Cutaneous nocardiosis in chronic renal insufficiency: Diagnostic and therapeutic considerations

Abstract

Nocardiosis remains a rare and often underdiagnosed bacterial infection, particularly in immunocompromised individuals. The case report by Zhang et al highlights the diagnostic and therapeutic challenges in managing Nocardia brasiliensis skin infection in a 93-year-old patient with chronic renal insufficiency. This editorial explores the importance of timely diagnosis, microbiological confirmation, and tailored antibiotic therapy. Emphasis is placed on the role of immune status evaluation, drug concentration monitoring, and the necessity of long-term antimicrobial therapy. Improved clinician awareness and adherence to evidence-based management protocols are essential to achieving better outcomes in nocardiosis cases.

Key Words: Nocardia species; Cutaneous infections; Chronic renal insufficiency; Personalized antibiotic therapy; Therapeutic drug monitoring

Core Tip: This editorial unravels the diagnostic and therapeutic challenges of nocardiosis in immunocompromised patients. It emphasizes the power of microbiological precision, tailored antibiotic regimens, and immune status assessment. A compelling case of Nocardia brasiliensis in chronic renal insufficiency offers key takeaways for clinicians tackling similar hurdles.

INTRODUCTION

Nocardiosis, caused by the genus Nocardia, is an uncommon and potentially life-threatening bacterial infection[1]. Despite advancements in diagnostic techniques and antimicrobial therapy, the disease remains underrecognized, particularly in immunocompromised patients[2]. Nocardia brasiliensis, a species predominantly responsible for cutaneous infections, poses diagnostic and therapeutic challenges[3]. The clinical manifestations of nocardiosis vary widely, ranging from localized cutaneous infections to severe disseminated disease involving the lungs, central nervous system (CNS), and other organs[4].

Patients with chronic renal insufficiency, malignancies, organ transplants, or those undergoing immunosuppressive therapy are at heightened risk for nocardial infections[5]. The opportunistic nature of Nocardia complicates the diagnosis, often leading to delayed treatment[6]. Zhang et al's case report highlights the importance of early recognition, microbiological confirmation, and individualized management strategies in improving outcomes for patients with nocardiosis[7]. Although nocardiosis is rare, its incidence is rising, particularly among immunocompromised individuals. Studies estimate the incidence at 0.3%-1.8% among solid organ transplant recipients and up to 2% in human immunodeficiency virus (HIV)-positive populations[4]. The non-specific presentation and indolent course often lead to delayed diagnosis, which increases the risk of dissemination, especially to the lungs and CNS. Prompt recognition and early initiation of appropriate therapy are crucial in improving the clinical outcomes[5,6].

This editorial further explores the epidemiology, pathophysiology, clinical presentations, diagnostic challenges, therapeutic strategies, and the clinical implications of managing nocardiosis. Emphasis is placed on the need for heightened clinical suspicion, timely diagnosis, and personalized therapeutic approaches to optimize patient care (Figure 1)[8].

Figure 1  Graphical abstract summarizing the diagnostic and therapeutic approach to cutaneous nocardiosis in patients with chronic renal insufficiency.

EPIDEMIOLOGY

Nocardia species are environmental saprophytes found in soil, organic matter, and water[9]. Human infection primarily occurs through direct inoculation of contaminated material via skin trauma or through inhalation, leading to pulmonary or disseminated nocardiosis[10]. Nocardia brasiliensis, a leading cause of primary cutaneous nocardiosis, is predominantly reported in tropical and subtropical regions[11].

Although nocardiosis is rare, its incidence is increasing, particularly among immunocompromised populations[12]. Studies indicate that up to 60% of nocardiosis cases occur in patients with weakened immune systems, including those with HIV, organ transplant recipients, and individuals receiving corticosteroids or cytotoxic chemotherapy[13]. However, sporadic cases have also been reported in immunocompetent individuals following traumatic inoculation[14].

Given the limited epidemiological data on nocardiosis, establishing accurate incidence rates remains challenging. Continuous surveillance and improved diagnostic capacities are essential to determine the true disease burden and identify emerging resistance patterns[15].

Pathophysiology

Nocardia species are facultative intracellular pathogens capable of surviving within phagocytes, thereby evading host immune responses[16]. Upon entry through skin abrasions or inhalation, Nocardia organisms trigger localized infections, which can disseminate, if not promptly controlled[17].

