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Introduction: Nocardiosis is an unusual infection caused by aerobic gram-positive bacteria in the genus Nocardia. Infections resulting from Nocardia species are frequent in immunosuppressive patients. Weakened immune systems caused by human immunodeficiency virus infection, diabetes, cancer, and other conditions such as chronic lung disease, renal failure, etc, are the main risk factors for nocardiosis. Central nervous system (CNS) nocardiosis has been reported to represent ~2% of all and to be present in 15% to 50% of patients with systemic infection. The patient in our case had an isolated CNS nocardiosis caused by Nocardia terpenica infection, a rare reclassified Nocardia pathogen of CNS nocardiosis., Case: We here present a 54-year-old Chinese male with a fever and headache for 15 days who showed positive meningeal irritation signs. Magnetic resonance imaging showed the right trigone of the lateral ventricular choroid plexitis and diffused leptomeningeal meningitis involving the bilateral cerebral hemisphere, cerebellar hemisphere, and brain stem. The patient was quickly diagnosed with CNS Nocardia infection by next-generation sequencing within 48 hours after admission. Meanwhile, the diagnosis was validated by Nocardia-positive staining in cerebral spinal fluid culturing. The patient was given trimethoprim-sulfamethoxazole, and his symptoms recovered after 3 days., Conclusions: In this case, the clinical, radiological, and microbiological findings highlight the importance of suspecting Nocardia as the potential pathogen in patients with central nervous system inflammation of doubted immune incompetence. In addition, next-generation sequencing as an effective test is also highly recommended for suspicious CNS infection patients to perform a rapid diagnosis and treatment., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Nocardia species can affect both immunocompetent and immunocompromised people., Method: This retrospective study, from 2009 to 2022, aims to compare the survival analyses of pulmonary nocardiosis in AIDS and non-AIDS patients in northeastern Thailand., Results: A total of 215 culture-confirmed cases of pulmonary nocardiosis: 97 with AIDS and 118 without AIDS. The median CD4 count of AIDS patients was 11 cells/µL (range: 1-198), and 33% had concurrent opportunistic infections. 63.6% of 118 non-AIDS patients received immunosuppressive medications, 28.8% had comorbidities, and 7.6% had no coexisting conditions. Disseminated nocardiosis and pleural effusion were more prevalent among AIDS patients, whereas non-AIDS patients revealed more shock and respiratory failure. One hundred-fifty patients underwent brain imaging; 15 (10%) had brain abscesses. Patients with pulmonary nocardiosis have overall 30-day and 1-year mortality rates of 38.5% (95% CI: 32.3%, 45.4%) and 52.1% (95% CI: 45.6%, 58.9%), respectively. The Cox survival analysis showed that AIDS patients with disseminated nocardiosis had a 7.93-fold (95% CI: 2.61-24.02, p < 0.001) increased risk of death within 30 days compared to non-AIDS patients when considering variables such as age, Charlson comorbidity index, concurrent opportunistic infections, duration of illness, shock, respiratory failure, multi-lobar pneumonia, lung abscesses, and combination antibiotic therapy. While AIDS and pulmonary nocardiosis had a tendency to die within 30 days (2.09 (95% CI, 0.74-5.87, p = 0.162))., Conclusion: AIDS with pulmonary nocardiosis, particularly disseminated disease, is a serious opportunistic infection. Early diagnosis and empiric treatment with a multidrug regimen may be the most appropriate approach in a resource-limited setting., (© 2024. The Author(s).)

