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Peritonitis due to Ochrobactrum anthropi in a patient undergoing continuous ambulatory peritoneal dialysis
Journal of Infection (2000) 40.205-208 doi:10.1053/jinf.1999.0569, available online at http://www.idealibrary.com
on
IOEbl@
Letters to the Editor Peritonitis due to Uchrobactrum anthropi in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis Sir, Ochrobactrum anthropi (formerly CDC group Vd) is a non-fermentative Gram-negative rod that is oxidase-positive, indole-negative, saccharolytic and motile due to peritrichous flagella.’ Ochrobactrum anthropi has been isolated from various environmental and human sources, and has been implicated in several cases of human infections.2,3 Here we report a case of peritonitis due to 0. nnthropi in a patient undergoing CAPD. The patient was a 79-year-old woman on CAPD since May 1996 because of diabetic nephropathy that consulted because of cloudy peritoneal fluid. Past medical history included two episodes of culture-negative peritonitis in the last year. A progressive deterioration of nutritional status had developed over the past 10 months. Current medications were insulin, amiodarone, erythropoietin, doxepin and oral nutritional supplements. Physical examination revealed a normal peritoneal catheter exit-site. The peritoneal effluent contained 1500 cells/@ (53% neutrophils). Empirical therapy was then started with intraperitoneal vancomycin and gentamicin, and a sample of peritoneal fluid was sent for culture. The peritoneal effluent was clear 48 h after therapy started, and another sample of peritoneal fluid was sent for culture as a control of therapy. When the results of cultures were received, therapy was changed to ofloxacin (200 mg/day) for 14 days. The patient recovered uneventfully, and died 2 months later from stroke that was unrelated to the episode of peritonitis. Peritoneal fluid samples were processed for culture according common techniques4 On the first day of incubation, abundant growth of a Gram-negative rod was detected on blood agar, chocolate agar and McConkey agar plates and in the aerobic bottle of the blood culture set. The bacterium was non-fermentative, oxidase-positive and was identified as 0. anthropi by using the API 20 NE system (bioMerieux, France), the code number being 1242344 (99.9% id, Tz0.92). Scanty growth of the same bacterium was obtained from the second sample of peritoneal fluid. A disc-plate susceptibility test was performed according to standard techniques,5 the isolate being resistant to ampicillin, amoxicillin/clavulanic acid, cefazolin, cefuroxime, ceftriaxone, ceftazidime, ticarcillin, cefepime and piperacillin/tazobactam. The isolate was susceptible to imipenem, meropenem, ciprofloxacin, cotrimoxazole, gentamicin and amikacin. A Medline search was performed using “Ochrobactrum”, “anthropi” and “CDC group Vd” as keywords on January 13, 1999. The search yielded 48, 42, and seven references respectively. Among these, 20 references were about human infections caused by 0. unthropi. No case of peritonitis due to this bacterium was found in this search. Human infections due to 0. unthropi are rarely reported in the literature. According to the Medline search, only 5 1 cases were reported, most of them being cases of bacteraemia (39 cases,
0163-4453/00/020205
+ 04 $35.00/O
