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ROENTGENOGRAM OF THE MONTH
I
ROENTGENOGRAM OF THE MONTH
WILLIAM C. ROBERTS, M.D.,· CONSl'AN W. BERARD, M.D. AND NINA S. BRAUNWALO, M.D.
Bethesda, Maryland
A
hepatic decompensation secondary to probable serum hepatitis superimposed on cardiac cirrhosis, and was treated thereafter with high doses of a corticosteroid. In January, 1965, he developed fever, night sweats, anorexia and dyspnea. Figures 1 and 2 were obtained at that time. He died on February 27, 1965.
45-VEAR-oLD WHITE MAN WITH RHEU-
matic mitral stenosis and aortic regurgitation underwent replacement of both mitral and aortic valves with StaITEdward~ prostheses on April 21, 1964. In October, 1964, he developed fulminating -From the Clinic of Surgery, National Heart Institute and the Pathologic Anatomy Branch, National Cancer Institute, National Institutes of Health.
2-18 -65 FIOURE
1
FIOURE
439
2
ROBERTS, BERARD AND BRAUNWALD
FIGURE 3
Diagnosis: PULMONARY NOCARDIOSIS The teleoroentgenogram and tomogram demonstrate an area of consolidation with an irregular central cavity. Figure 3A is a cut surface of the left upper lobe showing the cavity. Nocardia asteroides organisms, which were cultured from the sputa during life and from the pulmonary cavity at necropsy, are shown in Fig. 3B (Brown and Brenn stain; x 12(0) . Systemic nocardiosis, which is virtually always caused by N. asteroides, usually begins in the bronchial mucosa and spreads through the bronchial wall to the pulmonary parenchyma, resulting in extensive necrosis of tissue with the formation of confluent abscesses. I The infection may be
Diseases of the Chest
chronic or acute or even fulminating.' N. asteroides are aerobic, Gram-positive and variably acid-fast, delicate, branching filamentous fungi which break up into bacillary forms of varying lengths. Pulmonarycutaneous fistulas and granules are less common than in actinomycosis. Hematogenous spread results in metastatic lesions throughout the body, most commonly to the brain. The diagnosis of pulmonary nocardiosis is made by staining a smear of the sputa specifically for bacterial organisms (Brown and Brenn stain). The organism grows on a variety of simple media, including blood agar, but a three to four week period is required before the typical colonies are identifiable. Sulfonamides (4-8 gm daily in adults) constitute the treatment of systemic nocardiosis, and the therapy should be continued for two to three months after all signs and symptoms of the disease have disappeared.' The nocardiosis in this patient represents an infection in one whose resistance had been lowered by a combination of chronic diseases (cardiac and hepatic) and steroid therapy, although nocardiosis may occur as a primary disease.'·1 REFERENCES WEED, L. A., ANDERSEN, H. A., GooD, C. A. AND BAOOENSTOSS, A. H.: "Nocardiosis. Clinical, bacteriologic and pathologic aspects," New
Engl. J. Med., 253: 1137, 1955, 2 FREESE, J, W., YOUNG, W. G., JR., SEALY, W. C. AND CONANT, N. F.: "Pulmonary infection by Nocardia asteroid,s. Findin~s in eleven clinical cases," ]. Thor. and Card.ovGS.
Surg., 46:537, 1963. 3 SALTZMAN, H. A., CRICK, E. W. AND CONANT,
N. F.: "Nocardiosis as a complication of other diseases," Lab. Inv,st., II: 1110, 1962. BENJAMIN FELSON, M.D., Editor HAROLD SPITZ, M.D., Co-Editor
For reprints, please write: Dr. William C. Roberts, Laboratory of Pathology, Clinic of Surgery, National Heart Institute, National I nltitu tea of Health, Bethesda, Maryland 20014.
Readers are invited to submit articles for the Roen\8ellogrlm of the Month. Please submit a brief abstract of your case to Benjamin Felson, M.D.,Department of Radiology, Cincinnati General Hospital, Cincinnati, Ohio.
