Rescue "Mrs. Wen"-a case of Nocardia pneumonia diagnosis and treatment sharing

It is only for medical professionals to read and refer to the "Eastern Respiratory Alliance", which will take you to explore wonderful cases ~ Case profile 84-year-old female patient
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He was admitted to the hospital as the main complaint of "repeated cough and sputum for more than 30 years, worsening for 1 week"
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During the complaint, there was a coughing of yellow pus sputum, which was sticky in quality and difficult to cough up; intermittent fever; occasionally hemoptysis, bloodshot in the sputum; symptoms persisted and gradually aggravated; the above symptoms worsened again after a cold one week before admission, especially at night
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Activity endurance decreased significantly, accompanied by poor appetite and nausea
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In recent years, she was hospitalized 2-3 times a year due to fever, cough, sputum, and dyspnea
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He has previously diagnosed "Bronchiectasis" and "Mrs.
Windermere Syndrome"
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Physical examination: The wheelchair was pushed into the ward, the body was thin, malnourished, chronic wasting, and clubbing
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Low breath sounds in both lungs, scattered moist rales, thick phlegm sounds, bilateral lower lung fields, heart rate: 92 beats/min, regular rhythm, no murmur in the auscultation area of ​​each valve, abdomen Physical examination revealed no abnormalities, no edema in both lower limbs, physiological reflexes, and no pathological signs were elicited
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Main auxiliary examination: Admission blood routine: WBC 8.
52X109/L, NE% 72.
2%; serum amyloid 276.
42; CRP 153.
11mg/L; PCT 0.
052ng/ml; ESR 75mm/h; LPS 166.
8pg/L, chest CT : Along the bronchus, multiple consolidation and exudation of both lungs, with tree bud sign and bronchiectasis, small air sac-containing cavity can be seen in consolidation lesions, the lesions mainly involve the right middle lobe, left tongue lobe and both lower lungs
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No venous thrombosis was seen on extremity vascular ultrasound
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Blood tumor markers (-); Connective tissue disease and vasculitis related tests (-); Cell and humoral immune related tests (-); Sputum common bacterial smears, culture, DNA (-) antigen and antibody detection (-) Peripheral blood T-SPOT (-), Mycobacterium tuberculosis antibody (-), sputum acid-fast bacilli smear, culture, special staining, DNA, XPERT all (-) non-tuberculous mycobacterial smear, culture, special staining (-) respiratory tract Common viruses PCR DNA (-), RNA (-)
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Admission to the hospital underwent general anesthesia bronchoscopic alveolar washing and bronchoalveolar lavage fluid pathogenic detection
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Observations under the microscope: a large number of purulent secretions were seen in the lumen of the trachea to the left and right main bronchus and the bronchus of each lobe segment, the bronchial mucosa of each lobe segment was congested and edema, and it was easy to bleed when touched, and the mucosa of the right middle lobe and left lingual lobe could be spotted.
Aspirate the purulent secretions in the lumen, inject 0.
9% NaCl into the bronchus of each lobe segment for local flushing, and then perform bronchoalveolar lavage in the right middle lobe and left tongue lobe.
The cytology results of the toilet fluid show: colorless and turbid.
The total number of cells is 720, NE% 95%
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The NGS DNA of the wash liquid showed 6397 sequences of Nocardia guinea pigs, 23 sequences of Nocardia guinea pigs, and 10979 sequences of human parainfluenza virus type 1
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Diagnosis: community-acquired pneumonia (guinea pig otitis Nocardia infection), human parainfluenza virus infection
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Treatment plan: meropenem 2.
0 Q8h intravenous infusion + linezolid 0.
6 Q12h intravenous infusion + oseltamivir 75 mg bid orally + 0.
1% amikacin intrabronchial perfusion and flushing × 2 times, acetylcysteine ​​0.
6 tid nebulized inhalation , Intravenous gamma globulin + Ansu oral + high-nutrition diet
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After 21 days, she was changed to linezolid 0.
6 bid orally
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The total course of treatment was discontinued after 2 months
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Half a year after discharge from the hospital, the blood routine was rechecked, and the infection and inflammation related markers returned to normal
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Parainfluenza virus PCR (-)
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Under general anesthesia, the bronchial mucosa was smoothed, and there was no obvious congestion and edema, and no purulent secretions were seen in the cavity
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The cytology of bronchoalveolar lavage fluid is colorless and transparent.
The total number of cells is 240 and the percentage of neutrophils is 80%.
Wash liquid Nocardia smear, culture, PCR (-), Candida smear, culture (+), review Chest CT: Compared with the previous film, the lung lesions were significantly absorbed than before, and some lesions disappeared
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Mental, nutritional status and activity endurance have improved significantly, and they can engage in light physical activity
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The comparison results of blood routine inflammatory markers before and after treatment are shown in Table 1 and Table 2 respectively
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The comparison results of chest CT and bronchoscopy changes before and after treatment are shown in Figure 1 and Figure 2 respectively
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Table 1 Blood routine before and after treatment.
Table 2.
