r 2011 John Wiley & Sons A/S

Transplant Infectious Disease . ISSN 1398 -2273

Case report

Nocardia infection in kidney transplant recipients:

case report and analysis of 66 published cases




















































Abstract: Nocardiosis is a rare but life-threatening opportunistic


infection, especially in immune compromised patients, including

kidney transplant recipients. Primary pulmonary infection is the most 

common clinical pattern, and can easily result in disseminated


Nocardia infection if treatment therapy is not adequate at the


beginning. In this article, we report a new case of disseminated


nocardiosis (lungs, skin, and pericardium) after renal allograft

transplantation.We also review the English literature published from 
1980 to 2010 and analyze the clinical characteristics of nocardiosis in 

kidney transplant recipients.












X. Yu, F. Han, J.Wu, Q. He,W. Peng,Y.Wang, H. Huang, H. Li, R.Wang,
J. Chen. Nocardia infection in kidney transplant recipients: case report
and analysis of 66 published cases.
Transpl Infect Dis 2011: 13: 385^391. All rights reserved

Nocardiosis is a rare opportunistic infection caused by

aerobic Actinomycetes Nocardia and can be associated with
severe complications in kidney transplant recipients
receiving immunosuppressive therapy. Direct inhalation
of contaminated particles from soil containing this bacterium is considered the main route of infection (1), while
direct inoculation through the skin and soft tissues may
also occur. Nocardiosis may present as localized disease
(in 2/3 of cases) or disseminated suppurative disease (in
1/3 of cases) (2). Systemic infection, usually starting in the
lungs, has a particular predilection for the brain, skin, and
subcutaneous tissues, and rarely spreads to the thyroid
gland, transplant kidney, knee joint, or eyes (3^6).
Sulfonamides are the rst-line choice for treatment, and
trimethoprim-sulfamethoxazole (cotrimoxazole) is usually
selected as a component of combined therapy and used as a
prophylaxis drug.
We report a case of disseminated Nocardia infection in
lungs, skin, and pericardium after discontinuation of
cotrimoxazole prophylaxis, and then review the English
literature for renal nocardiosis.

X. Yu1,2, F. Han1,2, J. Wu1,2, Q. He1, W. Peng1,

Y. Wang1, H. Huang1, H. Li1, R. Wang1,
J. Chen1,2
1

Kidney Disease Center, The First Affiliated Hospital, College

of Medicine, Zhejiang University, China, 2Key Laboratory of
Multiple Organ Transplantation, Ministry of Health,
Hangzhou, Zhejiang, China
Key words: aerobic Actinomycetes; Nocardia; kidney
transplantation; clinical characteristics; cotrimoxazole
Correspondence to:
Jianghua Chen, The Kidney Disease Center, The First Aliated
Hospital, College of Medicine, Zhejiang University, 79
Qingchun Road, Hangzhou 310003 Zhejiang, China
Tel: 1 86 0571 8723 6992
Fax: 1 86 0571 8723 6189
Email: chenjianghua@zju.edu.cn
Received 1 September 2010, revised 22 November 2010,
accepted for publication 8 December 2010
DOI: 10.1111/j.1399-3062.2011.00607.x
Transpl Infect Dis 2011: 13: 385391

Case report
A 45 -year-old male with a 5 -month history of kidney transplantation was admitted to the hospital because of fever
and pain in the left scapular region for 12 days. The clinical
course is summarized in F|gure 1.
The patient had end-stage renal disease due to mesangial
proliferative glomerulonephritis. He received peritoneal
dialysis for about 10 months, and then he received a cadaveric renal transplant 5 months before admission. He had a
history of allograft rejection after operation, recovered
after intensive immune suppressive therapy including
plasmapheresis and anti-human T-lymphocyte immunoglobulin, and developed pneumonia with an unknown
pathogen.
After discharge, his medications consisted of mycophenolate mofetil (750 mg twice daily), tacrolimus (1.5 mg
twice daily), prednisone (20 mg daily), diltiazem, amlodipine, metoprolol, and cotrimoxazole. Two months before
admission, his oral cotrimoxzaole was discontinued.

