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Pneumonia After Aspiration of Grit
roentgenogram of the month Pneumonia After Aspiration of Grit* Sonja Zweegman, M.D.; Hans G.M. Koeleman, M.D.; Klaas W . van Kralingen , M.D.; and Pieter E. Postmus M.D., Ph.D. , F.C.C.P. (Chest 1994; 106:265-67)
man, in excellent previous health, A 30-year-old was admitted to the hospital after falling off a
scaffolding of 6 m height. He fell into grit and aspirated some of it. At presentation, physical examination revealed a man in acute distress. Blood pressure was 130/ 80 mm Hg, heart rate was 130/ min, respiratory rate was 38/ min, and rectal temperature was 36.6°C. Diminished breath sounds were heard over the right lung, percussion was normal. Findings from further examination were unremarkable. Laboratory studies showed the following: ESR , 2 mm/ h; hemoglobin, 8.1 mmol/L; hematocrit, 0.41; thrombocytes, 274X109 / L; leukocytes, 20X109 / L; creatinine, 128 J,Lmol/L; and alkaline phosphatase, 41 U/ L. A chest radiograph showed foreign bodies in the right lower lobe (Fig 1 and 2). Because of the appearance of foreign bodies, bronchoscopy was performed. Grit was observed in the upper and lower lobe bronchus of the right lung. Two stones were removed followed by irrigation of the two lobes. Prophylactic administration of penicillin was started; however, 4days after hospital admission, the patient developed a fever. A chest radiograph showed *From the Departments of Internal Medicine (Dr. Zweegman), Clinical Microbiology and Hospital Hygiene (Dr. Koeleman), and Pulmonology (Drs. van Kralingen and Postmus), Free University Hospital, Amsterdam, the Netherlands.
FIGURE
l
an infiltrate in the left lower lobe (Fig 3). Under suspicion of a bacterial superinfection, penicillin therapy was stopped; instead, broad-spectrum antibiotics were administered (erythromycin and cefotaxime) . However, the temperature did not decline neither and the radiographic abnormalities did not disappear. Microscopic investigation of sputum, later confirmed by culture, revealed the diagnosis.
FIG URE
2
FIGURE
3
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Diagnosis: Nacardia Pneumonia Gram stain showed Gram-positive, acid-fast, branching rods. Culture revealed Nocardia otitidiscaviarum. Susceptibility tests showed good activity against sulfamethoxazole, trimethoprim, doxycycline, gentamicin, imipenem, and ciprofloxacin. Therefore, the therapeutic regimen was changed to trimethoprim-sulfamethoxazole in a dosage of 480/ 2,400 four times daily. Because of progressive liver enzyme disturbances, persisting despite reducing the dose, this had to be discontinued. The patient was treated with imipenem and gentamicin. During this period initially progression of the infiltrate was observed. The patient remained febrile . Acomputed tomographic (CT) scan of the thorax was made to exclude pulmonary abcesses. The left lung appeared to be completely consolidated. No fluid-air levels were observed (Fig 4). Also, a CT scan of the brain and an isotope bone scintigraphy were performed to exclude dissemination. Neither abscesses nor hot spots were seen . Repeated blood cultures were negative. Finally, after 22 days of treatment (10 days of trimethoprim-sulfamethoxazole and 12 days of imipenem-gentamicin), temperature declined. A slight regression of the pulmonary infiltrates was observed after almost 6 weeks. It was decided then to replace intravenous antibiotic therapy by oral administration of ciprofloxacin (750 mg three times a day) . The patient was discharged from the hospital and followed in the outpatient clinic. Five months after hospital admission, he is well and free of fever. The radiographic abnormalities improved. DISCUSSION Nocardia, the organism reported in 1888 by Nocard1 as the cause of bovine farcy, was subsequently described as a human pathogen in 1890. 2 The genus Nocardia is composed of aerobic, Gram-positive, filamentous bacteria that fragment into bacillary forms and frequently are acid fast. They are ubiquitous in soil but not normally found as animal or human commensals. 3 Most infections in humans are caused by N asteroides; however, other Nocardia species, particularly N brasiliensis and N otitidis-caviarum are also associated with infections in humans. Primary infection usually begins in the respiratory tract. Dissemination predominantly occurs to the central nervous system. Other sites less commonly involved are skin, soft tissue, bone, and the eye. 4•5 In our patient, traumatic introduction of Nocardia in the respiratory tract was probably as a result of aspiration of grit. We could not demonstrate secondary dissemination by CT scan of the brain and an isotope bone scintigraphy. 266
