Nocardia veterana: disseminated infection with urinary tract infection

braz j infect dis.2015;19(2):216–219

www .e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Case

report

Nocardia

veterana:

disseminated

infection

with

urinary

tract

infection

Elodie

Poisnel

_,

_{Jean-Baptiste}

_Roseau

_,

_Cécile

_Landais

_,

_Veronica

_{Rodriguez-Nava}

_,

Emmanuel

Bussy

_,

_Tiphaine

_Gaillard

a_{DepartmentofMedicine,HospitalSainteAnne,Toulon,France} b_{DepartmentofPneumology,HospitalSainteAnne,Toulon,France} c_{DepartmentofMicrobiology,HospitalSainteAnne,Toulon,France}

d_{CenterforMicrobialEcology,NocardiosisFrenchObservatory,SchoolofPharmacy,UniversityClaudeBernardLyon1,Lyon,France} e_{DepartmentofNuclearMedicine,HospitalSainteAnne,Toulon,France}

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Articlehistory:

Received30July2014 Accepted12November2014 Availableonline28January2015

Keywords: Nocardiaveterana

Urinarytractinfection MALDI-TOFMSsystem 16SrDNAgenesequencing

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Nocardiaspp.areagroupofaerobicactinomyceteswidelydistributedinsoil,andassociated withsevereopportunisticinfections,essentiallypulmonaryinfections.

Wereportthefirstcaseofdisseminatedinfectionassociatedwithurinarytractinfection causedbyNocardiaveterana.Thediagnosiswasdifficult;despitethepresenceofpulmonary nodules,thelung biopsiesremainednegativewhile onlyoneaerobicbloodcultureand theurineculturewerepositiveforN.veterana,identifiedaftera16SrDNAgenesequence analysis.

FewcasesofclinicalimportanceduetoN.veteranahavebeenpublishedsinceits charac-terization.Thebacteriologicaldiagnosisofnocardiosiscanbedifficulttoestablishbecause ofthedelayedgrowthandthespecifictechniquesthatarerequired.Thiscaseillustrates thenecessityofperformingspecificinvestigationsinimmunocompromisedpatientswho presentwithinfectiousdiseasebecausetheseverityofthisinfectionrequiresearlydiagnosis andquickinitiationofappropriateantibiotictherapy.

©2015ElsevierEditoraLtda.Allrightsreserved.

Case

presentation

A51-year-oldmanwasadmittedtothehospitalto investi-gatehischestpainandweightloss(8kgintwomonths).His

Abbreviations: CAPD, continuous ambulatoryperitoneal dialysis;BAL, bronchoalveolarlavage; CT, computedtomography;FDG, deoxyglucoselabeledwithfluorine18;PAS,periodicacidSchiff;PCR,polymerasechainreaction;MALDI-TOFMS,matrix-assistedlaser desorption/ionizationtime-of-flightmassspectrometry.

∗ _{Correspondingauthorat:DepartmentofMicrobiology,HospitalSainteAnne,BoulevardSainteAnne,BP20545,83041Cedex09Toulon,}

France.

E-mailaddress:tiphaine.rousselgaillard@gmail.com(T.Gaillard).

pastmedicalhistoryincludedagrade4lefttemporal glioblas-toma, diagnosed11 monthsbefore, and multicystic kidney disease.Thepatient underwentsurgeryandradiation ther-apy,followedbyfirstlinechemotherapywithtemozolomide and second line chemotherapywithlomustine,vincristine,

http://dx.doi.org/10.1016/j.bjid.2014.11.003

brazj infect dis.2015;19(2):216–219

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Fig.1–ChestCTscanshowingright-sidedmultiple

pulmonarynoduleswithcavitation(A)andparenchymal

consolidationinthemiddlelobe(B).