385

Yu et al: Nocardiosis in renal transplant

Fig. 1. Timeline of events after transplantation. FK-506, tacrolimus; MMF, mycophenolate mofetil; MP, methylprednisolone; CT, computed tomography;
%, Diagnosis of Nocardia infection; Cotrimoxazole 1, 2 pills 3  a day; Cotrimoxazole 2, 1 pill 3  a day.

Twelve days before admission, he began to have recurrent fever (maximum 38.51C), and pain in the left scapular
region, so he was admitted to our hospital. A computed
tomographic (CT) scan of the thorax demonstrated diuse
infection of both lungs, small bilateral pleural eusion, and
moderate-sized pericardial eusion. He was started empirically on voriconazole, levooxacin, and cefuroxime
sodium, but his body temperature uctuated, and he
gradually developed an unproductive cough; moreover,
several subcutaneous hard nodules and small cutaneous
abscesses were present on his legs and scalp. Rapid smear
of the pus aspirated from the abscesses indicated
Actinomycetes. Culture of pus demonstrated Nocardia
infection.
The antimicrobial regimen was then changed to intravenous injection of imipenem (500 mg/6 h) together with oral
cotrimoxazole (2 pills 3 times daily) and voriconazole
(200 mg daily). All the immune suppressive drugs were
temporarily discontinued. However, the patients condition
worsened, sudden dyspnea and shortness of breath
occurred, and he developed orthopnea. An emergency
echocardiogram showed the pericardial space was lled
by occulant uid.
The patient underwent pericardial puncture and drainage, draining a total of about 300 mL purulent uid, and
the culture yielded Nocardia. Twelve days later, a new chest
CT scan still indicated development of infection in the

386

Transplant Infectious Disease 2011: 13: 385^391

lungs, with cavity formation in some lesions in the right

lung (Fig. 2). Blood culture was still positive for Nocardia.
Therefore, we commenced using intravenous injection of
ceftriaxone (2 g daily), uconazole (200 mg daily), linezolid
(600 mg twice daily), and oral cotrimoxazole (2 pills 3 times
a day) in place of the former antibiotic regimen.
Twenty days after starting the new regimen, the
patients condition had improved signicantly; he had no
obvious discomfort, and the subcutaneous abscesses on
the legs and scalp had disappeared. However, the blood
platelet count gradually deceased to 19  10 9/L and severe
anemia occurred (hemoglobin 55 g/L). Linezolid was discontinued because of its possible myelosuppressive eect.
The other 3 drugs were continued at decreasing dosages
until his discharge from the hospital. His immunosuppressive regimen was again mycophenolate mofetil (250 mg
twice daily), tacrolimus (0.25 mg twice daily), and methylprednisolone (8 mg daily).
The CT scan of the thorax taken 1 day before his discharge showed satisfactory resolution of the pulmonary
infection. After hospitalization for nearly 3 months, the
patient was discharged, maintained on low-dose cotrimoxazole (1 pill twice daily) for prevention of relapse.
Seven months after his discharge, CT scan of the thorax
showed excellent resolution of lesions in both lungs, with
only a bit of exudate remaining in his upper left lung
(Fig. 3).

Yu et al: Nocardiosis in renal transplant

66 cases were available. We reviewed the 66 cases and

analyzed the clinical characteristics of nocardiosis after
kidney transplantation.
The clinical characteristics of the selected cases are summarized inTables 1^3.The mean age was 48.2  11.29 years
(12.7^69 years). Thirty-nine patients (59.09%) received a
transplant from cadaver donors, and 15 from living donors
(7 from living-related and 8 from living-unrelated donors).
The onset of Nocardia infection occurred from 26 days to
22 years after kidney transplantation, with a mean interval

Summary of general demographics and medical history of renal transplant

cases with nocardiosis

Fig. 2. Computed tomography (CT) scan of the thorax taken 34 days

after admission showed multiple high-dense lesions throughout the
lungs. Some of the lesions are consolidated with air bronchogram. Small
cavity was formed in the lesion localized in upper right lung, liquefaction
was detected (CTvalue 9^17 HU) in the mass in front of the thoracic aorta,
and bilateral pleural eusions and pericardial eusion were greater than
before.