We introduce the case of a male patient in his 60s who was admitted to our emergency department with a persisting sore throat for the last 3 weeks and dysphagia. Fibre-endoscopic evaluation revealed an asymmetry at the base of the tongue. In combination with elevated white cell count and C reactive protein, a computerized tomography showed a superinfected thyroglossal duct cyst. Intravenous antibiotics were initiated, and the patient was taken to the operating room for cervicotomy. The microbiological swab taken intraoperatively detected Nocardia paucivorans Additional imaging revealed disseminated nocardiosis with cerebral and pulmonary manifestations.The patient was treated with oral trimethoprim/sulfamethoxazole and, over time, showed complete remission of central nervous system lesions and improvement of pulmonary involvement. Following this, the treatment was stopped 8 months after the initial diagnosis. In this report, we discuss treatment standards and outcomes of nocardiosis based on our management strategies of our patient., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Rationale: Chronic inflammatory demyelinating polyneuropathy (CIDP) is an immune-mediated motor sensory peripheral neuropathy that is rare in clinical practice. This treatment method aims to suppress potential immunopathology. Nocardiosis is a rare, destructive, opportunistic disease. We report a case of failed treatment of CIDP combined with pulmonary nocardiosis, and for the first time, we link these 2 diseases together., Patient Concerns: A 65-year-old man developed symmetrical limb weakness. Four months later, he was diagnosed with CIDP and started receiving glucocorticoid (GC) treatment. The disease progressed slowly and was treated with mycophenolate mofetil (MMF) in combination. He did not follow the doctor requirements for monthly follow-up visits, and the preventive medication for sulfamethoxazole/trimethoprim was not strictly implemented. Two months after the combination therapy, the patient developed fever, coughing and sputum production, as well as fatigue and poor appetite. Based on imaging and etiological results, he was diagnosed with pulmonary nocardiosis., Diagnoses: Chronic inflammatory demyelinating polyneuropathy, pulmonary nocardiosis., Interventions: After treatment with antibiotics, the patient lung infection temporarily improved. However, the patient CIDP condition progressed, limb weakness worsened, respiratory muscle involvement occurred, and intravenous immunoglobulin (IVIG) was administered. However, there was no significant improvement in the condition, and the patient died., Outcomes: In this report, we present a case of a patient with CIDP and pulmonary nocardiosis. It is worth noting that in order to avoid the progression and recurrence of CIDP, we did not stop using related therapeutic drugs during the treatment process, the patient had repeatedly refused to use IVIG. Despite this, the patient condition worsened when lung inflammation improved, leading to persistent respiratory failure and ultimately death. Treatment contradictions, medication issues, and patient compliance issues reflected in this case are worth considering., Lessons: For patients with CIDP receiving immunosuppressive therapy, attention should be paid to the occurrence and severity of Nocardia infection. Therefore, early detection and treatment are necessary. We need to pay attention to the compliance of patients with prophylactic use of antibiotics, strengthen the follow-up, and urge them to return to their appointments on time., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Declaration of Interest: The authors have no conflicts of interest.

A case is presented of a 64-year-old male patient who was admitted because of delirium, jaundice, a pattern of cholestasis in the liver profile and a right lung mass in the context of a constitutional syndrome and weight loss in the last eight months. The lung mass was punctured and the culture of the obtained material developed white colonies, identified by mass spectrometry (MALDI-TOF) as Nocardia cyriacigeorgica. Regarding the clinical diagnosis, it was considered as systemic lupus erythematosus (SLE), on the basis of fulfilling 8 criteria according to SLICC 2012 group, and 24 points according to EULAR/ACR 2019. The liver biopsy showed a mixt cellular infiltrate in portal spaces, with absence of interphase hepatitis and presence of peripheral ductular reaction. These findings were interpreted as liver compromise relate to SLE. Delirium was also considered as a neurological manifestation related to SLE on the basis of ruling out other causes. After being treated with antibiotics and documenting a reduction in the size of the lung mass he received cyclophosphamide in intravenous pulses, achieving normalization of his liver profile and his state of consciousness, and a progressively weight recovering. A year after he was in good health. The report of this case is justified because of the rare presenting form of late onset SLE, as well as the concomitant pulmonary nocardiosis in the absence of previous immunosuppressant treatment.

