Shannon K, Pasikhova Y, Ibekweh Q, Ludlow S, Baluch A
Department of Pharmacy, Morton Plant Hospital, BayCare Health System, Clearwater, Florida, USA.
Department of Pharmacy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA.
Transpl Infect Dis. 2016 Apr;18(2):169-75. doi: 10.1111/tid.12499. Epub 2016 Mar 29.
Nocardia species are ubiquitous environmental organisms that can cause a diverse spectrum of disease. Clinical manifestations range from localized skin and soft tissue infections to life-threatening pulmonary, central nervous system, and/or disseminated infections. Patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT) are at risk for nocardiosis, and further data in regard to characteristics of disease in this population are warranted.
We performed retrospective chart review of patients post allogeneic HSCT at Moffitt Cancer Center in Florida diagnosed with nocardiosis from 2003 to 2013.
In a decade, 15 cases of nocardiosis were identified. The majority of patients were men (11/15). The median age was 55 years (range 25-65). The most common type of transplant was matched-related donor (n = 8), followed by matched-unrelated donor (n = 3), mismatched-unrelated donor (n = 3), and double umbilical cord (n = 1). Ten received myeloablative conditioning (MAC) regimens. Twelve of 15 patients were on prednisone, 10 of which were on a total daily dose ≥20 mg. The median time from transplant to first positive culture was 10 months (range 1.5-93). Pulmonary nocardiosis was the most prevalent manifestation at 87%. Disseminated disease (2 or more sites of infection) was seen in 47%, whereas blood cultures were positive in 27% of the total cohort. The most common species was Nocardia nova (n = 4). At the time of diagnosis, 20% of the patients were receiving prophylaxis for Pneumocystis jirovecii pneumonia (PJP) with trimethoprim-sulfamethoxazole (TMP-SMX). Susceptibility data were available for 8 patients: all 8 samples were susceptible to TMP-SMX. Nocardiosis was treated with 2 or more active drugs in 93% of the patients. Overall mortality was 53%, with nocardiosis attributed as the cause in 62.5% (5/8). The absolute lymphocyte count at time of diagnoses was significantly lower in patients who ultimately experienced treatment failure.
Infection with Nocardia species in allogeneic HSCT recipients appears to be a late complication of transplantation and most commonly involves the lung. Two-thirds of the cohort received a MAC regimen and the majority of the patients were receiving steroids at the time of diagnosis. Most patients were not receiving TMP-SMX for PJP prophylaxis at the time of nocardiosis diagnosis, and TMP-SMX may therefore have a protective effect.
诺卡菌属是普遍存在的环境微生物，可引起多种疾病。临床表现从局部皮肤和软组织感染到危及生命的肺部、中枢神经系统和/或播散性感染。接受造血干细胞移植（HSCT）的血液系统恶性肿瘤患者有患诺卡菌病的风险，因此有必要进一步了解该人群疾病特征的数据。
我们对2003年至2013年在佛罗里达州莫菲特癌症中心诊断为诺卡菌病的异基因HSCT患者进行了回顾性病历审查。
在十年间，共确诊15例诺卡菌病。大多数患者为男性（11/15）。中位年龄为55岁（范围25 - 65岁）。最常见的移植类型是匹配相关供体（n = 8），其次是匹配无关供体（n = 3）、不匹配无关供体（n = 3）和双脐带血供体（n = 1）。10例患者接受了清髓性预处理（MAC）方案。15例患者中有12例服用泼尼松，其中10例每日总剂量≥20mg。从移植到首次培养阳性的中位时间为10个月（范围为$1.5 - 93$个月）。肺部诺卡菌病最为常见，占87%。47%的患者出现播散性疾病（2个或更多感染部位），而27%的患者血培养呈阳性。最常见的菌种是新星诺卡菌（n = 4）。在诊断时，20%的患者正在接受甲氧苄啶 - 磺胺甲恶唑（TMP - SMX）预防耶氏肺孢子菌肺炎（PJP）。有8例患者可获得药敏数据：所有8份样本对TMP - SMX敏感。93%的患者使用2种或更多种有效药物治疗诺卡菌病。总体死亡率为$53%$，其中62.5%（5/8）的死亡归因于诺卡菌病。最终治疗失败的患者在诊断时的绝对淋巴细胞计数显著更低。
异基因HSCT受者感染诺卡菌属似乎是移植后的晚期并发症，最常累及肺部。三分之二的队列接受了MAC方案，大多数患者在诊断时正在接受类固醇治疗。在诺卡菌病诊断时，大多数患者未接受TMP - SMX预防PJP，因此TMP - SMX可能具有保护作用。
