Published online Jun 7, 2015. doi: 10.3748/wjg.v21.i21.6491
Peer-review started: January 8, 2015
First decision: January 22, 2015
Revised: March 10, 2015
Accepted: March 31, 2015
Article in press: March 31, 2015
Published online: June 7, 2015
Human nocardiosis, caused by Nocardia spp., an ubiquitous soil-borne bacteria, is a rare granulomatous disease close related to immune dysfunctions. Clinically can occur as an acute life-threatening disease, with lung, brain and skin being commonly affected. The infection was classically diagnosed in HIV infected persons, organ transplanted recipients and long term corticosteroid treated patients. Currently the widespread use of immunomodulators and immunossupressors in the treatment of inflammatory diseases changed this scenario. Our purpose is to review all published cases of nocardiosis in immunomodulated patients due to inflammatory diseases and describe clinical and laboratory findings. We reviewed the literature concerning human cases of nocardiosis published between 1980 and 2014 in peer reviewed journals. Eleven cases of nocardiosis associated with anti-tumor necrosis factor (TNF) prescription (9 related with infliximab and 2 with adalimumab) were identified; 7 patients had inflammatory bowel disease (IBD), 4 had rheumatological conditions; nocardia infection presented as cutaneous involvement in 3 patients, lung disease in 4 patients, hepatic in one and disseminated disease in 3 patients. From the 10 cases described in IBD patients 7 were associated with anti-TNF and 3 with steroids and azathioprine. In conclusion, nocardiosis requires high levels of clinical suspicion and experience of laboratory staff, in order to establish a timely diagnosis and by doing so avoid worst outcomes. Treatment for long periods tailored by the susceptibility of the isolated species whenever possible is essential. The safety of restarting immunomodulators or anti-TNF after the disease or the value of prophylaxis with cotrimoxazole is still debated.
Core tip: Opportunistic infections in immunomodulated patients with inflammatory diseases has gained renewed interest because of the new biological therapies. Concerning inflammatory bowel disease, in particular anti-tumor necrosis factor drugs, turned granulomatous infection diseases a real risk. The awareness and knowledge about nocardiosis, a rare but severe granulomatous infection, is probably lacking for the majority of doctors treating these patients. Our aim is to increase the awareness about the infection and review the published cases in this particular group of patients. We would like that our reads increase knowledge about clinical manifestations and up-to-date treatment, be aware of the risk of the disease and when to suspect nocardiosis.