many of them catheter-related),h-’ 5 meningitis related with contamination of cadaveric pericardial tissue (three cases).lh endophthalmitis (two cases, one of them bilateral),“,‘* pyogenic infections (one infection related to abdominal drainage, one respiratory tract infection and one wound infection)3 and one case each of pacemaker leads infection,19 necrotizing fasciitis,20 urinary tract infection2’ and osteochondritis.22 In our patient, the origin of the strain is unknown. Ochrobactrum unthropi has been recovered from environmental sources1,2 and could have contaminated the dialysis system through the catheter tunnel. However, in one report 0. unthropi was isolated from theoretically sterile solutions,lh so contamination of the dialysis fluid could be possible, although this possibility is merely speculative. In conclusion, we report the first case of peritonitis due to 0. unthropi in a patient undergoing CAPD, expanding the clinical spectrum of diseases caused by this organism. J. Esteban’, A. Ortiz2, E. RollBn’, A. Reyero-L6pez2, E Soriano’ Departments of ‘Medical Microbiology and ‘Nephrology, Funducidn Iimdnez Diaz, Av. Reyes Cutdlicos 2, 28040-Madrid, Spain
References 1 von Graevenitz
2
3 4
5 6
7
A. Acinetobacter, AZ&genes, Moraxellu, and other nonfermentative gram-negative bacteria. In: Murray PR, Baron EJ, Pfaller MA, Tenover FC, Yolkeri RH (eds). Manual of Clinical Microbiology, 6th ed. Washington D.C.: American Society for Microbiology Press, 1995; 52&532. Holmes B, Popoff M, Kiredjian M, Kersters K. Ochrobacterum anthropi gen. nov. sp. nav. from human clinical specimens and previously known as group Vd. Int ISyst Bacterial 1988; 38: 406416. Cieslak TJ, Drabick CJ, Robb ML. Pyogenic infections due to Ochrobactrum anthropi. Clin Infect Dis 1996; 22: 845-847. Working Party of the British Society for Antimicrobial Chemotherapy. Diagnosis and management of peritonitis in continuous ambulatory peritoneal dialysis. Lnncet 1987; i: 845-848. NCCLS. Periormance Stnndurds for Antimicrobial Disk Susceptibility Test, Sixth Edition; Approved Standard. M2-A6, January 1997. T o r r e s L , Arazo E Seoane A, Marco ML. Bacteriemia por Ochrobuctrum anthropi en un paciente con SIDA. Med C/in (Bare)
1998: 111: 318. Yu WL, Lin CW, Wang DY. Clinical and microbiologic characteristics of Ochrobnctrum anthropi bacteremia. 1 Formos Med Assoc 1998: 97:
106-112. 8 Gill MV, Ly H, Mueenuddin M, Schoch PE, Cunha BA. Intravenous line infection due to Ochrobactrum anthropi (CDC Group Vd) in a normal host. Heart Lung 1997: 26: 335-336. 9 Haditsch M, Binder L, Tschurtschenthaler G, Watschinger R, Zauner G. Mittermayer H. Bacteremia caused by Ochrobactrum anthropi in an immunocompromised child. Infection 1994; 22: 291-292. 10 Alnor D, Frimodt-Moller N, Espersen F, Frederiksen W. Infections with the unusual human pathogens Agrobacterium species and Ochrobactrum anthropi. Clin Infect Dis 1994: 18: 914-920. 1 1 Ezzedine H, Mourad M, Van Ossel C et nl. An outbreak of Ochrobactrum anthropi bacteraemia in five organ transplant patients. IHospInfect 1994: 27: 35-42.
0 2000 The British Infection Society
206
Letters to the Editor
12 Kern WV, Oethinger M. Kaufhold A, Rozdzinski E, Marre R. Ochrobactrum anthropi bacteremia: report of four cases and short review. In&ction 1993: 21: 306-310. 13 Klein JD, Eppes SC. Ochrobactrum anthropi bacteremia in a child. De! MedJ 19Y3; 65: 493-495. 14 Gransden WR. Eykyn SJ. Seven cases of bacteremia due to Ochrobuctrum anthropi. Clin Infect Dis 1992; 15: 1068-1069. 15 Cieslak TJ, Robb ML, Drabick CJ, Fischer GW. Catheter-associated sepsis caused by Ochrobactrum anthropi: report of a case and review of related nonfermentative bacteria. Clin Infect Dis 1992; 14: 902-907. 16 Chang HJ, Christenson JC. Pavia AT et al. Ochrobartrum anthropi meningitis in pediatric pericardial allograft transplant recipients. J Infect Dis 1996: 173: 656-660. 17 Berman AJ, Del Priore LV, Fischer CK. Endogenous Ochrobactrum unthropi endophthalmitis. Am J Ophthulmol 1997; 123: 560-562. I8 Braun M. Jonas JB, Schonherr IT, Naumann GO. Ochrobuctrurn anthropi endophthalmitis after uncomplicated cataract surgery. Am ] Ophthulmol1996; 122: 272-273. 19 Earhart KC, Boyce K, Bone WD. Wallace MR. Ochrobnctrum unthropi infection of retained pacemaker leads. C/in In&t Dis 1997: 24: 2X1-282. 20 Brivet F, Guivert M, Kiredjian M. Dormont J. Necrotizing fasciitis. bacteremia, and multiorgan failure caused by Ochrobnctrum anthropi. ClinInfict Dis 1993: 17: 516-518. 2 1 Van Horn KG, Gedris CA, AhmedT, Wormser GP. Bacteremia and urinary tract infection associated with CDC group Vd biovar 2. 1 Chin