Rationale: In our search on PubMed, we found that reports of co-infections involving Aspergillus fumigatus and Nocardia cyriacigeorgica in the literature are notably scarce. Most cases have been documented in patients with compromised immune systems or underlying pulmonary conditions. In contrast, our patient did not present with any of these risk factors. Furthermore, there have been no recent incidents such as near-drowning or other accidents in the patient history. To the best of our knowledge, this case represents a hitherto unreported clinical scenario. To enhance comprehension, we conducted a comprehensive literature review by compiling a total of 20 case reports (spanning from 1984 to 2023) on co-infections involving Aspergillus and Nocardia species, retrieved from PubMed., Patient Concerns and Diagnosis: Chest CT revealed the presence of multiple nodules and clustered high-density shadows in both lungs. Bronchoscopy revealed mucosal congestion and edema in the apical segment of the right upper lobe of the lung, along with the presence of 2 spherical polypoid new organisms. The pathological analysis reported severe chronic inflammation with evidence of Aspergillus within the tissue. Next-Generation Sequencing of bronchoalveolar lavage fluid revealed the presence of reads corresponding to A fumigatus and N cyriacigeorgica. Positive cultures for A fumigatus and the Nocardia genus were yielded by prolonging the incubation of samples in the microbiology laboratory., Interventions: Treatment with voriconazole for A fumigatus and sulfamethoxazole-trimethoprim for N cyriacigeorgica infection was given., Outcomes: The patient improved and was discharged. After 6 months of telephone follow-up, the patient reported no clinical symptoms, discontinued the medication on his own., Lessons: A fumigatus and N cyriacigeorgica can manifest as a co-infection in immunocompetent patients. Clinicians should prioritize the significant advantages and value of NGS in detecting rare and mixed pathogens associated with pulmonary infections., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Nocardia pseudobrasiliensis is a new taxon constituting an emerging species of human pathogenic Nocardia , which shares morphological features with N. brasiliensis . However, N. pseudobrasiliensis is more invasive and more easily disseminated, and it exhibits distinctive antibiotic susceptibility. Few clinical cases related to N. pseudobrasiliensis infection have been reported, and N. pseudobrasiliensis hydrarthrosis has not been described. Here, we analyzed the case information, diagnostic process, treatment, and prognosis of a patient with N. pseudobrasiliensis hydrarthrosis who received treatment in Zhejiang Provincial People's Hospital. Magnetic resonance imaging showed joint cavity effusion and soft tissue swelling with high signal on proton density-fat saturated images and low signal on T1-weighted images. Oil microscopy revealed abundant acid-fast-positive filaments in hydrarthrosis puncture fluid. The pathogen was identified as N. pseudobrasiliensis by matrix-assisted laser desorption ionization-time of flight mass spectrometry. In contrast to the 100% ciprofloxacin resistance displayed by N. brasiliensis , this clinical isolate of N. pseudobrasiliensis was completely susceptible. In summary, this is the first report of N. pseudobrasiliensis in joint effusion from a patient with arthritis., Competing Interests: Declaration of conflicting interestsThe authors declare that there is no conflict of interest.

Objective: We describe a rare case of a disseminated Nocardia farcinica infection associated with hip osteomyelitis., Methods: A 91-year-old female patient was admitted with oedema of her right leg, fever of 38 °C and data consistent with ruptured Baker's cyst. A disseminated Nocardia farcinica infection including bloodstream infection, pneumonia and multiple abscesses along both lower limbs was observed., Results: After a four-week course of 320 mg / 1600 mg/12 h of intravenous trimethoprim/sulfamethoxazole and multiple chirurgic drainages the patient was discharged with oral trimethoprim/sulfamethoxazole. Nevertheless, the patient expired done month after being discharged from the hospital., Conclusions: The implementation of a combination of intravenous antibiotics and drainages resulted in an initial improvement in the patient's condition. However, despite these interventions, the patient ultimately passed away probably due to natural causes.

Abstract: A 74-year-old man with chronic obstructive pulmonary disease, glaucoma, and Stage IIIB squamous cell lung cancer experienced several minutes of flashing lights in his right visual hemifield, followed by onset of a right visual field defect. On examination, the patient had a right homonymous hemianopsia that was most dense inferiorly by confrontation testing. Emergent CT scan of the head revealed a 2.5 × 3 cm hypodensity in the left occipital lobe, which was interpreted as an acute stroke. Continuous EEG monitoring captured left posterior quadrant seizures that were temporally correlated to the positive visual phenomena. Subsequent MRI of the brain with and without contrast revealed a conglomerate of centrally necrotic and peripherally enhancing mass lesions. On biopsy, a thick purulent material was drained and Gram stain of the sample revealed gram-positive beaded rods, which speciated to Nocardia farcinica . The patient was treated with a six-week course of intravenous meropenem and a one-year course of oral trimethroprim-sulfamethoxazole. On follow-up, the patient experienced resolution of the right visual field deficit., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by North American Neuro-Ophthalmology Society.)

Background: Nocardia are aerobic Gram-positive bacilli that can invade multiple organ systems, including the brain and lungs. It is most frequently found in patients who are immunocompromised. Invasive nocardial disease is a potentially life-threatening infection that can pose a diagnostic challenge., Case Presentation: Our case details a 76-year-old Indian woman with poorly-controlled diabetes mellitus admitted for confusion and falls. Imaging revealed intracranial abscesses and necrotic masses in the mediastinum and lungs. The suspected diagnosis was tuberculosis; however, she underwent extensive workup without a final diagnosis. Ultimately, a craniotomy with partial brain abscess resection was performed. Dura matter samples revealed Nocardia farcinica., Conclusions: This case illustrates the importance of considering Nocardia in patients with brain abscesses, particularly in those with immunocompromised states and demonstrates the diagnostic challenges that may arise in definitively making this diagnosis. Invasive procedures may be needed for diagnostic confirmation., (© 2023. The Author(s).)

