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Pulmonary Nocardiosis Presenting as Exacerbation of Chronic Pulmonary Disease
Roopa Kancherla1, Ramanathan Palaniappan Ramanathan1, Bobbe Appalaraju2
1Department of Pulmonology, PSG Institute of Medical Sciences and Research, Peelamedu, Coimbatore, Tamil Nadu, India.
Background:
Pulmonary nocardiosis (PN) occurs in chronic pulmonary disease (CPD) in the absence of traditional risk factors. Clinical features that differentiate bacterial exacerbations (AE-CPDb) from PN-related exacerbations (AE-CPDPN) are not well described.
Objectives:
To describe a series of AE-CPDPN without traditional risk factors and compare clinical features, radiology and outcomes with age, gender and CLD-type matched AE-CPDb.
Materials And Methods:
Single-center retrospective review and case-control study.
Results:
AE-CPDPN had longer duration of symptoms and more leukocytosis at hospitalization. AE-CPDb patients were sicker with more chronic respiratory failure (OR 33.3, p = 0.01), cardiac disease and pulmonary hypertension (OR 6.2, p = 0.008) at diagnosis. More patients with AE-CPDb were discharged on domiciliary oxygen (OR 5.27, p = 0.01). On logistic regression, AE-CPDPN was independently associated with mechanical ventilation (OR 22.3, p = 0.01), length of hospital stay (median difference, 4 days, p = 0.016) but not to hospital mortality. 22.7% of AE-CPDPN died. Respiratory failure requiring oxygen, NIPPV or mechanical ventilation was associated with mortality in AE-CPDPN.
Conclusion:
PN is a rare cause of AE-CPD and can be suspected by longer symptom duration, more leukocytosis, consolidation and cavitation. AE-CPDPN is associated with longer hospital stay and mechanical ventilation. Respiratory failure is associated with mortality in AE-CPDPN.
Key Messages:
Pulmonary nocardiosis can present in advanced chronic lung disease as an exacerbation in the absence of traditional risk factors like immunosuppression.Bronchiectasis, followed by chronic obstructive pulmonary disease are the most common chronic lung disease risk factors.Pulmonary nocardiosis is a rare cause of acute exacerbation of chronic pulmonary disease (CPD).Compared to exacerbations of CPD due to bacterial infections, nocardiosis-related exacerbations (CPDPN) were independently related to need for mechanical ventilation and length of hospital stay.Respiratory failure requiring oxygen, noninvasive ventilation and mechanical ventilation are associated with mortality in AE-CPDPN.
How To Cite This Article:
Kancherla R, Ramanathan RM PL, Appalaraju B, Srinivas R. Pulmonary Nocardiosis Presenting as Exacerbation of Chronic Pulmonary Disease. Indian J Crit Care Med 2019;23(10):467-474.
Insights
Pulmonary nocardiosis (PN) is a rare cause of acute exacerbation in chronic pulmonary disease (CPD). PN exacerbations present with longer symptoms and leukocytosis, requiring longer hospital stays and mechanical ventilation.
Area of Science:
- Pulmonology
- Infectious Diseases
- Critical Care Medicine
Background:
- Pulmonary nocardiosis (PN) can occur in chronic pulmonary disease (CPD) without typical risk factors.
- Clinical distinctions between bacterial exacerbations (AE-CPDb) and PN-related exacerbations (AE-CPDPN) are not well-defined.
Purpose of the Study:
- To characterize AE-CPDPN in patients lacking traditional risk factors.
- To compare clinical features, radiology, and outcomes of AE-CPDPN with matched AE-CPDb.
Main Methods:
- Single-center retrospective review.
- Case-control study design.
Main Results:
- AE-CPDPN showed longer symptom duration and higher leukocytosis at admission.
- AE-CPDb patients had more chronic respiratory failure, cardiac disease, and pulmonary hypertension.
- AE-CPDPN was independently associated with mechanical ventilation and longer hospital stays, but not mortality.
Conclusions:
- PN is a rare cause of CPD exacerbation, suggested by prolonged symptoms, leukocytosis, consolidation, and cavitation.
- AE-CPDPN is linked to extended hospitalization and increased need for mechanical ventilation.
- Respiratory failure in AE-CPDPN is a significant predictor of mortality.
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