ROENTGENOGRAM OF THE MONTH
WILLIAM C. ROBERTS, M.D.,· CONSl'AN W. BERARD, M.D. AND NINA S. BRAUNWALO, M.D.
Bethesda, Maryland
A
hepatic decompensation secondary to probable serum hepatitis superimposed on cardiac cirrhosis, and was treated thereafter with high doses of a corticosteroid. In January, 1965, he developed fever, night sweats, anorexia and dyspnea. Figures 1 and 2 were obtained at that time. He died on February 27, 1965.
45-VEAR-oLD WHITE MAN WITH RHEU-
matic mitral stenosis and aortic regurgitation underwent replacement of both mitral and aortic valves with StaITEdward~ prostheses on April 21, 1964. In October, 1964, he developed fulminating -From the Clinic of Surgery, National Heart Institute and the Pathologic Anatomy Branch, National Cancer Institute, National Institutes of Health.
2-18 -65 FIOURE
1
FIOURE
439
2
ROBERTS, BERARD AND BRAUNWALD
FIGURE 3
Diagnosis: PULMONARY NOCARDIOSIS The teleoroentgenogram and tomogram demonstrate an area of consolidation with an irregular central cavity. Figure 3A is a cut surface of the left upper lobe showing the cavity. Nocardia asteroides organisms, which were cultured from the sputa during life and from the pulmonary cavity at necropsy, are shown in Fig. 3B (Brown and Brenn stain; x 12(0) . Systemic nocardiosis, which is virtually always caused by N. asteroides, usually begins in the bronchial mucosa and spreads through the bronchial wall to the pulmonary parenchyma, resulting in extensive necrosis of tissue with the formation of confluent abscesses. I The infection may be
Diseases of the Chest
chronic or acute or even fulminating.' N. asteroides are aerobic, Gram-positive and variably acid-fast, delicate, branching filamentous fungi which break up into bacillary forms of varying lengths. Pulmonarycutaneous fistulas and granules are less common than in actinomycosis. Hematogenous spread results in metastatic lesions throughout the body, most commonly to the brain. The diagnosis of pulmonary nocardiosis is made by staining a smear of the sputa specifically for bacterial organisms (Brown and Brenn stain). The organism grows on a variety of simple media, including blood agar, but a three to four week period is required before the typical colonies are identifiable. Sulfonamides (4-8 gm daily in adults) constitute the treatment of systemic nocardiosis, and the therapy should be continued for two to three months after all signs and symptoms of the disease have disappeared.' The nocardiosis in this patient represents an infection in one whose resistance had been lowered by a combination of chronic diseases (cardiac and hepatic) and steroid therapy, although nocardiosis may occur as a primary disease.'·1 REFERENCES WEED, L. A., ANDERSEN, H. A., GooD, C. A. AND BAOOENSTOSS, A. H.: "Nocardiosis. Clinical, bacteriologic and pathologic aspects," New
Engl. J. Med., 253: 1137, 1955, 2 FREESE, J, W., YOUNG, W. G., JR., SEALY, W. C. AND CONANT, N. F.: "Pulmonary infection by Nocardia asteroid,s. Findin~s in eleven clinical cases," ]. Thor. and Card.ovGS.
Surg., 46:537, 1963. 3 SALTZMAN, H. A., CRICK, E. W. AND CONANT,
N. F.: "Nocardiosis as a complication of other diseases," Lab. Inv,st., II: 1110, 1962. BENJAMIN FELSON, M.D., Editor HAROLD SPITZ, M.D., Co-Editor
For reprints, please write: Dr. William C. Roberts, Laboratory of Pathology, Clinic of Surgery, National Heart Institute, National I nltitu tea of Health, Bethesda, Maryland 20014.
Readers are invited to submit articles for the Roen\8ellogrlm of the Month. Please submit a brief abstract of your case to Benjamin Felson, M.D.,Department of Radiology, Cincinnati General Hospital, Cincinnati, Ohio.