Background: Fungal infections, other than candidiasis and aspergillosis, are an uncommon entity. Despite this, emerging pathogens are a growing threat. In the following case report, we present the case of an immunocompromised patient suffering from two serious opportunistic infections in the same episode: the first of these, Nocardia multilobar pneumonia; and the second, skin infection by Scedosporium apiospermum. These required prolonged antibacterial and antifungal treatment., Case Presentation: This case is a 71-year-old oncological patient admitted for recurrent pneumonias that was diagnosed for Nocardia pulmonary infection. Nervous system involvement was discarded and cotrimoxazole was started. Haemorrhagic skin ulcers in the lower limbs appeared after two weeks of hospital admission. We collected samples which were positive for Scedosporium apiospermum and we added voriconazole to the treatment. As a local complication, the patient presented a deep bruise that needed debridement. We completed 4 weeks of intravenous treatment with slow improvement and continued with oral treatment until the disappearance of the lesions occurs., Conclusions: Opportunistic infections are a rising entity as the number of immunocompromised patients is growing due to more use of immunosuppressive therapies and transplants. Clinicians must have a high suspicion to diagnose and treat them. A fluid collaboration with Microbiology is necessary as antimicrobial resistance is frequent., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Nocardia brain abscess is an uncommon but potentially life threatening opportunistic infection that generally occurs in immunocompromised patients. Nocardia cyriacigeorgica is a recently described species rarely reported as a cause of human disease. Pemphigus vulgaris is managed with immunosuppression. There have been four prior reports of brain abscess caused by Nocardia cyriacigeorgica .

Background: Nocardia are Gram-positive, aerobic, filamentous bacteria that can cause localized or disseminated infections. Immunocompromised patients are at a higher risk of developing Nocardia infection and further dissemination of the disease. To date, limited data have documented the relationship between nocardiosis and alcoholic liver disease., Case Presentation: We report the case of a 47-year-old man with a known history of alcoholic liver cirrhosis. The patient presented to our emergency department with redness, swelling in the left eye, and diminished bilateral vision. Fundus examination of the left eye was obscured, while that of the right eye was consistent with subretinal abscess. Therefore, endogenous endophthalmitis was suspected. Imaging revealed two ring-enhancing lesions in the brain, and multiple bilateral small cystic and cavitary lung lesions. Unfortunately, the left eye eventually eviscerated due to the rapid progression of the disease. Cultures from the left eye were positive for Nocardia farcinica. The patient was started on imipenem, trimethoprim/sulfamethoxazole, and amikacin based on culture sensitivity. The patient's hospitalization course was complicated by his aggressive and advanced condition, which led to his death., Conclusions: Although the patient's condition initially improved with the recommended antibiotic regimens, it led to death owing to the patient's advanced condition. Early detection of nocardial infection in patients with typical or atypical immunosuppressive conditions may improve overall mortality and morbidity. Liver cirrhosis disrupts cell-mediated immunity and may increase the risk of Nocardia infection., (© 2023. The Author(s).)

Background: Chronic obstructive pulmonary disease (COPD) is a common respiratory disease characterized by persistent airflow limitation. Infection with either Mycobacterium tuberculosis or Nocardia in COPD patients has been reported. However, co-infection with Mycobacterium tuberculosis and Nocardia is rare. Herein, we described such a patient with COPD in a primary hospital, and the diagnosis process., Case Presentation: A 79-year-old female farmer with COPD was consecutively admitted to two hospitals with chief complaints of worsening cough, sputum and gasping since January10, 2022. Microbiological examination was not performed at the first hospital due to unknown reasons, and empirical antibiotic treatment was not effective. The patient was subsequently referred to our hospital. After screening the source of infection and the pathogen, she was diagnosed with tuberculosis. However, the patient did not benefit from antituberculosis treatment, with no remission of respiratory tract symptoms. Cerebrospinal fluid and bronchoalveolar lavage fluid specimens were subsequently sent for microbiological examination. The results indicated Mycobacterium tuberculosis and Nocardia.spp. After four days of bacterial culture, Nocardia.spp grew on medium, and Nocardia.farcinica was identified by the MALDI-TOF MS system and 16 s RNA. The patient was prescribed trimethoprim sulfamethoxazole (TMP/SMX) in combination with anti-tuberculosis drugs to treat the co-infection. She showed gradual improvement and was discharged from the hospital on February 19, 2022. However, the follow-up results were unclear., Conclusions: Co-infection with Nocardia and Mycobacterium tuberculosis should be considered in COPD patients. Repeated microbiological and microscopy examinations are essential in primary hospitals., (© 2023. The Author(s).)

