A Case Series and Focused Review of Nocardiosis

Nocardia species are ubiquitous soil organisms that often infect patients with underlying immune compromise, pulmonary disease, or a history of surgery or trauma. We report 5 cases of nocardiosis representing various aspects of this "great imitator": 1) pneumonia in the setting of underlying malignancy, 2) chronic pneumonia with drug-resistant organism, 3) bacteremia and empyema with chronic hematologic malignancy, 4) primary cutaneous disease, and 5) sternal wound infection. We present a summary of the English literature from 1966 to 2003 with a focus on the teaching points of each of our 5 cases as well as the background epidemiology and microbiology of the Nocardia genus. Isolation of the organism may be achieved with routine media but longer incubation times may be necessary, delaying diagnosis and appropriate therapy. Treatment with a sulfa-containing regimen is standard of care, but resistance testing is warranted given emerging drug resistance, high rates of discontinuation due to adverse reactions, and the potential for nephrotoxicity in transplant recipients on cyclosporine.