FIGURE
4
The clinical manifestations and the chest radiographic abnormalities vary widely. Consolidations and large irregular nodules, often cavitary, are most common as are pleural lesions. Solitary masses, fine widely scattered nodules, and interstitial patterns may also occur. 6•7 Sulfonamides, either alone or in combination with another antibiotic to which the organism has been shown to be sensitive, are considered the antimicrobial agents of choice in the treatment of Nocardia infections. Other drugs reported to be successful are minocycline, cephalosporins, erythromycin, trimethoprim-sulfamethoxazole, Imlpenem, and ciprofloxacin. 8 The poor reaction with initial antimicrobial therapy in our patient could be explained by the in vitro resistance to erythromycin and the ,B-lactam antibiotics. Many aspects of the host defence against Nocardia infection remain poorly understood . An acute inflammatory reaction with neutrophilic predominance is thought to be the initial response to tissue invasion.9 Cellular immunity, like activation of macrophages, is also involved.l 0 That is probably the reason why a strong association of Nocardia infection with disorders of the immune system and long-term corticosteroid and immunosuppressive therapy has been noted. On the other hand, a review of the literature from 1966 to 1973, by Palmer et al, 4 demonstrated that in 49 percent of patients with Nocardia infection, no predisposing condition was present. To our knowledge, a patient with proved Nocardia infection after aspiration has never been described. REFERENCES 1 Nocard E. Note sur Ia maladie des boeufs de Ia Guadelope connue sons le nom de farcin . Ann Inst Pasteur 1888 ;2:293 2 Eppinger H. Ueber eine neue pathogene Cladothrix und eine durch sie hervorgerufene Pseudotuberculose. Wien Klin Wochenschr 1890; 3:321 Roentgenogram of the Month (Zweegman eta/)
3 Hosty TS, McDurmont C, Ajello L, eta!. Prevalence of Nocardia asteroides in sputa examined by a tuberculosis diagnostic laboratory. J Lab Clin Med 1961; 58:107-14 4 Palmer DL, Harvey RL, Wheeler JK. Diagnostic and therapeutic consideration in Nocardia infection. Medicine 1974; 53:391-401 5 Curry W A. Human nocardiosis: a clinical review with selected case reports. Arch Intern Med 1980; 140:818-26 6 Grossman CB, Bragg DG, Armstrong D. Roentgen manifestations of pulmonary nocardiosis. Radiology 1970; 96:325-30
7 Feigin DS. Nocardiosis of the lung: chest radiographic findings in 21 cases. Radiology 1986; 159:9-14 8 Gutmann L, Goldstien FW, Kitzis MD, e t a!. Susceptibility of Nocardia asteroides to 46 antibiotics, including 22 beta lactams. Antimicrob Agents Chemother 1983; 23:248-51 9 Filice GA. Inhibition of Nocardia asteroides by neutrophils. J Infect Dis 1985; 151:47-56 10 Sundararaj T, Agarwac SC. Cell mediated immunity in experimental Nocardia asteroides infection. Infect Immun 1977; 15:370-75
CHEST /106/1/ JULY, 1994
267
man, in excellent previous health, A 30-year-old was admitted to the hospital after falling off a
scaffolding of 6 m height. He fell into grit and aspirated some of it. At presentation, physical examination revealed a man in acute distress. Blood pressure was 130/ 80 mm Hg, heart rate was 130/ min, respiratory rate was 38/ min, and rectal temperature was 36.6°C. Diminished breath sounds were heard over the right lung, percussion was normal. Findings from further examination were unremarkable. Laboratory studies showed the following: ESR , 2 mm/ h; hemoglobin, 8.1 mmol/L; hematocrit, 0.41; thrombocytes, 274X109 / L; leukocytes, 20X109 / L; creatinine, 128 J,Lmol/L; and alkaline phosphatase, 41 U/ L. A chest radiograph showed foreign bodies in the right lower lobe (Fig 1 and 2). Because of the appearance of foreign bodies, bronchoscopy was performed. Grit was observed in the upper and lower lobe bronchus of the right lung. Two stones were removed followed by irrigation of the two lobes. Prophylactic administration of penicillin was started; however, 4days after hospital admission, the patient developed a fever. A chest radiograph showed *From the Departments of Internal Medicine (Dr. Zweegman), Clinical Microbiology and Hospital Hygiene (Dr. Koeleman), and Pulmonology (Drs. van Kralingen and Postmus), Free University Hospital, Amsterdam, the Netherlands.
FIGURE
l
an infiltrate in the left lower lobe (Fig 3). Under suspicion of a bacterial superinfection, penicillin therapy was stopped; instead, broad-spectrum antibiotics were administered (erythromycin and cefotaxime) . However, the temperature did not decline neither and the radiographic abnormalities did not disappear. Microscopic investigation of sputum, later confirmed by culture, revealed the diagnosis.
