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Abstract

In a retrospective study of 9 patients, who developed Nocardia spp. infection and were hospitalised between 2013 and 2019, 7 patients (5 men and 2 women) aged 27–90 years were described out of whom 6 patients developed lymphopenia and nocardiosis during immunosuppressant therapy with dexamethasone, temozolomide, methylprednisolone, cyclophosphamide or mycophenolate mofetil. The remaining one patient exhibited lack of efficacy with cotrimoxazole and meropenem for nocardiosis [ not all dosages, routes and indications stated; times to reaction onsets not stated ]. Six out of the 7 patients, who had a history of glioblastoma multiforme, microscopic polyangiitis, IgA-associated glomerulonephritis, myasthenia gravis, lung adenocarcinoma with brain metastases or unspecified indication, received immunosuppressant therapy with dexamethasone 8mg and temozolomide (n=1), methylprednisolone 40mg and cyclophosphamide 20mg (three cycles; n=1), pulse methyl prednisolone and mycophenolate mofetil (n=1), dexamethasone 8mg and temozolomide (n=1), pulse methyl prednisolone with methylprednisolone 192mg (n=1) and dexamethasone along with radiotherapy and chemotherapy (n=1). They received the immunosuppressant treatments for the duration of 1–12 months. The patients presented with the symptoms of fever, cough, phlegm, swelling in the arm, lesion with discharge in the leg, loss of vision, weakness in the right leg or dyspnoea. Investigations revealed leucocyte count of 4200–21000 /mm 3 and lymphocyte count of 400–2000 /mm 3 . Lymphopenia related to the steroids, temozolomide and cyclophosphamide was noted in all the patients. Subsequently, after 7–40 days, they were diagnosed with nocardiosis. CT scan of lungs showed multiple nodular infiltrations that form a cavity in the central region of bilateral lungs, bilateral nodular infiltrations, right mid-lobe millimetric consolidated region, lower right lobe lobar infiltration and cavity and right lung pleural effusion, bilateral pleural effusion, nodule and cavity in the upper and middle lobe of the right lung or infiltration which exhibited cavity formation in the lower right lobe. Cultures from sputum, bronchoalveolar lavage, pus or vitreous fluid confirmed diagnoses of pulmonary nocardiosis due to Nocardia cyriacigeorgica (n=2), disseminated nocardiosis (Nocardia spp.) with intramuscular abscesses on the chest wall and arms involvement (n=1) , disseminated nocardiosis (Nocardia spp.) with pulmonary and cerebral involvement (n=1), disseminated nocardiosis (Nocardia spp.) with intramuscular abscesses in the upper and lower extremities and pulmonary involvement (n=1) and disseminated nocardiosis due to Nocardia asteroids with pulmonary, cerebral and ocular involvement (n=1) secondary to the immunosuppressant therapy. Therefore, the patients were treated with cotrimoxazole, imipenem, meropenem, amikacin, moxifloxacin or amoxicillin/ clavulanic-acid [amoxicillin/clavunate]. One out of the 7 patients died despite receiving treatment with IV cotrimoxazole and IV meropenem for 2 weeks (lack of efficacy; n=1). Another patient died 1 month after discharge due to progression in his cranial lesions. The remaining patients were discharged after 4–6 weeks of parenteral antimicrobial therapy.