Nodular lymphangitis is an infectious disease characterised by the development of inflammatory skin nodules that follow the direction of lymphatic drainage. We present a woman in her 70s with nodular lymphangitis that developed after mild trauma with a cactus. Surgical intervention was performed on a finger abscess with isolation of Nocardia brasiliensis in the microbiological samples. Initial antibiotherapy was modified, treating with cotrimoxazole, firstly intravenous and finally oral, therapy during 3 months with a complete resolution of the infection., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Nocardial brain abscess is usually associated with immunodeficiency, but can sometimes emerge in healthy individuals. This infection can be acquired through inhalation or direct inoculation of the bacteria, followed by dissemination to various organs, including the brain, through blood circulation. Mortality rate due to nocardial cerebral abscess is three times higher than that associated with cerebral abscess caused by other types of bacteria. Moreover, patients with Nocardia asteroides -associated brain abscess show poorer prognosis compared to patients with brain abscess caused by other Nocardia species, which is probably due to the high tendency of N. asteroides to become resistant to numerous antibiotics. It is, therefore, of paramount importance to diagnose and treat N. asteroides cerebral abscess in patients as soon as possible. The current paper is a rare report of a brain abscess caused by N. asteroides in a diabetic patient who failed to respond to multiple antibiotics (trimethoprim/sulfamethoxazole and amikacin), but improved by receiving imipenem and linezolid, and was finally successfully treated by surgical operation and long-term antibiotic therapy (imipenem and linezolid)., (Copyright ©2022, Yale Journal of Biology and Medicine.)

Severe Cushing's syndrome is associated with significant complications including opportunistic infections. In the setting of infection, urgent reduction of circulating cortisol is warranted and commonly used oral medications have a slow onset of effect. Here we describe a 29-years old female who presented to an outside hospital with symptoms of untreated Cushing's syndrome on ketoconazole. Following identification of a pulmonary Nocardia spp infection, she was transferred for a higher level of care. Her initial serum ACTH and cortisol levels after transfer were 106pg/mL and 53.7mCg/dL respectively. Given the severity of her nocardiosis and lack of response to ketoconazole, the patient was placed in the ICU and started on a continuous etomidate infusion. Her serum cortisol rapidly decreased to 5.7mCg/dL. She was transitioned to metyarapone and the etomidate infusion was weaned to off. The etomidate infusion was well tolerated without adverse effects or need for an advanced airway. Following discontinuation of etomidate, she was found to have a pituitary microadenoma that was resected. The patient was discharged from the hospital on antibiotics for the management of her Nocardia spp infection. In patients with severe Cushing's syndrome, continuous etomidate may be safe and effective for patients who are unresponsive to other therapies.

The increasing occurrence of infectious complications during immune checkpoint inhibitor (ICI) therapy is an emerging challenge for oncologists. ICIs can reverse T-cell exhaustion, and this may lead to hyperinflammatory dysregulated immunity with subsequent potentially fatal infections. Nocardia spp. are opportunistic pathogens belonging to aerobic Actinomycetes. The authors report a case of Nocardia pneumonia in a 62-year-old male with oral squamous cell carcinoma and lung cancer while taking pembrolizumab. The patient did not take corticosteroids or other immunosuppressant medications. Since ICIs are able to stimulate the immune response, the authors hypothesize that immune reconstitution inflammatory syndrome due to pembrolizumab might cause this opportunistic infection.