and procarbazin,dueto diseaseprogression. Hewas given 32mgofmethylprednisoloneperdaystartingatthebeginning ofthechemotherapy.Multicystickidneydiseasecausedrenal terminalinsufficiency, which required continuous ambula-toryperitonealdialysis (CAPD)formorethan fourmonths. Thepatientpresentedwithaprogressiveshortnessofbreath, right-sidedchestpain, anddysuria.Hehadnofever,and a physicalexam showed right basalcrackles. Thelaboratory testresultswereasfollows:hemoglobin9.7g/dL;neutrophils 12×109_{/L; lymphocytes 4.2×10}9_{/L with a CD4}

lympho-cytecountof1.64×109_{/L;serumcreatinine630␮mol/L,and}

C-reactiveprotein113.5mg/L(referencevalue<10mg/L). Addi-tionally,two sets ofblood cultures and urine culturewere performed. Urine analysis revealed 1.3×106_{leukocytes/mL}

(normal range <103_{/mL) and Gram-positive short bacilli at}

microscopicexamination.Chestcomputedtomography(CT) showedmultiplesub-pleuralnodulesintherightlowerlobe thatwereadjacenttopleuralthickeningwithoutpleural effu-sion, and consolidation inthe middle lobe (Fig. 1). One of thenoduleswasexcavated. ThePETimagingperformed to demonstratedeepinfection showedanintenseand diffuse accumulationofthe deoxyglucose labeled withfluorine 18 (FDG)intheprostate(Fig.2)revealingprostatitis.

Abronchoalveolar lavage (BAL) and a CT-guidedneedle lungbiopsyoftheposteriornodulewere performed.Inthe laboratory, tissueanalysisfound acute suppurative inflam-mation, with negative PAS, Grocott and Giemsa staining.

Prostate

a

b

Fig.2–PETscanshowinganintenseanddiffuse

accumulationoftheFDGintheprostate(A:PETimaging;B:

scannedimagingoftheprostate).

Gram andacid-fast stainingwere processedandwere neg-ative onbothsamples.Standard cultureperformedonBAL was non-contributive, with polymicrobial non-pathogenic nasopharyngealflora;mycobacterialandmycologicalcultures remainednegative.Standardculturewasnotundertakenon thepulmonarybiopsybecauseofitsinsufficientamount.Both samplesweretestedfortuberculosisusingpolymerasechain reaction (PCR) on the MTB/RIF test platform (GenExpert®_;

Cepheid,Sunnyvale,CA,USA)andwerenegative.PCR ampli-ficationand sequencingof16S rDNAand18S rDNAforthe detectionofbacteriaandfungi,respectively,wereperformed onthepulmonarybiopsyafterdewaxing,andwerenegative. Fourdaysafterthepatient’sadmission,growthwasidentified inoneaerobicbloodcultureusingtheBacTAlert3D®_culture

system (BioMérieux, Marcyl’Etoile, France). The bacterium wasanon-motile,Gram-positiveorganismwithbranching fil-aments.Small,chalkywhite,roughcoloniesgrewwithin48h wheninoculatedonboiledbloodagarplatesthatwere incu-batedat37◦Cin5%CO2.Theywerepartiallyacid-fastandwere

consideredtolikelyrepresentNocardiaspp.AGram-positive bacteriumwasobservedsimultaneouslyintheurineculture, withmorethan 100,000colonies/mL. Thetwo strains,from bloodandurinecultures,wereidentifiedtothegenuslevelas

Nocardiaspp.usingtheMALDI-TOFMS(matrix-assistedlaser desorption–ionizationtime-of-flightmassspectrometry) sys-tem(BrukerDaltonik,Bremen,Germany)afteranextraction procedure.TheidentificationtothespecieslevelasNocardia veteranawasobtainedusinga16SrDNAgenesequence analy-sis(99.9%sequencematchingwiththetypestrainN.veterana

218

Prior to the isolation of Nocardia, the patient was empirically treated with intravenous trimethoprim-sulfamethoxazole(400mg/80mg,twicedaily)andceftriaxone (750mgtwicedaily).Doseswereadaptedtorenalfunction, withhemodialysisperformedthreetimesperweek. Antimi-crobialsusceptibilitywasassessedbytheFrenchObservatory ofNocardiosis(Lyon,France)bybrothmicrodilution accord-ingtotheClinicalandLaboratoryStandardsInstitute(CLSI0 methodsandbreakpoints).1_{Theprofilerevealedresistanceto}