Variable

Category

Sex

Male
Female

Mean age, years

(range)
Sources of donor

We searched the English-language literature published

from January 1, 1980 to January 1, 2010 (30 years) in the
PubMed database using the terms Nocardia infection and
kidney transplantation. A total of 49 articles containing

Fig. 3. Computed tomography scan of the thorax taken 7 months after

his discharge showed excellent resolution of lesions in both his lungs,
with only a bit of exudate remaining in his upper left lung.

44 (66.67%)
22 (33.33 )
48.2 (12.7^69)

Cadaver
Live related
Live unrelated
Not reported

Duration between Tx and onset of

infection, months (range)

Analysis of reported cases

Cases, n (%)

39 (59.09)
7 (10.61%)
8 (12.12% )
12 (18.18%)
34.41 (26 days^22 years)

History of rejection

Yes
No
Not reported

19 (33.33%)
22 (28.79%)
25 (37.88%)

Immunosuppression
therapy at the time of
infection; cases of
disseminated
infection

CsA 1 AZA 1 pred

CsA 1 MMF 1 pred
CsA 1 pred
FK 1 AZA 1 pred
FK 1 MMF 1 pred
FK 1 pred
Others
Not reported

17 (25.76%); 12 (70.59%)
4 (6.06%); 4 (100%)
14 (21.21%); 1 (7.14%)
5 (7.58%); 3 (60%)
9 (13.64); 2 (22.22%)
3 (4.55%); 2 (66.67%)
7 (12.12% ); 2 (25.0%)
5 (7.58%); 2 (40%)

Medical history

Cotrimoxazole
prophylaxis
CMV infection
Diabetes mellitus
Previous
pneumonia
Hypertension
Urinary infection
Hepatitis C
infection and nonviral hepatopathy
Surgery history
History of
tuberculosis
Others

11 (16.67%)
8 (12.12% )
7 (10.61)
7 (10.61)
6 (9.09%)
3 (4.55%)
2 1 3 (7.58%)

4 (6.06%)
2 (3.03%)
39 (59.09%)

Tx, transplantation; CsA, cyclosporin A; AZA, azathioprine; FK,

tacrolimus; MMF, mycophenolate mofetil; pred, prednisone or
methylprednisone; CMV, cytomegalovirus.

Table1

Transplant Infectious Disease 2011: 13: 385^391

387

Yu et al: Nocardiosis in renal transplant

Summary of clinical manifestations and Nocardia species

Summary of eective nocardiosis therapies and outcomes

Variable

Category

Cases, n (%)

Variable

Category

Cases, n (%)

Involved organs

Disseminated infection
With lung involvement
With brain involvement
Lung
With lung involvement
alone
Brain
With brain involvement
alone
With lung involvement
With skin or
subcutaneous tissue
involvement
Skin or subcutaneous
tissue
Other organs

29 (43.94%)
27 (93.10%)
22 (75.86%)
43 (65.15%)
16 (37.21%)

Eective antibiotic
agents

40 1 3 (87.76%)

N. asteroides
N. farcinica
Other Nocardia species
Not classied
Concomitant infection
of N. asteroides and
N. brasiliensis
Concomitant infection
of Nocardia and other
pathogen

37 (56.06%)
12 (18.18%)
13 (19.07%)
6 (9.09%)
1 case

Cotrimoxazole and
sulfadiazine
Cephalosporins
Ceftriaxone
Cefotaxime
Cefuroxime
Cefepime
Carbapenems
Imipenem
Meropenem
Penicillin
Amoxicillin and
clavulanate
Ampicillin-sulbactam
Gentamicins
Amikacin
Genticin
Other antibiotics
Linezolid
Ciprooxacin
Roxithromycin
Vancomycin
Minocycline

Fever
Headache
Confusion
Convulsion
Vision damage
Lethargy
Limb weakness
Dysphasia
Hemiparesis
Nausea and vomiting
Generalized weakness
Aggression, dizziness,
ataxia, fainting,
forgetfulness, gait

14 (51.85%)
9 (33.33%)
8 (29.63%)
6 (22.22%)
5 (18.52% )
5 (18.52% )
4 (14.81%)
4 (14.81%)
4 (14.81%)
3 (11.11%)
2 (7.41%)
1 case for
each
(3.70%)