The primary virulence factors include catalase and superoxide dismutase, which neutralize reactive oxygen species, allowing bacterial survival within macrophages[3]. Additionally, the production of trehalose dimycolate, a surface glycolipid, inhibits phagosome-lysosome fusion, further enhancing intracellular persistence[18].

In immunocompromised hosts, the diminished ability of macrophages and neutrophils to eliminate Nocardia leads to uncontrolled bacterial proliferation. Cutaneous nocardiosis often manifests as localized cellulitis, nodules, or abscesses with draining sinuses, resembling other bacterial or fungal infections[19]. In cases of systemic dissemination, the bacteria may spread hematogenously, leading to pulmonary, cerebral, or soft tissue involvement[20].

Understanding the pathogen's immune evasion mechanisms is critical for tailoring effective therapeutic strategies, particularly in vulnerable patient populations[21].

Clinical presentations

Cutaneous nocardiosis typically presents as a localized infection following traumatic inoculation, particularly in individuals with compromised immune systems[22]. The infection often manifests as pustules, nodules, or ulcers with purulent discharge, resembling bacterial or fungal skin infections[23]. In some cases, cutaneous lymphangitis or mycetoma, characterized by draining sinuses and granules, may occur[24].

Systemic symptoms such as fever, lymphadenopathy, and malaise may accompany cutaneous lesions, especially in cases of disseminated disease[25]. Immunocompromised individuals, including those with chronic renal insufficiency, are at greater risk for dissemination to the lungs, brain, or other organs[26]. The clinical course is often indolent, leading to delays in diagnosis and treatment.

The diagnosis is further complicated by the polymorphic appearance of nocardial skin infections, which can mimic cellulitis, pyoderma gangrenosum, or deep fungal infections[27]. High clinical suspicion and prompt microbiological investigations are essential for early diagnosis and effective management.

Diagnostic challenges

Diagnosing nocardiosis remains a challenge due to its nonspecific clinical manifestations and the slow growth of Nocardia in culture. The time to identify Nocardia species may range from several days to weeks, delaying appropriate treatment[28]. Misdiagnosis is common, particularly in resource-limited settings where specialized diagnostic facilities are unavailable[29].

Laboratory confirmation requires microbiological culture, often utilizing selective media such as buffered charcoal yeast extract or Sabouraud dextrose agar[30]. Additionally, molecular methods, including 16S rRNA gene sequencing and polymerase chain reaction (PCR), offer higher sensitivity and specificity for species identification[31].

Histopathological examination with modified acid-fast staining can support diagnosis by revealing characteristic acid–fast branching filamentous bacteria. Radiological imaging, such as computed tomography or magnetic resonance imaging, may aid in evaluating disseminated disease[32].

Given the diagnostic complexities, a multidisciplinary approach involving infectious disease specialists, microbiologists, and pathologists is essential to ensure accurate diagnosis and timely initiation of therapy[33].

Therapeutic strategies

The cornerstone of nocardiosis treatment is prolonged antibiotic therapy. Empirical treatment often includes trimethoprim-sulfamethoxazole (TMP-SMX), the first-line drug of choice, due to its bactericidal activity against most Nocardia species[34]. Combination therapy with imipenem, amikacin, or linezolid is recommended in severe or disseminated cases[35]. Recent advancements in antimicrobial susceptibility testing, using both molecular and phenotypic methods, have improved drug selection and optimized patient outcomes[36].

In immunocompromised individuals, the duration of therapy typically extends to 6-12 months to prevent relapse. Therapeutic drug monitoring (TDM) ensures adequate serum drug levels; particularly important for agents like linezolid, which may cause hematological toxicity with prolonged use[37].

Considerations in elderly and frail patients: While TMP-SMX remains effective, its long-term use can lead to adverse effects such as bone marrow suppression, nephrotoxicity, and hepatotoxicity. In elderly or frail patients, dose adjustments based on renal function, along with regular monitoring of blood counts and hepatic/renal parameters, are essential[34]. Alternative agents such as minocycline, moxifloxacin, or linezolid may be considered in cases of TMP-SMX intolerance or contraindication. Clinical decision-making should carefully balance antimicrobial efficacy with the potential for toxicity in these vulnerable populations[35,36].

Surgical intervention: Surgical debridement may be necessary in cases of extensive cutaneous involvement or abscess formation[38].