,Microbiol 1989; 27: 201-202. 22 Barson WJ. Cromer BA, Marcon MJ. Puncture wound osteochondritis of the foot caused by CDC group Vd. / Clin Microbial 1987: 25:
2014-2016. A~c~pytcnforpublication
25 ]unel999
doi:10.1053/jinf.1999.0593. available online at http://www.idealibrary.com
HIV
on
IOEF;l@
Cardiac Tamponade Caused by Nocardia asteroides in an HIV-infected Patient Sir, We describe a 34-year-old male HIV infected patient who developed cardiac tamponade due to Nocardia asteroides as the initial and limited presentation of nocardiosis. To our knowledge, this is the first documented case of cardiac tamponade caused by N. asteroides in HIV-infected patients. A 34-year-old, HIV seropositive white man, an intravenous drug abuser, was admitted with fever, dyspnoea and chest pain of 2 weeks’ duration. Significant findings were fever of 38.4”C: paradoxical pulse: jugular vein distension; blood pressure, 90/70 mm Hg; pulse, 120/min and respiration, 28/min. The ECG showed widespread elevation of the ST-segment, and diffuse PR depression. The OKT4/T8 ratio was 0.45 (total T-helper lymphocytes, 239/mm3). A chest radiograph revealed an enlarged cardiac silhouette without pulmonary infiltrates. The echocardiogram showed a large pericardial effusion, diastolic collapse of the right atrium and diastolic collapse of the right ventricule. A subxiphoid pericardiostomy was carried out and 800 ml of serosanguineous fluid were removed. Blood cultures were negatives. The pericardial cultures grew N. asteroides. All other cultures, including those for mycobacterium, were negative. Treatment was initiated with iv trimethoprimQ 2000 The British Infection Society
sulfamethoxazole and this was followed 5 days later with oral sulfadiazine. The patient improved and was discharged after 17 days in hospital. After discharge, the sulfadiazine therapy was maintained and highly active antiretroviral therapy (HAART) was begun. Three months later the T-helper lymphocyte count had increased (3231mm’) and the plasma level of HIV-RNA was undetectable. Sulfadiazine was discontinued. No relapse was observed during the follow up period (24 months). The incidence of nocardiosis in AIDS is low, (0.2-1.8%).‘, Although nocardiosis is often disseminated in patients with HIV infection, isolation of Nocardiu from the pericardium is uncommon.“’ In spite of the fact that pericardial effusion is common in patients with HIV infection, cardiac tamponade is an uncommon complication.” Previous reports have identified a spectrum of organisms that cause cardiac tamponade in HIV-infected patients. These include M.qcobacterium tuberculosis, Streptoroccus pneumoniae, Staphylococcus aureus, Klebsi& pneurnoniar. Crgptococcus neoformans. Cytomegalovirus, M. fivium intmcellulure and M. kansasii. Kaposi’s sarcoma and Lymphoma are also reported.i In addition, several cases of cardiac tamponade are attibuted to non-specific pericarditis.h Two reviews of Nocardiosis in HIV-infected patients mention two patients in whom N. asteroi&s was isolated from pericardial fluid?,’ though tamponade did not occur. even with large effusions. In another study of 30 HIV-infected patients with nocardiosis, ,X. lrsteroidcs was not isolated from the pericardial fluid.’ In non-HIV-infected populations cardiac tamponade is a rare manifestation of infection with N. rlstc>roides, and only few cases are described.: ” A recent review of 66 published cases of cardiac tamponade in infected
patients
does
not
mention
nocardiosis.’