Clinical manifestations in
patients with pulmonary
involvement

Fever
Cough
Productive cough
Chills
Dyspnea
Chest pain
Generalized weakness
Acute respiratory failure
and ARDS

28 (65.21%)
9 (20.93%)
6 (13.95%)
5 (11.63%)
5 (11.63%)
5 (11.63%)
2 (4.65%)
1 case each
(2.33%)

Clinical manifestations in
patients with cutaneous or
subcutaneous involvement

Nodule or nodules
Abscess
Fever
Swelling
Mass or cellulitis

Nocardia species

Clinical manifestations
in patients with cerebral
involvement

27 (40.91%)
5 (18.52% )
20 (74.07%)
5 (18.52% )

21 (31.82%)
21 (31.82%)

7 cases

7 (33.33%)
4 (19.05%)
4 (19.05%)
4 (19.05%)
4 (19.05%)

ARDS, acute respiratory distress syndrome.

Table 2

388

Transplant Infectious Disease 2011: 13: 385^391

Adverse eect of
sulfonamides

Outcome

Acute renal failure and

tubular damage
Elevation of liver enzyme
Leukopenia
Cured
Died
Relapsed

14 (28.57%)
7 (14.29%)
4 (8.16%)
2 (4.08%)
1 (2.04%)
16 (32.65%)
12 (24.49%)
4 (8.16%)
7 (14.28%)
6 (12.24%)
1 (2.04%)
9 (18.37%)
8 (16.33%)
1 (2.04%)
3 (6.12% )
2 (4.08%)
1 (2.04%)
1 (2.04%)
1 (2.04%)
1
1
1
49 (74.24%)
11 (16.67%)
6 (9.09%)

Table 3

of 34.41 months. About 1/3 of patients (19 cases) had prior

therapy for an episode of graft rejection. Nocardiosis developed in the patients with rejection between 32 days and 70
months after transplantation. Regarding the immunosuppressive therapy at the time of infection, a cyclosporinebased regimen was the agent most frequently associated
with Nocardia infection (37 cases).
Lung, brain, skin, and subcutaneous tissue were the
most frequently involved organs. The presence of lesions
in 2 or more organs of the body denes systemic or disseminated disease. Twenty-nine patients developed disseminated nocardiosis (43.94%), with 27 cases of pulmonary
involvement and 22 cases of cerebral involvement. Fortythree cases (65.15%) had pulmonary Nocardia infection
and 16 of them had lung involvement alone. Cerebral
nocardiosis occurred in 27 cases (40.91%), and only 5 of
these cases had brain involvement alone. Other less commonly involved organs included kidney graft (6 cases), eye
(5 cases), pleura (5 cases), pericardium (3 cases), and joints
(2 cases). The clinical manifestations of nocardiosis in
kidney transplant recipients were nonspecic. Localized

Yu et al: Nocardiosis in renal transplant

neurologic manifestations and psychological abnormality

were found in patients with cerebral nocardiosis, such as
limb weakness, hemiparesis, ataxia, confusion, lethargy,
aggression, or forgetfulness. Generally, typical symptoms
or signs of bacterial pneumonia could not be seen in
patients with pulmonary Nocardia involvement. The chest
x-ray or CTscan usually showed lobe inltrates or nodules
in patients with pulmonary nocardiosis.The right lobe was
more likely to be involved (3 cases, 53.49%), about twice as
often as the left lobes (12 cases, 27.91%). On both sides, the
upper lobes were more likely to be involved. Five cases had
disseminated lesions throughout both lungs.
Specimens obtained through puncture and drainage of the
primary lesion were the most valuable for positive culture results (29 cases, 43.94%). Other eective diagnostic methods
included biopsy of the lesion (16 cases, 24.24%), bronchoalveolar lavage (13 cases, 19.70%), and tracheal or bronchial aspiration (9 cases, 13.64%). Blood culture results were negative
in the majority of cases, with only 5 cases giving positive results. A total of 8 Nocardia species were reported, with the
most common species being Nocardia asteroides (37 cases,
56.06%), followed by Nocardia farcinica (12 cases, 18.18%),
and Nocardia brasiliensis (6 cases, 9.09%).
Surgery was chosen as a treatment method in 14 patients
(21.21%), including craniotomy and surgical drainage or excision of the abscess, removal of the transplant graft, sternotomy and pericardiotomy, open laminectomy, enucleation of
the eye, etc. Five patients with cerebral Nocardia infection received craniotomy, and 1 of them died. Twenty patients
(30.30%) had adjustment of their immunosuppressive medication during the treatment course, and 19 of them had satisfactory outcomes. Sulfonamides, especially cotrimoxazole,
were used as a component of combined antimicrobial therapy
in the majority of cases. Other eective agents included imipenem, amikacin, ceftriaxone, amoxicillin, clavulanate, etc.
Combined antimicrobial therapy was used in most patients.
In the 11 patients with cotrimoxazole prophylaxis, the
mean interval between transplantation and infection was
11.44 months, which is much less than the mean level of all
patients (34.41 months). Seven of them were infected by
N. asteroides, 3 by N. farcinica, and 1 by Nocardia
otitidiscaviarum. Their clinical courses were not specic.
Although only 6 of them showed sensitivity to cotrimoxazole in the susceptibility test, cotrimoxazole was used in 8
of the 9 patients who were cured.

