Nocardia farcinica meningitis in a patient with high-grade astrocytoma

We describe a case of 91-year-old male with astrocytoma who developed meningitis caused by Nocardia farcinica. He had a past medical history of anaplastic astrocytoma grade III. Endocranial computed tomography (CT) scan revealed mass lesion in the left occipital region associated with perilesional edema, without evidence of midline shift issue. The analyses of cerebrospinal fluid (CSF) revealed neutrophilic pleocytosis, hyperproteinorrachia and hypoglycorrhachia. Combined antimicrobial therapy was initiated (vancomycin, meropenem, acyclovir). CSF culture revealed Nocardia farcinica. Susceptibility testing revealed intermediate sensitivity to meropenem and antibiotic treatment was switched to trimethoprim-sulfamethoxazole and imipenem. After 7 days of treatment the patient developed progressive dyspnea. The chest CT scan revealed bilateral pleural effusion and alveolar infiltrate mostly in the right lobe. Ceftriaxone was added to the therapy, but the outcome was lethal. Nocardia spp. should be considered as differential diagnosis in the patients with brain tumor or meningitis in the setting of immune suppression and corticosteroid use. CSF cultures should be incubated longer with aim to allow fastidious organisms to grow, such as Nocardia spp.

Lung lesions of slaughtered horses in southern Brazil

ABSTRACT: Respiratory diseases cause significant veterinary costs, reduce performance and require withdrawal of horses. Yet, studies of the causes of pneumonia in horses are scant. This study aimed to describe the pathological and microbiological features of lung lesions in slaughtered horses in southern Brazil. In this study, 84 samples of lungs were examined, and a conclusive diagnosis was obtained in 74 cases. These were composed of bronchopneumonia in 50 cases, followed by granulomatous eosinophilic pneumonia (9/74), recurrent airway obstruction (7/74), lung fibrosis (4/74), lung hemorrhage (3/74) and pulmonary pythiosis (1/74). Bronchopneumonia had grossly firm focally extensive yellow to dark-red areas, which consisted microscopically of multifocal to coalescing infiltrate of degenerate neutrophils. Streptococcus equi subsp. zooepidemicus was identified in 21 of the 50 cases. Granulomatous eosinophilic pneumonia had multifocal pinpoint firm-hard yellow areas, which microscopically were composed of granulomas with a mineralized center surrounded by collagen fibers and severe infiltrate of eosinophils. Recurrent airway obstruction had mild multifocal pinpoint firm white areas that consisted microscopically of large amounts of mucus inside bronchi and bronchiole. Lung fibrosis had two patterns: focally extensive areas of consolidation and firm nodular areas. Microscopically, the first pattern had interstitial to peribronchial fibrosis, while the second had, in addition to the interstitial fibrosis, a severe pneumocyte hyperplasia and an alveolar infiltrate of neutrophils and macrophages with rare intranuclear inclusion bodies (equine herpesvirus 5, EHV-5). Pulmonary pythiosis presented a focal firm nodular area, with multiple kunkers observed in the cut surface, which corresponded microscopically to areas of necrosis surrounded by a mixed inflammatory infiltrate. At the periphery of the necrotic areas, multiple negatively stained hyphae were observed, which were evidenced through Grocott’s stain and immunohistochemistry anti-Pythium insidiosum.

Association Between Acute Graft Versus Host Disease and Lung Injury after Allogenic Hematopoietic Stem Cell Transplantation

To investigate the characteristics of chest computed tomography (CT) and pathogenesis of acute graft versus host disease(GVHD)-induced lung injury after allogenic hematopoietic stem cell transplantation. In 47 patients with acute GVHD of grade II–IV, CT showed abnormalities in 20 patients in which 17 cases were suspected of acute GVHD-induced lung injury. Of 17 patients, CT revealed diffused interstitial infiltrate in 5 cases, diffused interstitial and alveolar infiltrate in 7 cases,diffused interstitial and segmental lobar alveolar infiltrate in 5 cases. The levels of serum IFNγ and TNFα in patients were higher than those of the healthy group. The histopathology of lung showed disorganization, epithelial cell damage, interstitial fibroplasias and interstitial T cell or macrophage infiltrate. In 24 patients who survived more than 6 months, 3 cases each in cases with and without lung injury developed late-onset noninfectious lung injury; 11 patients had abnormal pulmonary function including 7 patients in 9 patients with lung injury and 4 patients in 15 patients without lung injury. We concluded that T cell, macrophage, IFNγ and TNFα might play a role in the pathogenesis of acute GVHD-induced lung injury. Acute GVHD-induced lung injury might progress to late-onset noninfectious lung injury.

Inter-observer agreement in interpreting chest X-rays on children with acute lower respiratory tract infections and concurrent wheezing

CONTEXT AND OBJECTIVE: Many children with acute lower respiratory tract infections (ALRI) present to the emergency ward with concurrent wheezing. A chest x-ray is often requested to rule out pneumonia. We assessed inter-observer agreement in interpreting x-rays on such children. DESIGNS AND SETTING: Prospective consecutive case study at Instituto de Salud del Niño, Lima, Peru. METHODS: Chest x-rays were obtained from eligible children younger than two years old with ALRI and concurrent wheezing who were seen in the emergency ward of a nationwide pediatric referral hospital. The x-rays were read independently by three different pediatric residents who were aware only that the children had a respiratory infection. All the children had received inhaled beta-adrenergic agonists before undergoing chest x-rays. Lobar and complicated pneumonia cases were excluded from the study. RESULTS: Two hundred x-rays were read. The overall kappa index was 0.2. The highest individual kappa values for specific x-ray findings ranged from 0.26 to 0.34 for rib horizontalization and from 0.14 to 0.31 for alveolar infiltrate. Inter-observer variation was intermediate for alveolar infiltrate (kappa 0.14 to 0.21) and for air bronchogram (kappa 0.13 to 0.23). Reinforcement of the bronchovascular network (kappa 0.10 to 0.16) and air trapping (kappa 0.05 to 0.20) had the lowest agreement. CONCLUSIONS: There was poor inter-observer agreement for chest x-ray interpretation on children with ALRI and concurrent wheezing seen at the emergency ward. This may preclude reliable diagnosing of pneumonia in settings where residents make management decisions regarding sick children. The effects of training on inter-observer variation need further studies.