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High-resolution Computed Tomography Findings in Patients with Pulmonary Nocardiosis

Posted Feb 29, 2016 Updated Apr 10, 2023
By Haruka Sato MD , Fumito Okada MD , Takaaki Mori MD , Asami Ono MD , Tomoko Nakayama MD , Yumiko Ando MD , Akira Matsumoto MD , Shuichi Tanoue MD , Kazufumi Hiramatsu MD , Takehiko Shigenaga MD , Masahiro Hata MD , Kenji Kishi MD , Hiromu Mori MD
10 min read

Rationale and Objectives

Nocardiosis is difficult to diagnose, and the diagnosis is thus frequently delayed. High-resolution computed tomography (HRCT) findings of patients with pulmonary nocardiosis have been documented in few reports. Our study objective was to assess HRCT findings of patients with pulmonary nocardiosis.

Materials and Methods

This was a retrospective study of 20 consecutive patients with pulmonary Nocardia infections who underwent HRCT of the chest at our institutions from January 2011 to August 2014. After the exclusion of two patients with concurrent infections, the study group comprised 18 patients (11 men, 7 women; age range, 39–83 years; mean, 67.9 years) with pulmonary Nocardia infections. Parenchymal abnormalities, enlarged lymph nodes, and pleural effusion were evaluated on HRCT.

Results

Underlying conditions included respiratory disease ( n = 6, 33.3%), collagen diseases ( n = 5, 27.8%), and diabetes mellitus ( n = 4, 22.2%). All patients showed abnormal HRCT findings, including the presence of a nodule/mass ( n = 17, 94.4%), ground-glass opacity ( n = 14, 77.8%), interlobular septal thickening ( n = 14, 77.8%), and cavitation ( n = 12, 66.7%). Pleural effusion was seen in two patients. There were no cases of lymph node enlargement.

Conclusions

Among the HRCT findings in patients with pneumonia, a nodule/mass with interlobular septal thickening and/or cavitation are suggestive of pulmonary nocardiosis.

Introduction

Nocardia are a group of aerobic, Gram-positive, partially acid-fast species that are ubiquitous in the environment as saprophytic components in dust, soil, water, decaying vegetation, and stagnant matter. They are not part of the normal human flora nor are they a common laboratory contaminant . Human infection mainly occurs through direct inoculation of the skin or by inhalation.

People susceptible to Nocardia infections include recipients of lung, heart, bone marrow, and kidney transplants; human immunodeficiency virus (HIV)-infected individuals; chronic steroid users; and patients with malignancies . However, as many as one-third of patients with nocardiosis have normal immunity . Clinically, pulmonary nocardiosis presents as pneumonia with nonspecific symptoms such as productive cough, fever, dyspnea, chills, weight loss, fatigue, and hemoptysis, with symptoms developing over a period of weeks to months . There are no suggestive clinical manifestations, and nocardiosis is difficult to diagnose .

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Materials and Methods

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Table 1

Patient Characteristics and Underlying Conditions

M, F 11, 7 Age (year) Range 39–83 Mean 67.9 Community acquired 15 (83.3) Nosocomial 3 (16.7) Underlying conditions Respiratory disease 6 (33.3) Collagen disease 5 (27.8) Diabetes mellitus 4 (22.2) Smoking habit 4 (22.2) Hypertension 3 (16.7) Alcoholic 2 (11.1) Nephrotic syndrome 1 (5.6) Malignancy 1 (5.6) Presenting symptoms Fever 7 (38.9) Cough 7 (38.9) Sputum 4 (22.2) Dyspnea 4 (22.2) Chest pain 1 (5.6)

Note: Data in parentheses are percentages.

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CT Examination

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CT Image Interpretation

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Results

Clinical Features

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CT Patterns

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Table 2

Thoracic CT Findings in 18 Patients

Findings No. of Patients Nodule/Mass 17 (94.4) Ground-glass opacity 14 (77.8) Interlobular septal thickening 14 (77.8) Cavitation 12 (66.7) Consolidation 6 (33.3) Bronchial wall thickening 1 (5.6) Intralobular reticular opacity 0 (0) Mucoid impaction 0 (0) Centrilobular nodules 0 (0) Pleural effusion 2 (11.1) Lymph node enlargement 0 (0)

CT, computed tomography.

Note: Data in parentheses are percentages.

Figure 1, Pulmonary nocardiosis in a 67-year-old male patient with adult-onset Still's disease, 50 days after the onset of fever. (a) Transverse computed tomography (CT) image (1-mm thickness) at the level of the aortic arch shows multiple nodules with ( arrows ) or without cavitation in both lungs. Bilateral pleural effusions are present. (b) Transverse CT image (1-mm thickness) at the level of the tracheal carina shows multiple nodules with ground-glass opacities (GGO) and interlobular septal thickening ( arrows ).

Figure 2, Pulmonary nocardiosis in a 40-year-old female patient with mixed connective tissue disease, 7 days after the onset of fever, cough, and sputum. Transverse computed tomography (CT) image (1-mm thickness) at the level of the top of the right diaphragm shows a round mass surrounded by ground-glass opacities (GGO) and exhibiting interlobular septal thickening ( arrows ) in the middle lobe. Centrilobular nodules and bronchial wall thickening cannot be seen.

Figure 3, Pulmonary nocardiosis in a 60-year-old male patient with nephrotic syndrome and rheumatoid arthritis, 5 days after the onset of fever. (a) Transverse computed tomography (CT) image (1-mm thickness) at the level of the left upper lobe shows consolidation, ground-glass opacities (GGO), and interlobular septal thickening ( arrow ). (b) Transverse CT image (1-mm thickness) at the level of the aortic arch (15 mm below the level in a ) shows a mass lesion with cavitation ( arrowhead ) in the left upper lobe. Interlobular septal thickening ( arrow ) and GGO are present.

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Disease Distribution

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Pleural Effusion and Lymph Nodes

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Follow-up

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Discussion

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Academic Radiology, Volume 23, Issue 3
Journals General Radiology
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