Clinical manifestations and diagnosis of nocardiosis
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Clinical manifestations and diagnosis of nocardiosis
AutorStanley W Chapman
Manifestaciones clínicas y diagnóstico de la nocardiosis
Dra. Rosa María EstradaJosé Nuñez del Prado R2P
Hospital Ángeles del Pedregal Departamento de pediatría
Marzo 2011
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Introducción
• Actinomiceto aeróbico, gram positivo, genero nocardia.
• Enfermedad localizada o sistémica purulenta.
• Disemina a cualquier órgano
• Recaída o progreso a pesar de tratamiento adecuado.
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pulmones
Sistema nervioso central
cutáneo
diseminada
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Riesgo• Inmuno-compromiso
• Inmunodeficiencia de Inmunidad Celular (64%)
• FACTORES INDEPENDIENTES EN TRASPLANTADOS:
• Glucocorticoides en dosis elevadas• Historia de citomegalovirus• Niveles elevados de calcinuerina
Beaman, BL, Beaman, L. Nocardia species: host-parasite relationships. Clin Microbiol Rev 1994; 7:213.
Peleg, AY, Husain, S, Qureshi, ZA, et al. Risk factors, clinical characteristics, and outcome of Nocardia infection in organ transplant recipients: a matched casecontrol study. Clin Infect Dis 2007; 44:1307.
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INMUNOCOMPROMISO• Trasplantes de células
madre hematopoyéticas• Trasplante de órganos
sólidos
• Terapia con corticosteroides
• VIH (CD4 menor a 100/mm3)
• Neoplasias (terapia con glucocorticoides o quimioterapia)
• Diabetes mellitus
• Alcoholismo
• Tabaquismo crónico
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Sitios de Infección
• Sistémica (≥2 sitios) — 32%– 44% compromiso del SNC
• Pulmonar — 39%• SNC — 9%• Cutáneo o linfo-cutáneos — 8%• Sítio extra pulmonar único — 12%
Beaman, BL, Beaman, L. Nocardia species: host-parasite relationships. Clin Microbiol Rev 1994; 7:213.
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Pulmonar
• 2/3 de los casos
• Aislamiento en esputo: signo de infección
• Aguda/ Sub-Aguda o Crónica
• Fiebre, diaforesis nocturna, astenia, anorexia, disnea, tos, hemoptisis, dolor pleurítico, pérdida de peso.
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Radiografía de Tórax
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Extra-pulmonares
• 1/3 de las infecciones
• 20% sin manifestaciones pulmonares
• Cerebral, mediastinitis, pericarditis, síndrome de vena cava superior.
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Sistema Nervioso Central
• Abscesos en cualquier región del encéfalo
• Signos inespecíficos: meningismo, focalización, convulsiones, déficit neurológico, cefalea.
• Inmunocompetentes: infección latente silenciosa
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IRM Abscesos
Menku, A, Kurtsoy, A, Tucer, B, et al. Nocardia brain abscess mimicking brain tumour in immunocompetent patients: report of two cases and review of the literature. Acta Neurochir (Wien) 2004; 146:411.
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TAC
Cráneo
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Cutánea
• 4 patrones:
• Cutáneo Primario: Inoculación directa
• Úlcera, pioderma, celulitis, nódulos, abscesos subcutáneos.
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• Linfocutáneo
– Linfangítis nodular
– Nocardiosis Sporotricoide
Inamadar, AC, Palit, A, Peerapur, BV, Rao, SD. Sporotrichoid nocardiosis caused by Nocardia nova in a patient infected with human immunodeficiency virus. Int J Dermatol 2004; 43:824.
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Manifestaciones cutáneas de nocardiosis diseminada
• Indistinguible clínicamente de nocardiosis cutánea primaria
• En todos los casos asumir como enfermedad diseminada.
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Micetoma• Causado por:
– Hongos
– Actinomicetos
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Infección diseminada
• Dos sitios de infección, no contíguos, con o sin foco pulmonar
• Cultivos por cuatro semanas, incrementan especificidad y utilidad.
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Bacteremia
• Cuerpo Extraño endo-vascular
– (catéter venoso central)
• Otros sitios
– Huesos, articulaciones, válvulas cardiacas, Riñones.
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Diagnóstico diferencial
• Cuadro cerebral, cutáneo, de tejidos blandos concomitante a proceso pulmonar.
• Inmunocompromiso
Arabi, Y, Fairfax, MR, Szuba, MJ, et al. Adrenal insufficiency, recurrent bacteremia, and disseminated abscesses caused by Nocardia asteroides in a patient with acquired immunodeficiency syndrome. Diagn Microbiol Infect Dis 1996; 24:47.
Carriere, C, Marchandin, H, Andrieu, JM, et al. Nocardia thyroiditis: unusual location of infection. J Clin Microbiol 1999; 37:2323.
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PulmonarHongos
MicobacteriasBacterias
Neoplasias
CutáneaHongos
Micobacterias no tuberculosis
BacteriasParasitos
CerebralHongos
ParasitosNeoplasias
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Tinción Gram
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Tinción de Ácido Rápido (Kinyoun)
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Conclusiones
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GRACIAS