Clinico-pathological analysis of a rare case of pulmonary nocardiosis under the mask of disseminated tuberculosis

Abstract

Nocardiosis is a rare infectious disease caused by bacteria of the genus Nocardia and characterized by the development of foci of purulent-necrotic inflammation of the lungs, brain, and internal organs. Clinical diagnosis of nocardiosis has objective difficulties. The aim of the study is to highlight a rare clinical case of pulmonary nocardiosis, to analyze mistakes in the clinical diagnostics of the main disease, to discuss the differential diagnosis of nocardiosis. Materials and methods. A clinico-pathological analysis of an inpatient and outpatient medical record card, and the results of an autopsy of a 58-year-old patient who died in an anti-tuberculosis institution from pulmonary nocardiosis has been carried out. Results. According to the anamnesis, the patient suffered from COPD and chronic polyposis rhinitis with hypertrophy of the nasal turbinates for many years. Polypectomy and submucosal resection of the nasal septum were performed in the otolaryngology department. Wegener's granulomatosis was suspected during the intravital pathomorphological examination of nasal polyps, and glucocorticoids were prescribed in the hospital. Histological preparations and biological material of the patient were examined in clinics in Berlin, the diagnosis of “Wegener's granulomatosis” was not confirmed, however, domestic doctors recommended Medrol, which the patient received continuously for 5 years at a dose of 12 mg/day. After 5 years, the patient was admitted to the hospital of a specialized anti-tuberculosis institution in serious condition with a clinical diagnosis: newly diagnosed disseminated tuberculosis of both lungs with disintegration, right-sided spontaneous tension pneumothorax, respiratory insufficiency of the III degree. According to urgent indications, thoracentesis and drainage of both pleural cavities were performed. Despite intensive therapy, the condition worsened, and biological death occurred 11 days after hospitalization. During the post-mortem pathological examination, signs of tuberculosis of both lungs were not detected, nocardiosis of both lungs was diagnosed, which pathomorphologically manifested as multiple foci of purulent-necrotic bronchopneumonia with disintegration. Pathological diagnosis was confirmed by bacteriological and PCR examination of the post-mortem material. The disease developed on the background of wrongly prescribed long-term glucocorticosteroid therapy, which was carried out for the misdiagnosis “Wegener's granulomatosis”. No signs of Wegener's granulomatosis were found at autopsy. The direct cause of death was acute respiratory failure. Conclusion. Thus, pulmonary nocardiosis was not diagnosed in the hospital, the reason for the misdiagnosis was the rarity of the disease and the objective difficulties of diagnostics. A decisive role in the development of nocardiosis was played by erroneously prescribed long-term glucocorticosteroid therapy, which should be considered as a pathology of the therapy