amoxicillin+clavulanate(MICof32/16␮g/mL),ciprofloxacin (MIC>4␮g/mL)anddoxycycline(MIC=8␮g/mL);intermediate susceptibilitytogentamicin(MICof8␮g/mL)andminocyclin (MIC=2␮g/mL);andsusceptibilitytocefotaxime(≤4␮g/mL), ceftriaxone (MIC=8␮g/mL), imipenem (MIC≤2␮g/mL), trimethoprim-sulfamethoxazole (MIC≤1/19␮g/mL) and linezolid (MIC≤4␮g/mL). After initiation of treatment, the respiratory symptoms slowly improved, and dysuria was completelyresolved.Thebiologicalinflammatorysyndrome decreased gradually, and a chest CT scan performed after onemonthofantibiotictherapyshowedamoderatedecrease innodulessize.Accordingly, theurinary and blood culture controlsshowedno remainingNocardia.Unfortunately, due toglioblastomaprogression,thepatient’sneurologicalstatus declined,andhediedtwomonthsaftertheinitialadmission. Nocardiosis infections are caused by the saprophytic aerobic, Gram-positive, branching and filamentous bacilli belongingtothegenusNocardia.Theidentificationof Nocar-dia isolates atthe species level is critical for defining the spectrumofdiseasesthatarecausedbyeachspeciesandto predictantimicrobialsusceptibility.2 _{Todate,approximately}

90specieshavebeendescribed(NCBItaxonomyforNocardia),

andathirdofthemhavebeenimplicatedinhumandisease.3

Ifisolatesgrowwellonbloodagarplates,theroutine identi-ficationofNocardiastrainsusingconventional phenotypical methods is a fastidious and time-consuming process that isnow restrictedtoreferencecenters.2 _{Inrecentyears,16S}

rDNAgenesequenceanalysishasbecomeaccessibleto clin-icallaboratoriesfordefinitive speciesidentification.4 _Inour

case,thestrainofN.veteranawasconfirmedatthe species level byalmost complete 16S rDNA genesequencing (1315 nt)byusing SQ1(5-AGAGTTGATCMTGGCTCAG-3)and SQ6 (5-CGGTGTGTACAAGGCCC-3)primers,accordingtoprevious publisheddata.5 _{Thesequencesobtainedpresenteda99.9%}

sequence similarity (one difference out of1315nt, exclud-ingthe primers)tothetypestrainN.veteranaDSM44445T_.

TheMALDI-TOFMSidentificationsystemsarebasedonthe comparison ofthe tested isolate mass spectrum with ref-erencedatabases.PreviousstudiesreportedthattheBruker MALDI-TOFMSsystemaccuratelyidentifiedspeciesfromthe genusNocardiaspp.6 _{but apreliminaryextractionstepwas}

mandatorytoobtainsatisfactoryresults.Inourcase,the iden-tificationwasobtainedtothegenuslevelafteranextraction procedure intwosteps(boilingfollowed byethanol–formic acidextraction).Atfirst,theidentificationbythedirectcolony methodfailedtoidentifythebacterium,althoughithasbeen recentlypublishedwithotherMALDI-TOFMSsystems.7

N.veteranaisaspeciesthatwascharacterizedin2001.8_The

difficultiesintheidentificationofthisspecies,untilrecently, may implythat it ismore common asa humanpathogen than previouslyreported.9 Indeed,little is known aboutN.

veteranabecausefewcasesofclinicalimportancehavebeen published.Oneisolatewasfromabrainabscess10_;threewere

reported in patients with pulmonary infections2,11–14_{; one}

isolate was recovered in a bowel abscessand was associ-atedwithcoloncarcinoma15_{;twocasesofmycetomasfrom}

Japan were published16,17_{; one isolate has been recovered}

from ascitic fluid,8 _{onewasresponsible foran endogenous}

endophtalmitis,18_{andrecently,acaseofN.veteranacausing}

nodularlymphangitiswasreported.19_{Bloodstreaminfection}

duetoN.veteranaisararecondition.Inourcase,thispathogen wasisolatedfrombloodandurinecultures,andthisisthefirst reportedcaseofurinarytractinfectionduetoN.veterana.This impliesthattheinfectiousspectrumofN.veteranacouldbe relativelybroad.