Discussion
Studies showed, in the last 2 decades, that the incidence of
Nocardia infection in kidney transplant recipients was
approximately 0.4^1.3%, which indicated a signicant

decrease from 2% to 20% in the 1980s (7^10).The mortality

rate of these 66 patients was 16.67%, which was much lower
than the 25% reported in the study of Kusne and Manez
(11). Many studies suggested that the rst 6 months after
transplantation was the period of greatest risk for Nocardia
infection; we found in our study this duration varied, ranging from 26 days to 22 years, with a mean interval of 34.41
months. Patients with previous graft rejection seemed to
undergo Nocardia infection much earlier, with a mean interval of 15.77 months, less than half the average.
Pulmonary nocardiosis is the most common clinical pattern, occuring in about 88% of kidney transplant recipients (12); these patients appear to be at greater risk of
systemic nocardiosis (12, 13), as in our patient described
here. Studies suggested 28^50% of patients with pulmonary nocardiosis would develop disseminated nocardiosis
(14^16). In our analysis, the majority of patients with disseminated Nocardia infection had pulmonary involvement
(27 of 29 cases), which suggested the possible spread of infection from the lung.
The clinical manifestations of kidney transplant recipients with Nocardia infection were nonspecic. Our review
found that the common radiological presentations of pulmonary nocardiosis were inltrates and abscess. CT scan
usually shows nodules in pulmonary nocardiosis (17 ),
which may present as intraparenchymal, pleural based, or
transpleural extension to the cardiac border or chest wall
(18). Cavitation may occur in up to 1/3 of patients (19) and
a solitary oval or round mass may present in 24^58% of patients (20, 21). Rarely, Nocardia species can invade preexisting lung cavities, producing a fungus ball appearance (1).
In our case, multiple nodules, a mass, and pleural and pericardial eusion were all seen in the CT scan at the beginning, so a fungal infection was highly suspected and we
used voriconazole initially. Purulent pericarditis is considered as a rare complication of disseminated Nocardia infection after renal transplantation. Cardiac tamponade may
occur if the pericardial eusion reaches a certain quantity
without invasive drainage. Sternotomy may be necessary
when intrapericardial abscess is formed (22).
Currently, there is no routine and single serodiagnostic
test to identify patients with nocardial infections (23), and
isolation of Nocardia pure culture remains the gold standard for detection. According to the experience of Lederman and Crum (24), although disseminated nocardiosis
was presumed to occur via hematogenous spread, capture
of the organism in blood cultures was unusual. Several
blood cultures of our patient in the rst few days were all
negative. This might be attributed to the fact that the
Nocardia were dicult to recognize and identify in the diagnostic laboratory, because of the slow growth and variable colony morphology of Nocardia (23). Specimens
obtained by aggressive approaches such as bronchoscopic