Our patient is, to our knowledge, the first documented case of cardiac tamponade caused by X crsteroides in HIV-infected patients. Perhaps nocardiosis should be included in the differential diagnosis of cardiac tamponade in HIV-positive patients.
Antonio Rivero, Adela Esteve,
jestis Santos, and Manuel Mhrquez
Unit of Infectious Diseasrs, University Hospital Virgen de la Victoria. Mdlaga. Spain
References 1 Uttamchandani RB, Daikos GL. Reyes RR c’t (11. Nocardiosis in 30 patients with advanced human immunodcficiency virus infection: Clinical features and outcome. Clin lnfvct Dis 1994; 18: 348-3 5 3. 2 Holtz HA, Lavery DP, Kapila R. Actinomycetales infection in the acquired immunodeficiency syndrome. Ann Intern Mcd 1985: 102: 203-205. 3 Javaly K, Horowitz HW, Wormser GP Nocardiosis in patients with human immunodeficiency virus infection. Medicinr 1992: 71: 128-138. 4 Himelman RB, Chung WS. Chernoff DN. Schiller NB, Hollander H. Cardiac manifestations of human immunodeficiency virus infection: a two-dimensional echocardiographic study. J An] Coil Cur&d 1989: 13: 1030-1036. 5 Estok L, Wallach F, Cardiac tamponadc in a patient with AIDS: a review of oericardial disease in oatients with HIV infection. Mt Sintri JMed 199;: 65: 33-39. _ 6 Kwan T, Karve MM, Emerole 0. Cardiac tamponade in patients infected with HIV A report from an inner-city hospital. Chest 199 3: 104: 1059-1062. 7 Hornick F! Harris P, Smith l? Nocardia asteroides purufent pericarditis. Eur] CardiothorucSurg 1995: 9: 46X-470.
on
IOEbl@
Letters to the Editor Peritonitis due to Uchrobactrum anthropi in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis Sir, Ochrobactrum anthropi (formerly CDC group Vd) is a non-fermentative Gram-negative rod that is oxidase-positive, indole-negative, saccharolytic and motile due to peritrichous flagella.’ Ochrobactrum anthropi has been isolated from various environmental and human sources, and has been implicated in several cases of human infections.2,3 Here we report a case of peritonitis due to 0. nnthropi in a patient undergoing CAPD. The patient was a 79-year-old woman on CAPD since May 1996 because of diabetic nephropathy that consulted because of cloudy peritoneal fluid. Past medical history included two episodes of culture-negative peritonitis in the last year. A progressive deterioration of nutritional status had developed over the past 10 months. Current medications were insulin, amiodarone, erythropoietin, doxepin and oral nutritional supplements. Physical examination revealed a normal peritoneal catheter exit-site. The peritoneal effluent contained 1500 cells/@ (53% neutrophils). Empirical therapy was then started with intraperitoneal vancomycin and gentamicin, and a sample of peritoneal fluid was sent for culture. The peritoneal effluent was clear 48 h after therapy started, and another sample of peritoneal fluid was sent for culture as a control of therapy. When the results of cultures were received, therapy was changed to ofloxacin (200 mg/day) for 14 days. The patient recovered uneventfully, and died 2 months later from stroke that was unrelated to the episode of peritonitis. Peritoneal fluid samples were processed for culture according common techniques4 On the first day of incubation, abundant growth of a Gram-negative rod was detected on blood agar, chocolate agar and McConkey agar plates and in the aerobic bottle of the blood culture set. The bacterium was non-fermentative, oxidase-positive and was identified as 0. anthropi by using the API 20 NE system (bioMerieux, France), the code number being 1242344 (99.9% id, Tz0.92). Scanty growth of the same bacterium was obtained from the second sample of peritoneal fluid. A disc-plate susceptibility test was performed according to standard techniques,5 the isolate being resistant to ampicillin, amoxicillin/clavulanic