host. Thus, the nocardiae are facultative intracellular pathogens that can persist within the host, probably in a cryptic form (L-form), for life. Silent invasion of brain cells by some Nocardia strains can induce neurodegeneration in experimental animals; however, the role of nocardiae in neurodegenerative diseases in humans needs to be investigated.
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              Risk factors, clinical characteristics, and outcome of Nocardia infection in organ transplant recipients: a matched case-control study.

              Anton Peleg, K. Shutt, Z Qureshi … (2007)
              Risk factors for Nocardia infection in organ transplant recipients have not been formally assessed in the current era of transplantation. We performed a matched case-control study (1:2 ratio) between January 1995 and December 2005. Control subjects were matched for transplant type and timing. Univariate matched odds ratios were determined and conditional logistic regression was performed to identify independent risk factors. Clinical and microbiological characteristics of all case patients were reviewed. Among 5126 organ transplant recipients, 35 (0.6%) were identified as having cases of Nocardia infection. The highest frequency was among recipients of lung transplants (18 [3.5%] of 521 patients), followed by recipients of heart (10 [2.5%] of 392), intestinal (2 [1.3%] of 155), kidney (3 [0.2%] of 1717), and liver (2 [0.1%] of 1840) transplants. In a comparison of case patients with 70 matched control subjects, receipt of high-dose steroids (odds ratio, 27; 95% confidence interval, 3.2-235; P=.003) and cytomegalovirus disease (odds ratio, 6.9; 95% confidence interval, 1.02-46; P=.047) in the preceding 6 months and a high median calcineurin inhibitor level in the preceding 30 days (odds ratio, 5.8; 95% confidence interval, 1.5-22; P=.012) were found to be independent risk factors for Nocardia infection. The majority of case patients (27 [77%] of 35) had pulmonary disease only. Seven transplant recipients (20%) had disseminated disease. Nocardia nova was the most common species (found in 17 [49%] of the patients), followed by Nocardia farcinica (9 [28%]), Nocardia asteroides (8 [23%]), and Nocardia brasiliensis (1 [3%]). Of the 35 case patients, 24 (69%) were receiving trimethoprim-sulfamethoxazole for Pneumocystis jirovecii pneumonia prophylaxis. Thirty-one case patients (89%) experienced cure of their Nocardia infection. Receipt of high-dose steroids, history of cytomegalovirus disease, and high levels of calcineurin inhibitors are independent risk factors for Nocardia infection in organ transplant recipients. Our study provides insights into the epidemiology of Nocardia infection in the current era, a period in which immunosuppressive and prophylactic regimens have greatly evolved.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Investig Med High Impact Case Rep
                Journal ID (iso-abbrev): J Investig Med High Impact Case Rep
                Journal ID (publisher-id): HIC
                Journal ID (hwp): sphic
                Title: Journal of Investigative Medicine High Impact Case Reports
                Publisher: SAGE Publications (Sage CA: Los Angeles, CA )
                ISSN (Electronic): 2324-7096
                Publication date (Electronic): 28 February 2020
                Publication date Collection: Jan-Dec 2020
                Volume: 8
                Electronic Location Identifier: 2324709620909243
                Affiliations
                [1 ]Augusta University Medical Center, Augusta, GA, USA
                [2 ]Kaweah Delta Medical Center, Visalia, CA, USA
                Author notes
                [*]Sandeep Anand Padala, MD, Department of Medicine, Nephrology, Augusta University, Medical College of Georgia, 1120 15th Street, Augusta, GA 30912, USA. Email: spadala@ 123456augusta.edu
                Author information
                https://orcid.org/0000-0002-8633-7717
                https://orcid.org/0000-0001-5608-5654
                https://orcid.org/0000-0002-8773-073X
                Article
                Publisher ID: 10.1177_2324709620909243
                DOI: 10.1177/2324709620909243
                PMC ID: 7052443
                PubMed ID: 32108507
                SO-VID: f0093fd1-fd9a-4d17-a0fe-0bd7b0e43dd6
                Copyright © © 2020 American Federation for Medical Research
                License:

                This article is distributed under the terms of the Creative Commons Attribution 4.0 License ( https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                Date received : 13 November 2019
                Date revision received : 24 January 2020
                Date accepted : 27 January 2020
                Categories
                Subject: Case Report
                Custom metadata
                cover-date January-December 2020
                typesetter ts1

                Keywords: kidney transplant,nocardia,nocardia transvalensis,disseminated nocardiosis,multidrug-resistant nocardia transvalensis,pulmonary nocardiosis,immunocompromised,linezolid
                Data availability:
                Keywords: kidney transplant, nocardia, nocardia transvalensis, disseminated nocardiosis, multidrug-resistant nocardia transvalensis, pulmonary nocardiosis, immunocompromised, linezolid

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