Which clinical history findings are characteristics of nocardiosis?

Updated: Jul 24, 2018
  • Author: George Kurdgelashvili, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Clinical manifestations of nocardiosis depend on the site of infection. [7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19]

Primary cutaneous nocardiosis may present as cutaneous infection, lymphocutaneous infection, or subcutaneous infection. Cutaneous nocardiosis generally manifests as either cellulitis or, more likely, single or multiple nontender erythematous nodule(s) at the site of traumatic inoculation. These nodules occasionally drain purulent material. Lymphocutaneous nocardiosis manifests as similar lesions accompanied by ascending regional lymphadenopathy. The lymphadenopathy may also occasionally drain purulent material. N brasiliensis is the most common cause of progressive cutaneous and lymphocutaneous (sporotrichoid) disease.

Nocardial species can cause mycetoma, a chronic, swollen, purulence-draining, subcutaneous infection of the extremities, typically encountered in tropical areas of the world, but also has been reported from the southern United States, Central and South Americas, and Australia. It is usually ascribed to N brasiliensis. [17, 20]

Postoperative wound infections due to Nocardia species are rare, but case clusters of nosocomial transmission have been described.

Traumatic inoculation nocardial arthritis has occurred but is rare. This presents as a subacute or chronic monarthritis, typically involving the knee.

Traumatic inoculation or postoperative nocardial keratitis has been well described in Asia and travelers returning from Asia.

Traumatic inoculation nocardial endophthalmitis has also occurred in rare instances.

Pulmonary disease is the predominant clinical finding in most patients with nocardiosis. [10, 18] Pulmonary nocardiosis may be acute, subacute, or chronic. Clinical manifestations include inflammatory endobronchial masses or localized or diffuse pneumonias, which may be accompanied by cavitation, abscess formation, pleural effusion, or empyema. Symptoms in patients with nocardiosis are indistinguishable from those in patients with similar pulmonary infections of other microbial etiology. Cough with sputum production and fever are the dominant symptoms. At least 40% of patients with disseminated nocardiosis have pulmonary infection; therefore, the clinical presentation may be dominated by the pulmonary symptoms.

Patients with nocardiosis may present with deep abscess at any site, particularly in the lower extremities or the CNS. In patients with extra-CNS abscesses, fever and local symptoms predominate. Up to 25% of reported nocardiosis cases (other than those involving mycetoma) involve the CNS. When occurring in isolation, CNS nocardiosis manifests as a slowly progressive mass lesion, with a host of specific neurologic findings related to the specific location of the abscess. CNS nocardiosis is detected in up to 44% of disseminated nocardial infections. [21] In two thirds of patients with CNS nocardiosis, clinical findings indicate abscess with or without meningitis, including fever, headache, stiff neck, and/or altered mental status.

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