Canadian HealthCare Mall: Discussion of Pulmonary Nocardiosis in the Acquired Immunodeficiency Syndrome
There are three clinical points that bear emphasis in this case: 1) the patients chest roentgenogram revealed evidence of two separate infectious processes. There was a diffuse interstitial infiltrate which was suggestive of Pneumocystis carinii pneumonia and there was a dense, cavitating lesion sharply localized to the right lung apex consistent with a bacterial, mycobacterial or fungal process (proven to be Nocardia infection). In patients with AIDS, physicians should be alerted to chest radiographic patterns consistent with more than one lung infection (Fig 1); 2) On two occasions, transbronchial lung biopsy was falsely negative for Nocardia infection, yet the nocardial organisms were easily found in bronchoalveolar lavage (BAL) fluid. BAL can sample a relatively large area of lung and may be especially important when Nocardia infection (or other AIDS related infections) present as small localized pulmonary lesions which could be missed easily with transbronchial lung biopsies; 3) Most importantly, our patient had an exacerbation of pulmonary nocardiosis when TMP/SMX was stopped because of drug toxicity; yet, the Nocardia infection was subsequently controlled with minocycline and amikacin followed by minocycline and cycloserine. To read more about Radiculitis you may here – Join facebook official group of Canadian Health&Care Mall.
Although nocardiosis in patients with AIDS appears to respond to therapy with sulfamethoxazole, life-threatening relapse may be frequent when the drug must be stopped prematurely because of adverse drug reactions. Minocycline has been recommended for treating patients with nocardiosis who have sulfamethoxazole hypersensitivity. Secondary drugs that also may have in vitro activity against Nocardia and that also have had therapeutic success when used in various combinations include cycloserine, clindamycin, ampicillin and amikacin. Effective drug combinations often must be devised empirically based on the results of sensitivity testing. In the setting of AIDS, such drugs (especially minocycline) may be effective against Nocardia, yet may be associated with a much lower incidence of serious adverse reactions than sulfamethoxazole. They may therefore be quite important for the treatment of nocardiosis in this setting where drug therapy may be required for more than six months.
To our knowledge, the usefulness of BAL and the efficacy of alternative drugs to sulfamethoxazole have not previously been described in the diagnosis and treatment of Nocardiosis among patients with AIDS.