Inflammatory markers before and after treatment.
Figure 1: Comparison of chest CT before and after treatment.
Hemoptysis was repeatedly hospitalized as the chief complaint
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Diagnosed "Bronchiectasis" and "Mrs.
Windermere Syndrome"
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The anti-infective treatment is not effective
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Auxiliary examination showed that inflammation-related markers were significantly increased, but white blood cells were not significantly increased.
Chest CT (Figure 1) showed exudation and consolidation of both lungs along the bronchial vascular bundles, accompanied by bronchial wall thickening and luminal dilatation, right lung "Lotus sign" in the middle leaf
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It suggests that chronic airway-derived pulmonary infectious diseases may be possible
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According to the diagnosis and treatment process recommended by China's 2016 edition of the "Community Acquired Pneumonia (CAP) Diagnosis and Treatment Guidelines", lung lesions caused by non-infectious diseases need to be excluded before the diagnosis of CAP (see Figure 3 for the diagnosis and treatment flow chart of CAP)
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Figure 3 The diagnosis and treatment process of CAP combined with the clinical characteristics of the patient's repeated and prolonged condition.
We carefully asked and evaluated the patient's underlying disease, immune status, and organ function based on the previous medical history, and excluded connective tissue diseases and blood vessels.
Inflammation-related lung invasion, pulmonary vascular disease and other non-infectious factors caused lung invasion
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The diagnosis of elderly CAP patients requires attention: the respiratory symptoms of elderly CAP patients are often atypical or even absent; peripheral blood leukocytes are not elevated or granulocytes are reduced; the imaging performance is atypical or the imaging features of underlying diseases at the same time make lung imaging more complicated; The underlying disease and the influence of medications, the auxiliary examination indicators are not typical, etc.
This patient has the characteristics of insignificant white blood cell elevation, chronic wasting caused by malnutrition, and bronchiectasis.
These factors need to be carefully screened during the diagnosis of CAP.

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During the diagnosis and treatment, we reassessed the basic co-existing disease status of the elderly patient, confirmed that the patient had anemia, malnutrition, and ruled out diabetes, chronic heart, liver, and renal insufficiency
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This patient was previously diagnosed with CAP, but the treatment effect is not obvious, and the condition is protracted.
For CAP patients with poor treatment effect and repeated conditions, we should actively look for factors that affect the efficacy, including immunosuppressed patients and lung infections with underlying diseases.
Patients with stroke and structural lung disease also need to be aware of the impact of repeated aspiration and decreased airway clearance on treatment
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This patient did not find underlying diseases affecting immune function, and did not use immunosuppressive drugs
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However, the body is thin, cough, and weak sputum expectoration.
Bronchoscopy and chest imaging all indicate the presence of bronchiectasis.
Therefore, there are risk factors for poor airway clearance and poor anti-infective treatment effects
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It is necessary to strengthen airway clearance while strengthening nutrition, bronchoalveolar lavage under bronchoscope and spraying of antibacterial drugs into the airway is an important measure in comprehensive treatment
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Anti-infective drug-resistant pathogen infections, special rare pathogen infections, and mixed infections are important reasons for the failure of conventional anti-bacterial infection treatments
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Fast and accurate diagnosis of lower respiratory tract pathogens is the key to guiding the target anti-infective treatment.
This patient has been tested by BALF-mNGS to determine the responsible pathogen of this infection: guinea pig otitis Nocardia + human parainfluenza virus infection, refer to Sanford The "Guidelines for Antimicrobial Treatment of Fever" (48 Edition) recommends that the corresponding target anti-infective treatment is given, and the whole body is combined with local anti-infective treatment in the airway, and good therapeutic effects have been achieved
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The course of anti-infective treatment is affected by pathogenic characteristics, patients' underlying diseases and immune status, and individual differences are large
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The patient’s total anti-infective treatment course reached 2 months, which is not completely consistent with the literature report.
The main reason is that the patient’s compliance with anti-infective treatment after discharge from the hospital is not satisfactory, coupled with the inconvenience of follow-up, the 3 months of treatment has not been completed, but half a year In the follow-up visit, the infection-related indicators were all within the normal range, and the microscopic and chest imaging manifestations were well recovered
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The rookie mNGS pathogen detection, which is a molecular diagnosis of pathogens, has incomparable advantages in terms of rapidity, recall and sensitivity of pathogens.
In this case, the traditional detection method is to obtain pathogenic evidence, the BALF-mNGS detection does not matter.
