A 30-year-old man.

A 30-year-old man, in extremely good previous health, was admitted to the hospital after falling against a scaffolding of 6 m height. He blood-thirsty into grit and aspirated more [i]or[/i] less of it. At presentation, physical examination revealed a man in acute distress. kin pressure was 130/80 mm Hg heart rate was 130/min, respiratory rate was 38/min, and rectal temperature was 366[degrees] C Diminished breath hales were heard over the right lung percussion was normal. Findings from further examination were unremarkable.

Laboratory studies showed the following: ESR 2 mm/h; hemoglobin, 81 mmol/L; hematocrit, 041; thrombocyte 274x[10sup9]/L; leukocyte 20x[10sup9]/L; creatinine, 128 [micro]mol/L; and alkaline phosphatase, 41 U/L A chest radiograph showed foreign bodies in the right lower lobe (Fig 1 and 2) Because of the appearance of foreign bodies, bronchoscopy was performed. Grit was observ in the upper and lower lobe bronchus of the right lung pair stones were removed followed on irrigation of the two lobes.

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Prophylactic administration of penicillin was started; however, 4 days after hospital admission, the patient unfolded a fever. A chest radiograph showed an infiltrate in the left lower lobe (Fig 3) subject to suspicion of a bacterial superinfection, penicillin therapy was stopped; instead, broad-spectrum antibiotics were administered (erythromycin and cefotaxime). However, the temperature did not decline neither and the radiographic abnormalities did not disappear. Microscopic investigation of sputum later confirmed by dint of culture, revealed the diagnosis.

Gram stain showed Gram-positive, acid-fast, branching slender stems Culture revealed Nocardia otitidis-caviarum. Susceptibility exhibitions showed good activity against sulfamethoxazole, trimethoprim, doxycycline, gentamicin, imipenem, and ciprofloxacin. Therefore, the therapeutic regimen was changed to trimethoprim-sulfamethoxazole in a dosage of 480/2400 four times daily. Because of progressive liver enzyme disturbances, persisting despite reducing the dose, this had to be discontinued. The patient was treated with imipenem and gentamicin. During this period initially progression of the infiltrate was observ The patient remained febrile. A comput tomographic (CT) scan of the thorax was made to preclude pulmonary abcesses. The left lung appeared to be completely consolidated. No fluid-air flushs were observed (Fig 4). Also, a CT scan of the brain and an isotope bone scintigraphy were performed to withhold dissemination. Neither abscesses nor irascible spots were seen. Repeated life-current cultures were negative.

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Finally, after 22 days of treatment (10 days of trimethoprim-sulfamethoxazole and 12 days of imipenem-gentamicin), temperature declined. A slight regression of the pulmonary infiltrates was observ after almost 6 weeks. It was decided then to replace intravenous antibiotic therapy at oral administration of ciprofloxacin (750 mg three times a day). The patient was discharged from the hospital and followed in the outpatient clinic. Five month after hospital admission, he is well and independent of fever. The radiographic abnormalities improved.

DISCUSSION

Nocardia, the organism reported in 1888 from Nocard(1) as the cause of bovine farcy, was subsequently described as a human pathogen in 1890(2) The genus Nocardia is compos of aerobic, Gram-positive, filamentous bacteria that fragment into bacillary forms and not seldom are acid fast. They are ubiquitous in soil on the other hand not normally found as animal or human commensals.(3) greatest in number infections in humans are caused by the agency of N asteroides; however, other Nocardia species, particularly N brasiliensis and N otitidis-caviarum are also associated with infections in humans. Primary infection usually begins in the respiratory tract. Dissemination predominantly fall outs to the central nervous rule Other sites less commonly involved are skin, plastic tissue, bone, and the eye(4)(5) In our patient, traumatic introduction of Nocardia in the respiratory tract was probably as a conclusion of aspiration of grit. We could not demonstrate secondary dissemination through CT scan of the brain and an isotope bone scintigraphy.

The clinical manifestations and the chest radiographic abnormalities vary widely. Consolidations and large irregular nodules, frequently cavitary, are most common as are pleural lesions. Solitary masses, fine widely scattered nodules, and interstitial patterns may also occur(6)(7) Sulfonamides, either alone or in combination with another antibiotic to which the organism has been shown to be sensitive, are considered the antimicrobial agents of choice in the treatment of Nocardia infections. Other remedys reported to be successful are minocycline, cephalosporins, erythromycin, trimethoprim-sulfamethoxazole, imipenem, and ciprofloxacin.(8) The poor reaction with initial antimicrobial therapy in our patient could be explained by means of the in vitro resistance to erythromycin and the [beta]-lactam antibiotics.

Many aspects of the innkeeper defence against Nocardia infection remain poorly understood. An acute inflammatory reaction with neutrophilic predominance is consideration to be the initial answer to tissue invasion.(9) Cellular immunity, like activation of macrophages, is also involved.(10) That is probably the reason wherefore a strong association of Nocardia infection with disorders of the immune regularity and long-term corticosteroid and immunosuppressive therapy has been noted. onward the other hand, a review of the literature from 1966 to 1973 through Palmer et al,(4) demonstrated that in 49 percent of patients with Nocardia infection, no predisposing condition was current To our knowledge, a patient with prov Nocardia infection after aspiration has not been described.

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