Nocardiosis in patients with human immunodeficiency virus infection

BACKGROUND. Nocardiosis is a bacterial disease that occurs in immunocompromised patients, including those infected by the human immunodeficiency virus (HIV). METHODS. We retrospectively analyzed the clinical records of 27 HIV-positive patients with nocardiosis seen during the period of 1993 to 2004. Clinical presentations, diagnostic methods, predominant species, antimicrobial therapy and outcome were analyzed. RESULTS. Among the total, 81% were males and the median age was 30 years. There was an elevated percentage of alcoholism (89%), smoking (80%) and intravenous drug use (82%). A previous positive serology for HIV infection was present in 85% of the patients. Plasma CD4+ T cell count at the time of diagnosis in 15 of 17 patients (88%) was below 50 cells/wl (median 15 cells/wl). The most frequent clinical onset was pulmonary in 70%, followed by cutaneous in 11% and disseminated in 11%. The main specimens for diagnostic bacterial isolation were sputum (54%), skin and soft tissues (22%) and bronchoalveolar lavage (19%). The predominant pulmonary radiological pattern was alveolar infiltration (74%), followed by cavitations (32%). The species was identified in 13 patients (48%); Nocardia asteroides was isolated in 84% (n = 11). The main antimicrobial drugs prescribed were cotrimoxazole (78%), amikacin (59%) and ciprofloxacin (33%). Dual therapy was used in 78% of the cases, with cotrimoxazole-amikacin being the most frequent. Overall mortality was 37%. CONCLUSIONS. Nocardiosis is an unusual infection among HIV-infected patients. The diagnosis should be considered in patients with CD4+ T cell counts below 50/mu L and lung or pericardial involvement.