acid, cefazolin, cefuroxime, ceftriaxone, ceftazidime, ticarcillin, cefepime and piperacillin/tazobactam. The isolate was susceptible to imipenem, meropenem, ciprofloxacin, cotrimoxazole, gentamicin and amikacin. A Medline search was performed using “Ochrobactrum”, “anthropi” and “CDC group Vd” as keywords on January 13, 1999. The search yielded 48, 42, and seven references respectively. Among these, 20 references were about human infections caused by 0. unthropi. No case of peritonitis due to this bacterium was found in this search. Human infections due to 0. unthropi are rarely reported in the literature. According to the Medline search, only 5 1 cases were reported, most of them being cases of bacteraemia (39 cases,
0163-4453/00/020205
+ 04 $35.00/O
many of them catheter-related),h-’ 5 meningitis related with contamination of cadaveric pericardial tissue (three cases).lh endophthalmitis (two cases, one of them bilateral),“,‘* pyogenic infections (one infection related to abdominal drainage, one respiratory tract infection and one wound infection)3 and one case each of pacemaker leads infection,19 necrotizing fasciitis,20 urinary tract infection2’ and osteochondritis.22 In our patient, the origin of the strain is unknown. Ochrobactrum unthropi has been recovered from environmental sources1,2 and could have contaminated the dialysis system through the catheter tunnel. However, in one report 0. unthropi was isolated from theoretically sterile solutions,lh so contamination of the dialysis fluid could be possible, although this possibility is merely speculative. In conclusion, we report the first case of peritonitis due to 0. unthropi in a patient undergoing CAPD, expanding the clinical spectrum of diseases caused by this organism. J. Esteban’, A. Ortiz2, E. RollBn’, A. Reyero-L6pez2, E Soriano’ Departments of ‘Medical Microbiology and ‘Nephrology, Funducidn Iimdnez Diaz, Av. Reyes Cutdlicos 2, 28040-Madrid, Spain
References 1 von Graevenitz
2
3 4
5 6
7
A. Acinetobacter, AZ&genes, Moraxellu, and other nonfermentative gram-negative bacteria. In: Murray PR, Baron EJ, Pfaller MA, Tenover FC, Yolkeri RH (eds). Manual of Clinical Microbiology, 6th ed. Washington D.C.: American Society for Microbiology Press, 1995; 52&532. Holmes B, Popoff M, Kiredjian M, Kersters K. Ochrobacterum anthropi gen. nov. sp. nav. from human clinical specimens and previously known as group Vd. Int ISyst Bacterial 1988; 38: 406416. Cieslak TJ, Drabick CJ, Robb ML. Pyogenic infections due to Ochrobactrum anthropi. Clin Infect Dis 1996; 22: 845-847. Working Party of the British Society for Antimicrobial Chemotherapy. Diagnosis and management of peritonitis in continuous ambulatory peritoneal dialysis. Lnncet 1987; i: 845-848. NCCLS. Periormance Stnndurds for Antimicrobial Disk Susceptibility Test, Sixth Edition; Approved Standard. M2-A6, January 1997. T o r r e s L , Arazo E Seoane A, Marco ML. Bacteriemia por Ochrobuctrum anthropi en un paciente con SIDA. Med C/in (Bare)
1998: 111: 318. Yu WL, Lin CW, Wang DY. Clinical and microbiologic characteristics of Ochrobnctrum anthropi bacteremia. 1 Formos Med Assoc 1998: 97:
106-112. 8 Gill MV, Ly H, Mueenuddin M, Schoch PE, Cunha BA. Intravenous line infection due to Ochrobactrum anthropi (CDC Group Vd) in a normal host. Heart Lung 1997: 26: 335-336. 9 Haditsch M, Binder L, Tschurtschenthaler G, Watschinger R, Zauner G. Mittermayer H. Bacteremia caused by Ochrobactrum anthropi in an immunocompromised child. Infection 1994; 22: 291-292. 10 Alnor D, Frimodt-Moller N, Espersen F, Frederiksen W. Infections with the unusual human pathogens Agrobacterium species and Ochrobactrum anthropi. Clin Infect Dis 1994: 18: 914-920. 1 1 Ezzedine H, Mourad M, Van Ossel C et nl. An outbreak of Ochrobactrum anthropi bacteraemia in five organ transplant patients. IHospInfect 1994: 27: 35-42.