Both DNA and RNA testing have clear positive findings
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The reason for the negative wash liquid smear and culture negative in this patient may be related to laboratory testing techniques and the application of antibacterial drugs, indicating that there are certain false positives and false negatives in any pathogen test results, and every infected patient should be treated before anti-infection Obtain specimens of the infected lesions as much as possible in accordance with the aseptic operation process, and actively multiple detection methods are sent at the same time, the test results are mutually confirmed, and the pathogen diagnosis rate is submitted
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Faced with the test results, clinicians should carefully analyze the test results based on the clinical characteristics of patients while improving accurate sampling techniques and make reasonable judgments
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Nocardia is an aerobic gram-positive branch-like saprophytic bacterium widely distributed in nature, belonging to Actinomycetes, Nocardiaceae, and different from tuberculosis and non-tuberculous mycobacteria, Nocardia is a filamentous weak acid-fast Stain positive bacteria
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(The acid-fast and weak acid-fast stains of Mycobacterium tuberculosis, non-tuberculous mycobacteria and Nocardia are shown in Figure 4; and the morphology of Nocardia and colonies are shown in Figure 5)
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Figure 4 Comparison of acid-fast and weak acid-fast staining of tuberculosis, non-tuberculous mycobacteria, and Nocardia Mycosis is usually regarded as an opportunistic infection, with impaired immune function, especially in patients with cellular immune deficiency, who are susceptible to nocardiac disease, but about one-third of infected persons have normal immune function
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The separation or culture of the lesion site to find Nocardia is the "gold standard" for the diagnosis of Nocardiasis.
The main pathological features of the lesion are purulent infection and chronic inflammatory granuloma
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Nocardiasis has two clinical features: ① It can spread to almost any organ, especially the central nervous system (CNS); ② Despite proper treatment, there is still a tendency to relapse or progress
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Respiratory tract inhalation can cause primary purulent infection of the lungs.
Chronic infections are similar to tuberculosis or pulmonary fungal disease; those with structural lung diseases (such as bronchiectasis, COPD) may have respiratory tract colonization, and the host's systemic or local immune defense function declines When causing endogenous infection
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The clinical manifestations of pulmonary nocardiac disease are not specific and are easy to be misdiagnosed and missed.
Therefore, any patients with brain, soft tissue or skin lesions and concurrent or recent lung diseases should be suspected of the possibility of nocardiac disease
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The images of pulmonary nocardiasis are diverse and not specific
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Basic signs include consolidation, nodules, masses, cavities, GG0, bronchiectasis, tree bud sign, thickening of interlobular septum, pleural effusion, hilar (mediastinal) lymph node enlargement, etc.
Various signs can appear alone or coexist.
The most common manifestations are lung consolidation, nodules or masses
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The first choice of treatment is TMP-SMX combined with imipenem for anti-infective therapy.
Alternatives include linezolid and amikacin.
It is reported in the literature that ceftriaxone or cefotaxime is also effective for the treatment of some Nocardia infections
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In recent years, it has been found that the trend of sulfa drug resistance is on the rise
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Carbapenem drugs and linezolid have been found to be uniformly effective against all pathogenic Nocardia bacteria
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The course of treatment for nocardiasis is longer, generally at least 3 months, and immunosuppressed patients need two effective anti-infective drugs combined for at least 6 months
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Expert Profile Dr.
Sun He, Associate Chief Physician, Associate Professor, Associate Chief Physician of the Department of Respiratory and Critical Care Medicine, Oriental Hospital Affiliated to Tongji University, Visiting Scholar, University of California, San Francisco, United States National Committee Member of the Chinese Anti-Cancer Association, Infectious Science Group of the Chinese Anti-Cancer Association Respiratory Oncology Branch, participated in the compilation of 3 higher medical education textbooks.
Participated in 3 research projects.
Won the Provincial Science and Technology Achievement Award.
2 Won the National Patent.
2 Professional Research Directions: Respiration Systemic infection and immune expertise: differential diagnosis and comprehensive treatment of lower respiratory tract infections in difficult, severe, and immunosuppressed patients; comprehensive diagnosis and treatment of lung tumors and chronic airway diseases.
Gu Xia, Master of Clinical Medicine, Tongji University, Lecturer, Tongji University, Affiliated to Tongji University Teaching Secretary of the Attending Physician of the Department of Respiratory and Critical Care of Dongfang Hospital, Member of the Youth Committee of Pulmonary Oncology, China Medical Education Association, Secretary of the Chronic Obstructive Pulmonology Group, Respiratory Branch of Shanghai Medical Association, Shanghai Pudong New Area Medical Association A total of one author published 3 papers, one corresponding author participated in the compilation of two monographs, and participated in a number of clinical trials and research and national natural topics.
Familiar with the diagnosis and treatment of various diseases in the Department of Respiratory Medicine, especially chronic obstructive pulmonary disease, asthma, lung cancer and other diseases.
Proficiency in thoracentesis, bronchoscopy and other operating techniques, while participating in a number of clinical trials.
Introduction of experts Chen Si, Ph.
D.
in Clinical Medicine, Navy Military Medical University, Ph.
D.
, Joint Training of Johns Hopkins University, Shanghai Oriental Hospital, Department of Respiratory and Critical Care, Respiratory Critical Care The first or co-author of the resident in the intensive care unit has published 5 papers, and translated 1 work (associate translation).
Participated in multiple drug clinical trials and national natural topics.
Research directions: diagnosis and treatment of lung cancer and full-process management, benign airway stenosis, Lung infection, chronic obstructive pulmonary disease Remarks: Some pictures in this article are from the Internet