Rationale: Nocardia farcinica is an opportunistic pathogen that rarely causes ocular infections. This study reviewed a case of N. farcinica-mediated scleritis involving the corneal limbus., Patient Concerns: A 56-year-old man was admitted to the Department of Keratology of Jinan Second People's Hospital due to "a red and swollen right eye accompanied with severe pain for >1 month." He denied any history of hypertension, diabetes, systemic immune diseases and eye surgery., Diagnoses: Corneal defect and scleral necrosis were observed by slit lamp. Combination of anterior segment optical coherence tomography and ophthalmic ultrasound biomicroscopy was used for diagnosis and evaluation of corneal and scleral conditions. Culture and metagenomic sequencing verified that the pathogen of scleritis was N. farcinica., Interventions: The patient was treated by sulfacetamide sodium eye drops, oral administration of sulfamethoxazole tablets, amikacin anterior chamber flushing, scleral debridement, and allogeneic scleral transplantation., Outcomes: The disease was successfully controlled., Lessons: Infectious scleritis caused by N. farcinica is extremely rare. Culture of pathogenic microorganisms remains to be the gold standard for the diagnosis of infectious eye diseases. Metagenomic sequencing shows potential promise in the diagnosis of infectious eye diseases. N. farcinica is sensitive to sulfonamides and amikacin., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Aims: Chronic lung diseases are a recognized risk factor for Nocardia spp., Infection: Nocardia spp. isolation does not inevitably imply disease, and thus colonization must be considered. Here, we aimed to analyse the differences between pulmonary nocardiosis (PN) and Nocardia spp. colonization in patients with chronic lung diseases., Methods and Results: A retrospective study of patients with laboratory confirmation of isolation of Nocardia spp. in at least one respiratory sample was performed. Patients with PN and Nocardia spp. colonization were compared. There were 71 patients with Nocardia spp. identification, 64.8% were male, with a mean age of 67.7 ± 11.2 years. All patients had ≥1 pre-existing chronic lung disease, and 19.7% of patients were immunocompromised. PN and Nocardia spp. colonization were considered in 26.8% and 73.2% of patients, respectively. Symptoms and chest CT findings were significantly more frequent in patients with PN (p < 0.001). During follow-up time, 12 (16.9%) patients died, 6 in PN group. Immunosuppression, constitutional symptoms, haematological malignancy and PN diagnosis were associated with significantly shorter survival times, despite only immunosuppression (HR 3.399; 95% CI 1.052-10.989) and PN diagnosis (HR 3.568; 95% CI 1.078-11.910) remained associated with a higher death risk in multivariate analysis., Conclusions: PN was associated with clinical worsening, more chest CT findings and worse clinical outcomes., Significance and Impact of Study: Nocardia spp. isolation in chronic lung disease patients is more common than expected and the differentiation between colonization and disease is crucial., (© 2022 Society for Applied Microbiology.)

Objectives: Nocardiosis is a rare opportunistic infection that is frequently associated with dissemination (i.e. involvement of several body sites). Identifying the factors associated with Nocardia spp. dissemination may help improving the management of patients with nocardiosis., Methods: This 10-year (2010-2020) retrospective multicenter cohort study included adult patients with Nocardia-confirmed infections. The first objective was to determine the factors associated with disseminated nocardiosis. The secondary endpoints were to determine and compare the management and the 12-month overall mortality in patients with localized and disseminated nocardiosis. Univariate and multivariate logistic regression analyses were used., Results: Nocardia spp. infection was confirmed in 110 patients, of whom 38 (34.5%) had disseminated nocardiosis. In univariate analysis, the factors associated with dissemination were immunosuppressive conditions: having an auto-immune disease and receiving high-dose corticosteroid (31.5% vs 8.3%, P = 0.003 and 52.6% vs 26.3%, P = 0.007, respectively). Absolute lymphocyte count <1 G/L at diagnosis was the only biomarker associated with dissemination (57.2% vs 26.3%, P = 0.007). Nocardia farcinica was not only the most frequent species identified in patient specimens (n = 22, 20%) but was also associated with a higher rate of dissemination (36.8% vs 11.1%, P = 0.002). Multivariate analysis confirmed the association between auto-immune diseases, lymphopenia, N. farcinica species and the higher rate of dissemination. Even though patients with disseminated nocardiosis were treated longer and more often with an antibiotic combination therapy, their 12-month overall mortality was significantly higher than that of patients with localized nocardiosis (36.8% vs 18%)., Conclusions: Dissemination of Nocardia spp. is favoured by auto-immune diseases, lymphopenia, and infection with N. farcinica., Competing Interests: Declaration of Competing Interest The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest or financial conflict with the subject matter or materials discussed in the manuscript. Production of this manuscript did not require writing assistance., (Copyright © 2022 The British Infection Association. Published by Elsevier Ltd. All rights reserved.)

