Case report on Nocardia pseudobrasiliensis and SARS-CoV-2 concomitant infection

Background

Nocardia species are Gram stain-superb and barely acid-fast-staining aerobic-kind actinomycetes species which could reason disseminated ailment amongst immunosuppressed people. Nocardiosis ought to be covered withinside the differential diagnoses of pneumonia amongst immunocompromised people, no matter different concomitant infections.

Carbapenem/sulfonamide aggregate remedy is used for empirical remedy of Nocardia infections, and figuring out the causative species is crucial to pick out the maximum most efficient healing strategy. Co-infections with different pathogenic organisms all through or following coronavirus ailment 2019 (COVID-19) aren't common, and specially, Nocardia and SARS-CoV-2 co-infections were documented rarely.

About the case report

In the existing case report, researchers supplied an immunosuppressed male COVID-19 affected person, elderly fifty two years, identified with Nocardia pseudobrasiliensis-triggered pneumonia withinside the United States of America (USA).

In July of 2022, the male affected person visited the Virginia Commonwealth college healthcare system`s emergency branch because of respiratory problems following the SARS-CoV-2-superb end result of a home-primarily based totally test. He evolved signs 10.zero days previous to being hospitalized in a hypoxic country on account of COVID-19-related pneumonia. The signs did now no longer encompass sore throat, chills, fever, diarrhea, or belly pain.

The affected person became taking empagliflozin for diabetes mellitus kind 2 and had a preceding records of bronchiectasis, and systemic sarcoidosis, consisting of advanced-degree pulmonary sarcoidosis and cardiac sarcoidosis, controlled through orally administered hydroxychloroquine (200.zero mg two times daily), intravenously (IV) administered infliximab (at dose 800.zero mg 8 weeks apart) and implanted cardioverter defibrillator. He had end smoking for 30 years and labored withinside the condominium renovation branch.

At hospitalization, breathing misery and wheezing had been documented, with chest radiography findings related to sarcoidosis with none acute cardiopulmonary illness. IV remdesivir (200.zero mg daily) and dexamethasone (six mg daily) had been initiated; however, hypoxia worsened, and the subsequent day, he became administered 5.zero L in line with minute oxygen thru face mask. Subsequently, the medical doctors discontinued remdesivir because of the gastrointestinal tract (GIT)-related negative effects. SARS-CoV-2-superb polymerase chain reaction (PCR) report, accelerated leukocyte counts of 10 × 109 leukocytes/L, and C-reactive protein stages of 15 mg in line with dL had been obtained.

Three days later, contrast-improved computed tomography findings of bilateral innovative consolidation, maximum outstanding at the bottom of the lungs, with out floor glass-kind appearance, had been located. Sputum cultures had been obtained, and the affected person became administered IV tazobactam/piperacillin (3.forty grams six hourly). After every week of hospitalization, sputum subculture reviews indicated gram-superb, beaded rod presence, suggestive of Nocardia. The affected person became shifted to imipenem (500.zero mg six hourly) and IV sulfamethoxazole/trimethoprim (SMX/TMP) (5 mg/kg 8 hourly). In spite of twin remedy, hypoxia became persistent, and on day 12.zero of hospitalization, innovative consolidatory nodular opacities had been located withinside the basal area of the left lobe of the lungs. On no reaction to remedy, the medical doctors integrated orally administered linezolid (six hundred.zero mg 12 hourly) into the antibiotic area, following which hypoxia resolved.

Four days later, matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry findings showed Nocardia pseudobrasiliensis contamination, and chalky-white colonies, having an orange-coloured pigmentation, of the microbe had been located. Susceptibility checking out indicated imipenem resistance. The affected person acquired health center discharge following 20 days of hospitalization, with a prescription of ciprofloxacin (500.zero mg two times daily) and linezolid (six hundred mg two times daily), for >6.zero weeks. Pre-discharge mind magnetic resonance imaging (MRI) scans confirmed no ring enhancement or imperative anxious system (CNS) involvement.

Two weeks put up-discharge, diminished breathing pain became located, with most effective intermittent oxygen supplementation required, following exertion, and 4 weeks put up-discharge, imaging confirmed pulmonary nodular development. Symptomatic development persisted as much as a month put up-discharge. The affected person briefly discontinued remedy because of financial constraints and became transitioned to SMX/TMP ( capsules of SMX 800.zero mg and TMP 160.zero mg 8 hourly) with orally administered ciprofloxacin (500.zero mg two times daily). Dual antibiotic remedy became persisted for the reason that affected person became below glucocorticoid remedy for sarcoidosis. Four months-put up discharge from the health center, the male skilled dyspnea most effective after widespread exertion. He became to be shifted to SMX or TMP monotherapy following considerable development withinside the lung nodules.

At present, 10 Nocardia infections were said all through or after SARS-CoV-2 contamination. The majority of sufferers evolved nocardiosis 5 to 50.zero days put up-SARS-CoV-2 diagnosis, and the suggest time to identity of co-contamination became 17.zero days. Pulmonary-kind nocardiosis became maximum normally located, maximum infections had been due to Nocardia farcinica, and all of the affected people acquired glucocorticoid remedy all through hospitalization. Linezolid, clarithromycin, and ciprofloxacin are typically powerful in coping with Nocardia pseudobrasiliensis infections. Overall, the chance of concomitant infections with SARS-CoV-2 is low; however, regarding SARS-CoV-2-superb sufferers with invasive mechanical air flow requirements, the co-contamination occurrence quotes are greater.  

Based at the case report, Nocardia and SARS-CoV-2 co-infections can also additionally occur, specially amongst immunosuppressed people with comorbidities and glucocorticoid use records. The behind schedule development in medical symptoms and symptoms and signs after linezolid management underscores the significance of activate identity of Nocardia and its antibiotic susceptibilities.