FIG URE
2
FIGURE
3
CHEST / 106 / 1 / JULY, 1994
265
Diagnosis: Nacardia Pneumonia Gram stain showed Gram-positive, acid-fast, branching rods. Culture revealed Nocardia otitidiscaviarum. Susceptibility tests showed good activity against sulfamethoxazole, trimethoprim, doxycycline, gentamicin, imipenem, and ciprofloxacin. Therefore, the therapeutic regimen was changed to trimethoprim-sulfamethoxazole in a dosage of 480/ 2,400 four times daily. Because of progressive liver enzyme disturbances, persisting despite reducing the dose, this had to be discontinued. The patient was treated with imipenem and gentamicin. During this period initially progression of the infiltrate was observed. The patient remained febrile . Acomputed tomographic (CT) scan of the thorax was made to exclude pulmonary abcesses. The left lung appeared to be completely consolidated. No fluid-air levels were observed (Fig 4). Also, a CT scan of the brain and an isotope bone scintigraphy were performed to exclude dissemination. Neither abscesses nor hot spots were seen . Repeated blood cultures were negative. Finally, after 22 days of treatment (10 days of trimethoprim-sulfamethoxazole and 12 days of imipenem-gentamicin), temperature declined. A slight regression of the pulmonary infiltrates was observed after almost 6 weeks. It was decided then to replace intravenous antibiotic therapy by oral administration of ciprofloxacin (750 mg three times a day) . The patient was discharged from the hospital and followed in the outpatient clinic. Five months after hospital admission, he is well and free of fever. The radiographic abnormalities improved. DISCUSSION Nocardia, the organism reported in 1888 by Nocard1 as the cause of bovine farcy, was subsequently described as a human pathogen in 1890. 2 The genus Nocardia is composed of aerobic, Gram-positive, filamentous bacteria that fragment into bacillary forms and frequently are acid fast. They are ubiquitous in soil but not normally found as animal or human commensals. 3 Most infections in humans are caused by N asteroides; however, other Nocardia species, particularly N brasiliensis and N otitidis-caviarum are also associated with infections in humans. Primary infection usually begins in the respiratory tract. Dissemination predominantly occurs to the central nervous system. Other sites less commonly involved are skin, soft tissue, bone, and the eye. 4•5 In our patient, traumatic introduction of Nocardia in the respiratory tract was probably as a result of aspiration of grit. We could not demonstrate secondary dissemination by CT scan of the brain and an isotope bone scintigraphy. 266
FIGURE
4
The clinical manifestations and the chest radiographic abnormalities vary widely. Consolidations and large irregular nodules, often cavitary, are most common as are pleural lesions. Solitary masses, fine widely scattered nodules, and interstitial patterns may also occur. 6•7 Sulfonamides, either alone or in combination with another antibiotic to which the organism has been shown to be sensitive, are considered the antimicrobial agents of choice in the treatment of Nocardia infections. Other drugs reported to be successful are minocycline, cephalosporins, erythromycin, trimethoprim-sulfamethoxazole, Imlpenem, and ciprofloxacin. 8 The poor reaction with initial antimicrobial therapy in our patient could be explained by the in vitro resistance to erythromycin and the ,B-lactam antibiotics. Many aspects of the host defence against Nocardia infection remain poorly understood . An acute inflammatory reaction with neutrophilic predominance is thought to be the initial response to tissue invasion.9 Cellular immunity, like activation of macrophages, is also involved.l 0 That is probably the reason why a strong association of Nocardia infection with disorders of the immune system and long-term corticosteroid and immunosuppressive therapy has been noted. On the other hand, a review of the literature from 1966 to 1973, by Palmer et al, 4 demonstrated that in 49 percent of patients with Nocardia infection, no predisposing condition was present. To our knowledge, a patient with proved Nocardia infection after aspiration has never been described. REFERENCES 1 Nocard E. Note sur Ia maladie des boeufs de Ia Guadelope connue sons le nom de farcin . Ann Inst Pasteur 1888 ;2:293 2 Eppinger H. Ueber eine neue pathogene Cladothrix und eine durch sie hervorgerufene Pseudotuberculose. Wien Klin Wochenschr 1890; 3:321 Roentgenogram of the Month (Zweegman eta/)
3 Hosty TS, McDurmont C, Ajello L, eta!. Prevalence of Nocardia asteroides in sputa examined by a tuberculosis diagnostic laboratory. J Lab Clin Med 1961; 58:107-14 4 Palmer DL, Harvey RL, Wheeler JK. Diagnostic and therapeutic consideration in Nocardia infection. Medicine 1974; 53:391-401 5 Curry W A. Human nocardiosis: a clinical review with selected case reports. Arch Intern Med 1980; 140:818-26 6 Grossman CB, Bragg DG, Armstrong D. Roentgen manifestations of pulmonary nocardiosis. Radiology 1970; 96:325-30
7 Feigin DS. Nocardiosis of the lung: chest radiographic findings in 21 cases. Radiology 1986; 159:9-14 8 Gutmann L, Goldstien FW, Kitzis MD, e t a!. Susceptibility of Nocardia asteroides to 46 antibiotics, including 22 beta lactams. Antimicrob Agents Chemother 1983; 23:248-51 9 Filice GA. Inhibition of Nocardia asteroides by neutrophils. J Infect Dis 1985; 151:47-56 10 Sundararaj T, Agarwac SC. Cell mediated immunity in experimental Nocardia asteroides infection. Infect Immun 1977; 15:370-75
CHEST /106/1/ JULY, 1994
267