Transplant Infectious Disease 2011: 13: 385^391

389

Yu et al: Nocardiosis in renal transplant

lavage, ne-needle aspiration of the abscess, or biopsy of

the aected region, were valuable for diagnosis.
Cotrimoxazole was accepted as the rst-line choice to
treat Nocardia infection (1, 25). A low dose of cotrimoxazole
was usually recommended for prophylaxis of Pneumocystis, Nocardia, or other opportunistic infection in bone marrow transplant patients and renal transplant recipients (12,
26). In our center, cotrimoxazole (1 pill, twice daily) was
routinely recommended in the rst 4 months after operation for prophylaxis of Pneumocystis, and this method successfully reduced the incidence of pulmonary infection
from 10.5% to 2.4% within 6 months after operation. In
renal transplant recipients, alimentary system discomfort
and deterioration in renal function may develop when using
cotrimoxazole (27 ), leading to drug intolerance. In our
patient, discontinuation of oral cotrimoxazole 3 months
after transplantation was caused by elevation of serum
creatinine; however, this discontinuation seemed to be related to the development of Nocardia infection. Carbapenems are another ecacious agent. Synergy may exist
between imipenem and cotrimoxazole, and imipenem and
cefotaxime (28). A recent study that assessed in vitro activity of carbapenems against Nocardia species showed the
anti-Nocardia species activities of the 4 tested carbapenems ranked in the order of meropenem and doripenem,
followed by imipenem and ertapenem (29). However, imipenem had no obvious eect in our patient. This lack of eect
might be caused by resistance of the Nocardia species infecting this patient. Previous studies showed a great deal
of discrepancy existed between in vitro sensitivity testing
and the clinical response (2, 23). Cephalosporins were demonstrated to be eective in clinical experience (30, 31).
Ceftriaxone, cefotaxime, and cefuroxime are useful to treat
nocardiosis, especially in patients with cerebral nocardiosis because of the excellent cerebrospinal uid penetration
and low toxicity (1). The in vitro activities against dierent
Nocardia species are not consistent, according to dierent
authors (29, 32).
New and ecacious agents include nemonoxacin, linezolid, and tigecycline. Nemonoxacin and tigecycline were new
drugs, and both of them showed promising in vitro activity
against Nocardia species, but need further clinical evaluation (29, 33, 34). Linezolid showed excellent in vitro activity
against Nocardia isolates and species, according to dierent studies (29, 33), while it was also used successfully in
the treatment of clinical cases of nocardiosis (35, 36).
Because of less drug interactions with other agents, some
authors considered linezolid as a welcome and useful
choice to treat HIV/AIDS or organ transplant patients
who have already taken complex medical regimens (35).
Despite the encouraging result, adverse reactions are
possible. Linezolid-induced myelosuppression has been
reported (35, 37 ); 45% and 18% of the studied patients

390

Transplant Infectious Disease 2011: 13: 385^391

developed myelosuppression and neuropathy, respectively,

when linezolid was used to treat nocardiosis (38).
For kidney transplant recipients, a duration of antiNocardia therapy of 6 months after clinical improvement
was recommended by dierent studies (8, 10, 24, 39). Longer
duration lasting for 1 year or even life-long maintenance in
combination with reduction of immunosuppression agents
(1, 7, 40) were recommended by others (12, 30, 41, 42). For
patients with central nervous system involvement, the
duration of treatment must be established according to clinical and imaging responses, but therapy usually must be
continued for a year or longer (43). Low-dose cotrimoxazole
was most often the treatment choice for prevention of
relapse. After taking low-dose cotrimoxazole (1 pill twice
daily) for 7 months, our patient had nearly complete resolution of lesions in his lungs, with only a bit of exudate
remaining in his upper left lung.
To conclude, we report a case of disseminated nocardiosis in lungs, skin, and pericardium, and analyze the
English literature associated with Nocardia infection in
kidney transplant recipients published in the last 2 decades. Transplant physicians should be aware of Nocardia
infection in kidney transplant recipients. Cotrimoxazole is
a useful agent for prevention of Nocardia infection.

Acknowledgements:
This study was supported by grants from the National Natural Science Foundation of Peoples Republic of China
(30801148), the Key Projects in the National Science & Technology Pillar Program in the Eleventh Five-year Plan
Period (2008BAI60B04), and the Major projects of Zhejiang
Science and Technology Department (2008C13026 -2).

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