0 2000 The British Infection Society
206
Letters to the Editor
12 Kern WV, Oethinger M. Kaufhold A, Rozdzinski E, Marre R. Ochrobactrum anthropi bacteremia: report of four cases and short review. In&ction 1993: 21: 306-310. 13 Klein JD, Eppes SC. Ochrobactrum anthropi bacteremia in a child. De! MedJ 19Y3; 65: 493-495. 14 Gransden WR. Eykyn SJ. Seven cases of bacteremia due to Ochrobuctrum anthropi. Clin Infect Dis 1992; 15: 1068-1069. 15 Cieslak TJ, Robb ML, Drabick CJ, Fischer GW. Catheter-associated sepsis caused by Ochrobactrum anthropi: report of a case and review of related nonfermentative bacteria. Clin Infect Dis 1992; 14: 902-907. 16 Chang HJ, Christenson JC. Pavia AT et al. Ochrobartrum anthropi meningitis in pediatric pericardial allograft transplant recipients. J Infect Dis 1996: 173: 656-660. 17 Berman AJ, Del Priore LV, Fischer CK. Endogenous Ochrobactrum unthropi endophthalmitis. Am J Ophthulmol 1997; 123: 560-562. I8 Braun M. Jonas JB, Schonherr IT, Naumann GO. Ochrobuctrurn anthropi endophthalmitis after uncomplicated cataract surgery. Am ] Ophthulmol1996; 122: 272-273. 19 Earhart KC, Boyce K, Bone WD. Wallace MR. Ochrobnctrum unthropi infection of retained pacemaker leads. C/in In&t Dis 1997: 24: 2X1-282. 20 Brivet F, Guivert M, Kiredjian M. Dormont J. Necrotizing fasciitis. bacteremia, and multiorgan failure caused by Ochrobnctrum anthropi. ClinInfict Dis 1993: 17: 516-518. 2 1 Van Horn KG, Gedris CA, AhmedT, Wormser GP. Bacteremia and urinary tract infection associated with CDC group Vd biovar 2. 1 Chin
,Microbiol 1989; 27: 201-202. 22 Barson WJ. Cromer BA, Marcon MJ. Puncture wound osteochondritis of the foot caused by CDC group Vd. / Clin Microbial 1987: 25:
2014-2016. A~c~pytcnforpublication
25 ]unel999
doi:10.1053/jinf.1999.0593. available online at http://www.idealibrary.com
HIV
on
IOEF;l@
Cardiac Tamponade Caused by Nocardia asteroides in an HIV-infected Patient Sir, We describe a 34-year-old male HIV infected patient who developed cardiac tamponade due to Nocardia asteroides as the initial and limited presentation of nocardiosis. To our knowledge, this is the first documented case of cardiac tamponade caused by N. asteroides in HIV-infected patients. A 34-year-old, HIV seropositive white man, an intravenous drug abuser, was admitted with fever, dyspnoea and chest pain of 2 weeks’ duration. Significant findings were fever of 38.4”C: paradoxical pulse: jugular vein distension; blood pressure, 90/70 mm Hg; pulse, 120/min and respiration, 28/min. The ECG showed widespread elevation of the ST-segment, and diffuse PR depression. The OKT4/T8 ratio was 0.45 (total T-helper lymphocytes, 239/mm3). A chest radiograph revealed an enlarged cardiac silhouette without pulmonary infiltrates. The echocardiogram showed a large pericardial effusion, diastolic collapse of the right atrium and diastolic collapse of the right ventricule. A subxiphoid pericardiostomy was carried out and 800 ml of serosanguineous fluid were removed. Blood cultures were negatives. The pericardial cultures grew N. asteroides. All other cultures, including those for mycobacterium, were negative. Treatment was initiated with iv trimethoprimQ 2000 The British Infection Society
