Li Shan, Song Xin Yu, Zhao Yu Yue, Xu Kai, Bi Ya Lan, Huang Hui, Xu Zuo Jun
From the Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #1 Shuaifuyuan Street, Dongcheng District, Beijing, China, 100730 (SL, XYS, YYZ, HH, ZJX); Radiological Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #1 Shuaifuyuan Street, Dongcheng District, Beijing, China, 100730 (KX); and Pathological Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, #1 Shuaifuyuan Street, Dongcheng District, Beijing, China, 100730 (YLB).
Medicine (Baltimore). 2015 Sep;94(39):e1561. doi: 10.1097/MD.0000000000001561.
Nocardiosis is an opportunistic infection that most commonly involves the lung; however, only a few case reports of autoimmune disease complicated by pulmonary nocardiosis exist in the literature. We conducted a retrospective analysis of 24 cases of both autoimmune disease and pulmonary nocardiosis at the Peking Union Medical College Hospital between 1990 and 2012. Fifty-two cases were hospitalized with nocardiosis, 24 of whom had at least 1 autoimmune disease before the diagnosis of pulmonary nocardiosis. The cohort patients consisted of 5 men and 19 women, with a mean age of 44.2 years. All were negative for human immunodeficiency virus. All but 1 patient had received immunosuppressants, including corticosteroids, cyclophosphamide, azathioprine, methotrexate, or hydroxychloroquine. Fever (87.5%), cough (83.3%), and sputum (79.2%) were the most common clinical manifestations. Ten cases were accompanied by subcutaneous nodules and/or cutaneous abscesses, and 4 had brain abscess. Half of them were lymphocytopenic. Thirteen of the 16 cases who underwent lymphocyte subtype analysis had decreased CD4+ T-cell counts. Nineteen cases had decreased serum albumin levels. Nocardia was isolated from sputum (13/24), bronchoalveolar lavage fluid (4/6), lung tissue (5/6), pleural effusions (3/5), skin or cutaneous pus (7/10), and brain tissue (1/1). The most common imaging findings were air-space opacities (83.3%), followed by nodules (62.5%), cavitations (45.8%), and masses (37.5%). Five were administered co-trimoxazole only, and the others were treated with 2 or more antibiotics. All 5 cases with skin abscesses and 2 of the 4 cases with brain abscesses were treated by surgical incision and drainage. None underwent thoracic surgery. Corticosteroid dosages were decreased in all cases, and cytotoxic agents were discontinued in some cases. Twenty-two cases recovered, and 2 died. Pulmonary nocardiosis associated with an underlying autoimmune disease showed a female predominance and presentation at younger age. Immunosuppressant therapy, lymphocytopenia, particularly low CD4+ T-lymphocyte counts, and low serum albumin levels may be disease susceptibility factors. Air-space opacities and nodules were the most common chest imaging features, and disseminated nocardiosis with lung and skin involvement was more common among them. Early diagnosis and anti-nocardial antibiotics with modulation of the basic immunosuppressive therapy were important for them.
诺卡菌病是一种机会性感染，最常累及肺部；然而，文献中仅有少数自身免疫性疾病并发肺部诺卡菌病的病例报告。我们对1990年至2012年期间北京协和医院收治的24例自身免疫性疾病合并肺部诺卡菌病的病例进行了回顾性分析。52例患者因诺卡菌病住院，其中24例在诊断肺部诺卡菌病之前至少患有一种自身免疫性疾病。队列患者包括5名男性和19名女性，平均年龄44.2岁。所有患者人类免疫缺陷病毒检测均为阴性。除1例患者外，所有患者均接受过免疫抑制剂治疗，包括皮质类固醇、环磷酰胺、硫唑嘌呤、甲氨蝶呤或羟氯喹。发热（87.5%）、咳嗽（83.3%）和咳痰（79.2%）是最常见的临床表现。10例伴有皮下结节和/或皮肤脓肿，4例有脑脓肿。其中一半患者淋巴细胞减少。16例进行淋巴细胞亚群分析的患者中有13例CD4+T细胞计数降低。19例患者血清白蛋白水平降低。诺卡菌从痰液（13/24）、支气管肺泡灌洗液（4/6）、肺组织（5/6）、胸腔积液（3/5）、皮肤或皮肤脓液（7/10）和脑组织（1/1）中分离得到。最常见的影像学表现为气腔实变（83.3%），其次为结节（62.5%）、空洞（45.8%）和肿块（37.5%）。5例仅接受复方新诺明治疗，其他患者接受2种或更多种抗生素治疗。所有5例皮肤脓肿患者和4例脑脓肿患者中的2例接受了手术切开引流。均未进行胸外科手术。所有病例均减少了皮质类固醇剂量，部分病例停用了细胞毒性药物。22例康复，2例死亡。与潜在自身免疫性疾病相关的肺部诺卡菌病以女性居多，发病年龄较轻。免疫抑制治疗、淋巴细胞减少，尤其是低CD4+T淋巴细胞计数和低血清白蛋白水平可能是疾病易感性因素。气腔实变和结节是最常见的胸部影像学特征，其中肺部和皮肤受累的播散性诺卡菌病更为常见。早期诊断以及使用抗诺卡菌抗生素并调整基础免疫抑制治疗对其至关重要。