LikeotherspeciesofNocardiaspp.,N.veteranacauses infec-tionsmainlyinimmunocompromisedhosts.Aspredisposing factors,thepatientwasadministeredlong-termcorticosteroid and chemotherapy (including temozolomide) for neoplas-tic disease. However,in a recent study of nocardiosis and AIDS, it was shown that despite deep immunodepression, nocardiosiswasanuncommoncomplication. Trimethoprim-sulfamethoxazole,whichisusedinprimaryprophylaxisfor toxoplasmosis,couldbeeffectiveagainstnocardiosisaswell. ItisunclearhowourpatientbecameinfectedbyN.veterana.

Pulmonaryinfectionisthemostcommonsiteofnocardiosis, and it isusuallyacquiredbyinhalationofsporulated frag-mentednocardialmyceliafoundintheenvironment.11,20_Most

ofthetime,diagnosisisbasedontheisolationofNocardiafrom respiratorysamples.Inourcase,weidentifiedadisseminated

N.veteranainfection withthe presenceofthisbacteriumin peripheralbloodcultureandurine.Thehypothesisofairborne contamination,withaninfectionthatwasinitiallylimitedto thelungandasecondaryhematologicaldissemination, some-timestothecentralnervoussystemandsofttissue,8_maybe

considered.However,wehavenotprovedthepresenceofN. veteranainthechest,althoughtherewereseveralindications ofitspresence,includingthepatient’spulmonary presenta-tion,chestCTscanfeatureswithnodulesandparenchymal consolidation12 _{(Fig.1)and thenegativityofall}

bacteriolog-icalchestsamplingforotherpathogens.Thecontamination of the BALby non-pathogenic nasopharyngeal floraof the upperrespiratorytractcouldhaveinterferedwithculturing ofNocardiaspp.Wehavenoexplanationforthenegativityof PCRamplificationof16SrDNAperformedonthepulmonary biopsyafterdewaxing;the lowsensitivityofPCR amplifica-tioncouldexplaintheresult.Furthermore,theroleofCAPD mustbeconsidered,asseveralcasesofperitoneal nocardio-sishavebeen reported.21 _{Ourpatient haddailyhome-and}

self-madeCAPD,whichcouldhavebeenapredisposing fac-torforthis infection becauseofnon-optimalskills.Wedid notperformbacteriologicaltestingofasciticfluidbecauseour patienthadnoabdominalpain,whichmakesthehypothesis ofCAPD-inducedcontaminationlesslikely.

The antimicrobial agents to be used against N. veter-ana remain controversial due to discrepancies regarding methodologicalvariations,differencesininterpretations con-cerningbreakpointsand,therefore,susceptibilities.Basedon limited in vitrostudies of antimicrobialagentsagainst this microorganism,theempiricdrugofchoiceforthispathogen would be trimethoprim-sulfamethoxazole9,22 _{at a dose of}

brazj infect dis.2015;19(2):216–219

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10–15mg/kgdaily.Inourcase,N.veteranaremainedsensitive totrimethroprim-sulfamethoxazole and ceftriaxone,which wastheinitialempiricaltreatment.Thetreatmentof nocar-diosismustbeextendedbyconsideringmanyfactors,such astheseverityofinfectionortheimmunizingstatus.Inthe previouslypublishedcases,thedurationoftreatmentranged fromafewweekstoanumberofyearsbasedonexpert opin-iononthetreatmentofotherNocardiainfections.10_Because

thepatientdiedtwomonthsaftertheinitialadmission,we couldnotevaluatehisresponsetotheantibiotictreatment.

Conclusion

Inconclusion,thisisthefirstreportedcaseofurinarytract infectionduetoN.veterana.NocardiosisduetoN.veteranaisa raredisease,butitsincidencewillmostlikelyincreaseinthe comingyearsbecauseofthegrowingpopulationof immuno-compromised hosts. This case illustrates the difficulty of establishingabacteriologicaldiagnosisofnocardiosisandthe necessityofperforming specificinvestigations in immuno-compromisedpatientswho presentwithinfectious disease becausetheseverityofthisinfectionrequiresearlydiagnosis andquickinitiationofappropriateantibiotictherapy.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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