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OJHAS Vol. 10, Issue 4:
(Oct-Dec 2011) |
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Successful
Intra-peritoneal Antibiotic Therapy for Primary Abdominal Nocardiosis
in an Immunocompetent Young Female Masquerading as Carcinoma Ovary |
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Ravi N Patil,
UD Bafna, Pallavi VR, PS Rathod,
Kidwai Memorial Institute of
Oncology. Dr. MH Marigowda Road, Bangalore - 560029, Karnataka, India |
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Address for Correspondence |
#152, 2nd cross,
UAS layout, Sanjaynagar,
RMV II stage, Bengaluru-560094,
Karnataka, India.
E-mail:
ravi2varsha@yahoo.co.in |
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Patil RN, Bafna UD, Pallavi VR, Rathod PS. Successful
Intra-peritoneal Antibiotic Therapy for Primary Abdominal Nocardiosis
in an Immunocompetent Young Female Masquerading as Carcinoma Ovary. Online J Health Allied Scs.
2011;10(4):11 |
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Submitted: Sep 29, 2011; Accepted: Jan
4, 2012; Published: Jan 15, 2012 |
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| Abstract: |
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Nocardiosis
is a common opportunistic infection in the immunocompromised and in
patients with chronic debilitating diseases,e.g continuous ambulatory
peritoneal dialysis (CAPD) patients. Primary abdominal nocardiosis is
rare and is indeed a very rare infection in immunocompetent persons.
Only two cases have been reported in immunocompetent patients so far
and this may be third case to the best of our knowledge and first in
India. About 11 cases have been reported in CAPD patients and AIDS patients.We
report a case of Nocardiosis in an immunocompetent young female who
presented with an abdomino-pelvic mass masquerading as carcinoma ovary.After
initial resistance to various antibiotics, she responded to intraperitoneal
and oral linezolid and oral ciprofloxacin.
Key Words:
Nocardiosis; CAPD
patients, Trimethoprim-sulfamethoxazole (TMP-SMX); Amikacin; Intraperitoneal.
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Nocardia is
an aerobic, gram positive, partially acid fast bacterium that characteristically
produces a mycelium that often fragments into bacillary and coccoid
elements.(1,2) Nocardiosis is an acute, subacute or chronic infectious
disease that occurs as cutaneous, pulmonary and disseminated forms that
may involve any organ (mainly brain and meninges).(1,2) Nocardia is found
worldwide as an ubiquitous saprophyte in soil ,decaying organic matter and
water.(1,2)
The main risk
factors for nocardiosis are a weakened immune system, chronic lung disease,
chronic steroid therapy, peritoneal dialysis, cancer, AIDS and bone marrow
transplantation.(1-3)
Primary abdominal
nocardiosis is a very rare infection usually seen in CAPD patients or
in immunocompromised patients. To the best of our knowledge 11 such
cases have been reported so far in the literature (eight in CAPD, three
in AIDS patients). (4,5).
In immunocompetent
persons, only two cases have been reported in the literature(6,7) to
the best of our knowledge and this probably represents the third
case in world and the first in India.
A 32 years old
young parous female presented with the complaints of mass per abdomen,
pain abdomen and dyspeptic symptoms of one month’s duration.
On examination
there was a vague abdominal mass in the umbilical and the epigastric
region and bilateral adnexal masses (6×5×5 cms) with restricted mobility.
Ultrasound
Colour Doppler scan showed bilateral adnexal masses with increased vascularity
and low Pulsatality Index and Resistance Index, omental thickening with
increased vascularity and pelvic and para-aortic lymph node enlargement
with minimal ascites. The CA-125 was 141 u\ml. The chest x-ray was normal.
A clinical
diagnosis of carcinoma ovary was made and she was taken up for exploratory
laparotomy. Intraoperatively, the omentum appeared ‘caked
up’ and was apparently infiltrating the anterior abdominal wall. There
were bilateral ovarian tumors with hydrosalpinx, tumor deposits over
the intestines and peritoneum and enlarged pelvic and para-aortic lymph
nodes with minimal ascites.
Total abdominal
hysterectomy, bilateral salpingo-oophorectomy, total omentectomy, tumor
debulking with partial excision of anterior and posterior rectus sheath
and pelvic and para-aortic lymph node dissection was carried out. The
abdomen was closed with a prolene mesh.
The histopathology
of the surgical specimens revealed nocardiosis (acid fast) involving
the ovaries, tubes and omentum. (Figure 1, Figure 2).