Background: Nocardia cyriacigeorgica was first described in 2001. It is an emerging pathogen that mainly affects immunocompromised patients. A brain abscess caused by N. cyriacigeorgica has been reported only in immunocompromised hosts. We present a rare case of brain abscess caused by N. cyriacigeorgica in an adult male receiving low dose steroids., Case Presentation: A 75-year-old male weekend gardener without an immunocompromising condition presented with neurological complaints that were initially attributed to an ischemic stroke. Due to the unusual presentation and rapid progression, his condition was thought to be caused by a cerebral space-occupying lesion. He underwent an emergent right-sided parietal craniotomy and the histopathological report of the specimen was an abscess caused by N. cyriacigeorgica. The patient received appropriate antibiotic treatment and completely recovered without sequelae., Conclusions: Nocardia species are a rare cause of brain abscess in immunocompetent patients. Their clinical presentation can mimic other more common cerebral diseases, such as brain tumors (primary and secondary) and stroke. The possibility of an abscess caused by N. cyriacigeorgica should also be considered in the differential diagnosis in an immunocompetent patient., (© 2022. The Author(s).)

Competing Interests: None

Competing Interests: None

A 61-year-old woman was transferred with a complaint of a fever and productive cough. She had tested positive for Mycobacterium avium and Nocardia cyriacigeorgica at least twice, and Streptococcus pneumonia (PISP) was isolated (3+) from her purulent sputum. As radiological findings, a lower lung field-dominant infiltration shadow and nodular shadow with cavity were recognized in the bilateral lung fields. We diagnosed her with pneumococcal pneumonia co-infection with M. avium and N. cyriacigeorgica. She was treated with MEPM for pneumococcal pneumonia, a standard regimen containing clarithromycin for pulmonary M. avium complex (MAC) disease, and sulfamethoxazole/trimethoprim for pulmonary nocardiosis. She improved with appropriate treatment.

Nocardiosis is a rare opportunistic gram-positive bacterial infection. The genus Nocardia consists of non-motile, aerobic, non-spore-forming, catalase-positive, filamentous-branching bacteria with fragmentation into coccoid or bacillary forms. Opportunistic infections due to Nocardia are reported in immunocompromised patients. Aspergillus fumigatus is a conidia forming fungus that can be found in soil, plant matter and dust, causing invasive pulmonary and disseminated infection in immunocompromised patients. Both Nocardia cyriacigeorgica and A. fumigatus are known to cause pulmonary infection with metastatic dissemination to the central nervous system. We present a case of Nocardia and Aspergillus co-infection in a patient who presented within a few days of initiation of immunosuppressants for suspected systemic lupus erythematosus., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Intracranial infections caused by Nocardia Farcinica are challenging to treat and potentially lethal because of the organism's tendency to resist antibiotics and high relapse rates. Such infections usually occur in immunocompromised patients who have predisposing factors. Nocardia brain abscesses carry a higher morbidity and mortality rate than other bacterial brain abscesses, with reported mortality rates of 55% (even up to 90% in cases of late diagnosis) in immunocompromised patients. An aggressive therapeutic approach is required and an early identification of the microorganism is paramount. Given the high microbial resistance, it is usually an infection with a low cure rate. We present the case of a patient with primary brain abscesses due to Nocardia Farcinica, successfully treated with intrathecal Amikacin administration through ventricular drain, in addition to surgical evacuation and intravenous antibiotic therapy. In this case, clinical and radiological improvement were observed once the intrathecal treatment was started. To our best knowledge, no cases of intraventricular use of Amikacin have been previously reported to treat this type of infection and we believe that it may be useful in properly selected patients., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Brain abscess due to the Nocardia genus is rarely reported and it is usually found in immunocompromised patients. Treatment of Nocardia brain abscess is troublesome and requires consideration of the severity of the underlying systemic disease. The difficulties in identifying the bacterium and the frequent delay in initiating adequate therapy often influence the prognosis of patients., Case Presentation: Here, we report a rare case of brain abscess caused by Nocardia farcinica. The patient's medical history was complicated: he was hospitalized several times, but no pathogens were found. At last, bacteria were found in the culture of brain abscess puncture fluid; the colony was identified as Nocardia farcinica by mass spectrometry. Targeted antibiotic treatment was implemented, brain abscess tended to alleviate, but the patient eventually developed fungal pneumonia and died of acute respiratory distress syndrome (ARDS)., Conclusion: Brain abscess caused by Nocardia farcinica can appear in non-immunocompromised individuals. Early diagnosis, reasonable surgical intervention, and targeted antibiotic treatment are critical for Nocardia brain abscess treatment. In the treatment of Nocardia brain abscess, attention should paid be to the changes in patients' immunity and infection with other pathogens, especially fungi, avoided., (© 2021. The Author(s).)

