Abstract:

ABSTRACT Objective: To evaluate the clinical manifestations, diagnosis, treatment and outcome of disseminated nocardiosis in nephrotic syndrome patients. Methodology: Nine cases of culture-proven disseminated nocardial infections diagnosed in recent years were reviewed retrospectively. Their clinical manifestations, treatment and outcomes were analyzed. Results: There were three males and six females with the mean age of 33.6±9.8 years. At the onset of Nocardia infection, the mean prednisolone dose was 34.4±12.6mg/d. The median time to develop Nocardia infection after the usage of glucocorticoid was 6 months, and 6 patients within 6 months. 8 patients had fever with the mean body temperature of 38.8±1.0℃. White blood cell counts and C-reactive protein in peripheral blood were elevated. Procalcitonin level was slightly increased in one out of the 5 patients who had detected. 4 out of 7 patients had low CD4+ T-cell counts, 3 lower than 200 cells per μl. All patients had pulmonary Nocardiosis. Radiologic findings of 5 cases were characterized by isolated or scattered nodules and mass, usually close to the pleura, and cavitation could be found. All them also had disseminated diseases including subcutaneous abscess in 7cases, thoracic cavity in 3, liver in 2, brain in one, ocular in one, and adrenal gland in one case.The positive rate of culture in samples of subcutaneous abscess and pleural fluid reached to 100%. 3 species of Nocardia were indentified: Nocardia otitidiscaviarum (n=1), Nocardia asteroids (n=1), Nocardia brasiliensis (n=1), and the other 6 isolates were not determined. 7 patients were treated with oral TMP-SMX, including 2 patients combining with carbapenem antibiotics, as an induction therapy, and the other 2 patients received carbapenem monotherapy. The long-term prognosis was good, with a treatment success rate of 100%. Conclusions: NS patients often receive long-term treatment with glucocorticoid and immunosuppressants, when one suffers with systemic multiple abscess, and lung image is characterized by isolated or scattered nodules and mass, usually close to the pleura, but procalcitonin level is within normal limits or just slightly increased, nocardial infection should be considered. The diagnosis relies on the microbiologic culture. Early diagnosis and specific treatment may have a positive effect on the outcome.

Key words: nephrotic syndrome, nocardiosis, clinical manifestations, cell-mediated immunity, procalcitonin