Amber Anwar, Saira Naseem, Ikram A Burney, Mohammad Khursheed.
Nocardiosis in Cancer patients : Case series and review of Literature.
Infect Dis J Jan ;10(2):23-5.

CASE I- A 25 years old male patient was admitted with the chief complaint of generalized aches and pains for six months and highgrade fever for the past one month. Physical examination revealed an anaemic patient with a temperature of 10 1F and a palpable spleen. There was a marked area of cellulitis in the right inguinal region that was red and indurated, about 4x5 cm in size and was tender and fluctuant on palpation. The rest of the systemic examination was within normal limits. Blood analysis revealed hemoglobin of 10.2 gm/dL, a total leukocyte count of 213x109 /L and platelet count of 50x109 /L. The BUN was 10gm/dL and liver function tests were within normal limits. Serum albumin was 2.7g/dL, globulin 2.5 g/dL, LDH was 297 IU/L and serum uric acid was 3.9mg/dL. Bone marrow examination revealed acute lymphoblastic leukemia (ALL). On aspiration, there was a purulent discharge, which showed presence of grampositive branching rods. Subsequent culture studies revealed the organism to be Nocardia asteroides, sensitive to cotrimaxazole, tetracycline, amikacin and erythromycin. The patient was started on a combination of amikacin and cotrimaxazole. One week later induction chemotherapy was initiated for ALL. Five weeks post initiation of treatment the patient went into hematological remission and the indurated area in the groin completely resolved. Amikacin was discontinued and cotrimaxazole was continued for total of two months. CASE II: A 73 years old male with a six month past history of chronic lymphocytic leukaemia (CLL) and laryngeal carcinoma had received radiation therapy to the larynx and was being treated with intermittent doses of prednisone. He was admitted with severe breathlessness, fever and a productive cough of two-month duration. Systemic examination revealed pedal edema, inspiratory stridor and bilateral crackles up to the mid zones of both the lungs, especially on the right side. Laboratory results showed haemoglobin of 12.6g/dL, WBC of 158.4x109/L, Plt 141x109/L, Cr. 0.9mg/dL, Na 124meq/L, K 4.2 meq/L, total bilirubin, 0.7 mg/dL, SGPT 23 IU/L, AlkPhosp, 203 IU/L Ca 7.3 mg/dL, P04 3.Omg/dL, Uric Acid 1.9mg/dL. Chest X-ray revealed increased density in the distal portion of the lungs suggestive of infectious process. Attempted bronchoscopy was not successful due to obstruction at the laryngeal inlet. Subsequently, an elective tracheostomy was performed, and the patient was started on fluconazole due to suspicion of a fungal infection. Smear and culture from the tracheal aspirate revealed moderate grampositive branching rods suggestive of Nocardiosis, which was confirmed by culture. The culture also grew few colonies of Klebsiella pneumoniae, sensitive to gentamicin and cefotaxime. The patient was started on amikacin, cloxacillin and cotrimaxazole. Patient`s condition continued to deteriorate with persistently low oxygen saturation and respiratory distress. During the hospital stay his pneumonia did not respond to antibiotics and after five days of treatment, the patient expired.

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