Nokardiosis A43.1

Nocard 1888; Eppinger 1890;

Gram-positive, aerobic rods (formerly assigned to fungi, like actinomycetes), which are widespread in the soil. Mainly Nocardia asteroides, also Nocardia brasiliensis, Nocardia madurae and Nocardia pelletieri. According to their natural occurrence in the soil, nocardia are exogenous infections.

Inoculation of the pathogen in the presence of wounds (skin nocardiosis, usually Nocardia brasiliensis) or by inhalation of the pathogen (pulmonary nocardiosis, usually Nocardia asteroides). Inoculation of contaminated material into the skin results in cutaneous nocardiosis. Inhalation of contaminated dust leads to pulmonary nocardiosis.

Person-to-person transmission does not occur.

Approximately 85% of affected patients are immunocompromised (HIV/AIDS, neoplasms, collagenoses, pre-existing chronic lung disease) - (Hémar V et al. 2018).

Mostly occurring in immunosuppressed patients (Z.n. organ transplantation, HIV infection) or in severe underlying diseases (e.g. lupus erythematosus, systemic).

Superficial form: Especially on the feet and hands, abscessing nodules are found in a chain-like arrangement along the lymphatic drainage area (sporotrichoid spread), occasionally mycetoma formation.

Lymphocutaneous form due to Nocardia asteroides.

Oculoglandular form with conjunctivitis and lymphadenopathy may result from smear infection. Most commonly caused by Nocardia brasiliensis.

Pulmonary and systemic form especially in immunocompromised patients (Uttamchandani RB et al. 1994).

Pathogen detection in pus or sputum. The cultural detection is possible on universal culture media or media for tuberculosis diagnostics (e.g. Löwenstein-Jensen medium).

Antibiosis after antibiogram. 1st choice are sulfonamides like sulfadiazine (e.g. Sulfadiazine Heyl) 4-8-12g/day or cotrimoxazole (e.g. Cotrimox Wolff). Long-term treatment until several weeks after healing is important to avoid recurrence.

Alternatively (used more and more frequently due to increasing resistance of the pathogens) imipenem/cilastatin (e.g. Zienam 4 g/day) in combination with amikacin (e.g. Biklin 1 g/day) in maximum dosages can be considered.

Good results have also been described with minocycline (e.g. Klinomycin 100 Filmtbl.) 2 times/day 100 mg p.o. as monotherapy or in combination with sulfonamides.

If necessary, other antibiotics depending on the resistance of the pathogen.

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