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Figure 1: Colonies of Nocardia in omentum |
Figure 2: High power view of a
Nocardia
colony |
She started developing ascites on the fifteenth postoperative day which
gradually became massive. She was initially started on oral minocycline
200mg BID which was continued for three weeks as there was no
response she was then started on oral trimethoprim-sulfamethoxazole
(TMP-SMX) BID, and Inj. Amikacin 750 mg OD intravenously. This treatment
was continued for three months with regular ascitic tapping. However,
there was no improvement with increasing ascites and associated
weight loss. Computed tomography scan at this time revealed only loculated
ascites in the abdomen and pelvis.
Ascitic fluid
culture and sensitivity was done at this juncture, which grew nocardia
that was sensitive to linezolid and ciprofloxacin. Direct intraperitoneal
Linezolid injection 600mg (direct prick with 18 G needle under local
anaesthesia) into the ascitic fluid twice a week with oral linezolid
600mg BID, and oral ciprofloxacin 500 mg BID, was started.
The intraperitoneal route was decided as she didn’t have response
to intravenous amikacin even though sensitive.
After about
three weeks of such treatment her ascites started reducing and by 7-8
weeks, it had completely disappeared. She was continued on oral linezolid
and ciprofloxacin for a total of six months. At six month’s
follow up, she is free of disease and well.
In the general
population nocardiosis is a rare infection but is a common opportunistic
infection in immunocompromised hosts. Primary abdominal nocardiosis
is a rare infection. The review of literature shows eight cases in CAPD patients
and three cases in AIDS patients.(4,5)
In immunocompetent persons only two cases have been reported. The first was a 11-year-old Sudanese girl who presented with
liver and renal abscesses that were treated successfully with
oral trimethoprim-sulfamethoxazole and parenteral amikacin.(6)
The second case presented as a pancreatic abscess in a 76 year old male
and was cured with intravenous amikacin when treatment with trimethoprim-sulfamethoxazole
failed.(7)
Peritonitis
caused by nocardiosis in CAPD patients has been reported and treated
successfully with intraperitoneal trimethoprim-sulfamethoxazole and
/or amikacin.(4,8,9) Our case presented as an abdomino-pelvic mass. The probable source
of infection could be the intra uterine Copper T device which she had
3-4 years back. The most commonly recommended therapy for nocardiosis
is TMP-SMX and amikacin.(1,2) The present case did not respond to
these antibiotics but responded well to linezolid therapy which had
been tried successfully in one case previously.(1) We wish to highlight
that abdomino-pelvic nocardiosis can simulate malignancy very closely
at presentation and preoperatively, and is an eminently treatable condition.
-
Greenfield
AR Nocardiosis. (eMedicine Infectious Diseases Website). Oct-14, 2008. Available at
http://www.emedicine.medscape.com/article/224123-overview. Accessed Feb 11, 2010.
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Filice AG. Nocardiosis. In:
Braunwald E et al. (eds) Harrison’s-Principles
of Internal Medicine, 15th edition. McGraw Hill Companies. pp. 1006-1008.
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Ortiz MA, Rabagliati R, Machuca E. Successful Treatment of Nocardia asteroids
Peritonitis in a Patient Undergoing Automated Peritoneal Dialysis and
Receiving Immuno-suppressive Therapy.
Adv Perit Dial. 2005;21:66-68.
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Li SY, Yu
KW, Yang WC et al. Nocardia Peritonitis — a Case Report and Literature
Review. Peritl Dial Int. 2008;28(5):544-547.
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John MA, Madiba TE, Mahabeer P et al. Disseminated nocardiosis masquerading as abdominal tuberculosis.
S Afr J Surg. 2004;42(1):17-19.
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Salfield
SAW, Duerden BI, Dickson JA et al. Abdominal nocardiosis in a Sudanese
girl. Eur J Pediatr.1983;140(2):135-137.
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Meiers
B, Metzger U, Maller
F et al. Successful
Treatment of a Pancreatic Nocardia asteroids Abscess with Amikacin and
Surgical Drainage. Antimicrob
Agents Chemother.
1986;29(1):150-151.
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Lopes JO, Alves SH, Benevenga JP
et al. Nocardia asteroides peritonitis during continuous ambulatory peritoneal
dialysis. Rev
Inst Med Trop Sao Paulo.
1993;35(4):377-9.
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Chu KH,
Fung KS, Tsang WK et al. Nocardia Peritonitis: Satisfactory Response
to Intraperitoneal Trimethoprim-Sulfamethoxazole. Perit Dial Int. 2003;23(2):197–199.
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