Background: Empyema necessitans is a rare pulmonary condition described as the presence of pus in the pleural cavity with insidious extension into the surrounding soft tissue. The common microbial aetiology of empyema necessitans is tuberculosis. Nocardiosis a cause of empyema necessitans is rarely described in the literature. We herein present a case of an 80-year-old male with empyema necessitans with osteomyelitis of rib caused by Nocardia farcinica., Case Presentation: An 80-year-old male presented with complaints of soft swelling on the left lower posterior chest wall associated with dry cough and breathlessness on exertion. Computed Tomography (CT) thorax demonstrated empyema necessitans with features of left fifth rib osteomyelitis. Radiological guided aspiration of the chest wall collection revealed Nocardia species and surgical drainage of abscess was performed. Matrix-assisted laser desorption/ionization time-of-flight-mass spectrometry (MALDI-TOF-MS) identified the isolate as Nocardia farcinica. He was treated with three-drug regimen: Trimethoprim-sulfamethoxazole, amikacin and ceftriaxone for 2 weeks. After showing improvement patient was discharged and advised to take oral Trimethoprim-sulfamethoxazole for the next 6 months with periodic follow-up., Conclusions: As our case demonstrates, the possibility of invasive Nocardiosis should not be overlooked even in immunocompetent patients. Clinicians should aware of this rare entity while treating patients with empyema necessitans., (© 2021. The Author(s).)

Rationale: Nocardiosis is an uncommon and potentially life-threatening infection that usually affects immunocompromised hosts. No clinical guidelines have been established for managing this rare disease, and the optimal treatment modality remains unclear. Nocardia farcinica, a relatively infrequent pathogen of nocardiosis, causes a clinically aggressive infection. In addition to our patient data, our search of the literature for patients who presented with empyema caused by N. farcinica will provide fundamental information for optimal treatment modalities., Patient Concerns: A 64-year-old man was diagnosed with empyema, 4 days following surgery for sigmoid colon cancer. Brain lesions were evaluated only after N. farcinica was isolated and identified as the causative pathogen through repeated culture tests., Diagnoses: N. farcinica was isolated from the pleural effusion and confirmed as the pathogen through 16S rRNA sequencing., Interventions: The patient was successfully treated with tube thoracotomy, neurosurgical evacuation, and a combination of trimethoprim/sulfamethoxazole plus imipenem. Long-term antibiotic therapy was required to prevent recurrence., Outcomes: Pyothorax showed a good clinical response to antimicrobial therapy and drainage of pleural effusion, whereas brain abscess did not respond to medical therapy and required surgery. The patient eventually recovered and continued chemotherapy as treatment for sigmoid colon cancer., Lessons: Although extremely rare, this report demonstrates the importance of considering Nocardia infection as the differential diagnosis in immunocompromised patients who present with empyema. In particular, because of the N. farcinica infection's tendency to spread and the resistance of the organism to antibiotics, aggressive evaluation of metastatic lesions and standardized support from microbiological laboratories are important. Surgery may be required in some patients with brain abscesses to improve the chance of survival., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Idiopathic pulmonary hemosiderosis (IPH) encompasses a rare and agnogenic group of diffuse alveolar capillary hemorrhagic diseases. Corticosteroid treatment is the globally preferred therapeutic strategy for IPH; however, it can cause immunodeficiency. Nocardia infection often occurs in immunocompromised patients and primarily involves the pleura and lungs. Herein, we describe a case of pediatric pulmonary Nocardia infection after the corticosteroid treatment of IPH., Case Presentation: A 7-year-old girl presented with chief complaints of pale complexion persisting for 1 year and a cough for 20 days. Abundant hemosiderin-laden macrophages were detected in the gastric juice, which supported the diagnosis of IPH. Uninterrupted doses of corticosteroids were administered during the last hospitalization. After nearly 2 months of corticosteroids therapy, the patient began to cough and produce a purulent sputum. Next-generation sequencing of the bronchoalveolar lavage fluid revealed Nocardia abscessus (N. abscessus) DNA. Linezolid was administered with good response, and the patient was discharged after 18 days of hospitalization. Her symptoms and pulmonary lesions had recovered, and the IPH appeared to be well-controlled with low dose of corticosteroids in follow-up., Conclusions: Nocardia infection should be considered in the differential diagnoses for IPH patients receiving corticosteroid therapy, especially in patients with poor response to conventional empirical antibiotic therapy. Next-generation sequencing of bronchoalveolar lavage fluid may be used to quickly identify the Nocardia. Sulfonamides or linezolid are effective for pediatric pulmonary Nocardia infection.