Emerging therapies and mechanisms of drug resistance: Emerging therapies targeting bacterial resistance mechanisms; such as novel beta-lactamase inhibitors, are under investigation and may offer new options in refractory or multidrug-resistant cases. Nocardia species exhibit a range of resistance mechanisms. Resistance to sulfonamides like TMP-SMX may occur due to mutations in the dihydropteroate synthase gene. Other mechanisms include overexpression of efflux pumps, reduced permeability of the bacterial cell wall, and enzymatic modification of target sites, contributing to resistance against beta-lactams and aminoglycosides. Given the molecular variability across Nocardia species, species-level identification and susceptibility testing are essential to guide effective therapy[39].

Clinical implications

The successful management of nocardiosis in immunocompromised individuals, as highlighted in Zhang et al's case report, underscores the importance of early diagnosis and individualized treatment[7]. Clinicians must maintain a high index of suspicion for nocardiosis in patients presenting with non-healing skin lesions, particularly those with underlying conditions like chronic renal insufficiency or those on immunosuppressive therapy[40]. Delayed diagnosis can lead to disease progression, dissemination, and increased morbidity and mortality.

Accurate microbiological identification is crucial for targeted antimicrobial therapy. Molecular diagnostic tools, including PCR and 16S rRNA sequencing, offer rapid and specific identification of Nocardia species, aiding in early therapeutic decisions[41]. Enhanced access to these diagnostics in resource-limited settings can significantly improve patient outcomes.

Furthermore, TDM plays a pivotal role in ensuring optimal drug concentrations while minimizing adverse effects. Regular monitoring of serum levels of TMP-SMX and linezolid can prevent toxicity, particularly in elderly and renaly impaired patients[42]. Clinicians should remain vigilant for adverse effects, including myelosuppression, hepatotoxicity, and nephrotoxicity, necessitating dose adjustments as appropriate.

From a public health perspective, understanding the epidemiology of nocardiosis through continuous surveillance is essential. Increased awareness and reporting will enable the identification of emerging resistance patterns, ensuring the effective use of antimicrobials. Multidisciplinary collaboration between infectious disease specialists, microbiologists, and pharmacists remains crucial in developing region-specific treatment guidelines.

Lastly, patient education on recognizing early symptoms, especially in immunocompromised individuals, can facilitate prompt medical attention. Comprehensive follow-up care is necessary to monitor treatment response, manage drug toxicity, and prevent relapse. Personalized management plans, incorporating immune status assessments and drug susceptibility testing, represent the cornerstone of successful treatment of nocardiosis.

The insights from this case report provide valuable guidance for clinicians managing similar cases, reinforcing the importance of timely diagnosis, targeted therapy, and multidisciplinary care in the management of Nocardia brasiliensis infections.

Preventive measures in high-risk groups: Immunocompromised individuals, including those with organ transplants, hematologic malignancies, or long-term corticosteroid use, are particularly susceptible to nocardial infections[41]. Preventive strategies include minimizing exposure to soil and organic dust, especially during gardening, landscaping, or construction activities. While routine screening is not currently recommended, heightened clinical awareness and early evaluation of non-healing lesions or unexplained pulmonary symptoms are critical in high-risk patients[4]. Patient education plays a pivotal role in reducing exposure and promoting timely medical consultation.

EDITORIAL COMMENTS

The case report by Zhang et al[7] serves as a critical reminder of the diagnostic and therapeutic complexities associated with nocardiosis. It highlights the necessity of maintaining a high index of suspicion in immunocompromised individuals presenting with atypical skin lesions. Early microbiological identification and species-level differentiation remain paramount in guiding targeted therapy.

Furthermore, this case underscores the importance of a personalized approach to antimicrobial management, considering patient-specific factors such as immune status, renal function, and potential drug toxicities. Collaborative decision-making involving infectious disease specialists, dermatologists, and microbiologists can optimize treatment outcomes and minimize therapeutic failures.

CONCLUSION

Nocardiosis, particularly cutaneous Nocardia brasiliensis infection, presents significant diagnostic and therapeutic challenges in immunocompromised patients. Early clinical suspicion, prompt microbiological diagnosis, and individualized antibiotic therapy are essential for successful management. For patients with chronic renal insufficiency, careful drug selection and monitoring are crucial to minimize adverse effects. Multidisciplinary collaboration and continued research on antimicrobial resistance and novel treatments will further improve patient outcomes.

ACKNOWLEDGEMENTS

Authors are thankful to Prof. Anant Kale, Stratizen Research & Innovation Services Pvt. Ltd., Pune, India for revising this article for syntax and scientific language style. Authors are also thankful to Mr. Vinod Jogdand for technical support in the preparation of manuscript.