sulfamethoxazole and this was followed 5 days later with oral sulfadiazine. The patient improved and was discharged after 17 days in hospital. After discharge, the sulfadiazine therapy was maintained and highly active antiretroviral therapy (HAART) was begun. Three months later the T-helper lymphocyte count had increased (3231mm’) and the plasma level of HIV-RNA was undetectable. Sulfadiazine was discontinued. No relapse was observed during the follow up period (24 months). The incidence of nocardiosis in AIDS is low, (0.2-1.8%).‘, Although nocardiosis is often disseminated in patients with HIV infection, isolation of Nocardiu from the pericardium is uncommon.“’ In spite of the fact that pericardial effusion is common in patients with HIV infection, cardiac tamponade is an uncommon complication.” Previous reports have identified a spectrum of organisms that cause cardiac tamponade in HIV-infected patients. These include M.qcobacterium tuberculosis, Streptoroccus pneumoniae, Staphylococcus aureus, Klebsi& pneurnoniar. Crgptococcus neoformans. Cytomegalovirus, M. fivium intmcellulure and M. kansasii. Kaposi’s sarcoma and Lymphoma are also reported.i In addition, several cases of cardiac tamponade are attibuted to non-specific pericarditis.h Two reviews of Nocardiosis in HIV-infected patients mention two patients in whom N. asteroi&s was isolated from pericardial fluid?,’ though tamponade did not occur. even with large effusions. In another study of 30 HIV-infected patients with nocardiosis, ,X. lrsteroidcs was not isolated from the pericardial fluid.’ In non-HIV-infected populations cardiac tamponade is a rare manifestation of infection with N. rlstc>roides, and only few cases are described.: ” A recent review of 66 published cases of cardiac tamponade in infected
patients
does
not
mention
nocardiosis.’
Our patient is, to our knowledge, the first documented case of cardiac tamponade caused by X crsteroides in HIV-infected patients. Perhaps nocardiosis should be included in the differential diagnosis of cardiac tamponade in HIV-positive patients.
Antonio Rivero, Adela Esteve,
jestis Santos, and Manuel Mhrquez
Unit of Infectious Diseasrs, University Hospital Virgen de la Victoria. Mdlaga. Spain
References 1 Uttamchandani RB, Daikos GL. Reyes RR c’t (11. Nocardiosis in 30 patients with advanced human immunodcficiency virus infection: Clinical features and outcome. Clin lnfvct Dis 1994; 18: 348-3 5 3. 2 Holtz HA, Lavery DP, Kapila R. Actinomycetales infection in the acquired immunodeficiency syndrome. Ann Intern Mcd 1985: 102: 203-205. 3 Javaly K, Horowitz HW, Wormser GP Nocardiosis in patients with human immunodeficiency virus infection. Medicinr 1992: 71: 128-138. 4 Himelman RB, Chung WS. Chernoff DN. Schiller NB, Hollander H. Cardiac manifestations of human immunodeficiency virus infection: a two-dimensional echocardiographic study. J An] Coil Cur&d 1989: 13: 1030-1036. 5 Estok L, Wallach F, Cardiac tamponadc in a patient with AIDS: a review of oericardial disease in oatients with HIV infection. Mt Sintri JMed 199;: 65: 33-39. _ 6 Kwan T, Karve MM, Emerole 0. Cardiac tamponade in patients infected with HIV A report from an inner-city hospital. Chest 199 3: 104: 1059-1062. 7 Hornick F! Harris P, Smith l? Nocardia asteroides purufent pericarditis. Eur] CardiothorucSurg 1995: 9: 46X-470.