1052 www.japi.org © JAPI • VOL. 53 • DECEMBER 2005
Pictorial CME
Nocardiosis in AIDS - An Unusual Presentation
A 40 year gentleman presented with history of
retrosternal chest pain radiating to back with swelling
in upper back for last 2 months associated with low grade
fever for last 1 month. In 2001 he had cryptococcal
meningitis and was detected HIV positive. On
examination he had fullness with tenderness localized
to left paraspinal region at 3rd and 4th dorsal vertebral
level. MRI showed pus collection at left 3rd and 4th rib
posteriorly along with paravertebral collection with
extension into epidural space. CT guided FNAC showed
nocardia on microscopic pus examination and
confirmed by culture.
Nocardiosis is a bacterial disease that occurs mostly in
immunocompromised patients. It is an unusual infection
among HIV infected patients. The diagnosis should be
considered in patients with CD4 T cell count < 250 µ l/L.
Pneumonia is by far the most common presentation of
nocardial disease. In half of all cases of pulmonary
nocardiosis, disease appears outside the lung. In one-
fifth of cases of disseminated disease, lung disease is
Fig. 1 : T2 and T1 W sagittal image showing hypo and hyperintense
left paravertebral collection, respectively in the upper dorsal region. It
shows intermittent signal isointense to the muscles.
Fig. 2 : T2W axial image showing a left paravertebral hyperintense
signal intensity collection at D3/4 level. There is involvement of the
posterior aspect of the rib and the posterior spinal muscle on left side.
Fig. 3 : Microscopic appearance of nocardia in smear stained with
modified Kinyoun stain. (oil immersion 1000x)
not apparent. The most common site of dissemination is brain. The other common sites include the skin and supporting
structures, kidneys, bone and muscle but almost any organ can be involved. The typical manifestation of
extrapulmonary dissemination is a subacute abscess. Nocardia are crooked, branching, beaded Gram positive filaments
1 mm wide and upto 50 mm long. They are acid fast in direct smear (modified Kinyoun method) and also take up silver
stain.
Our patient’s CD4 count was 38 µ l/L and he did not have pulmonary involvement. He was treated with Amikacin and
Minocycline as he was allergic to sulpha drugs, along with antiretroviral therapy.
This pictorial CME presentation is to make treating physicians aware of the rare possibility of extrapulmonary
nocardiosis in HIV infected persons with low CD4 cell count.
N Jain*, L Duggal*, A Rohtagi**, A Sharma***
*Consultant, Department of Medicine; **Consultant, Department of Neurology; ***Consultant, Department of Microbiology;
Sir Ganga Ram Hospital, New Delhi - 110 060.  Received : 13.10.2005; Accepted : 14.11.2005