Case Study

Asian Cardiovascular & Thoracic Annals

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ß The Author(s) 2017
Surgery of a nocardia lung abscess Reprints and permissions:
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presenting as a tension pyopneumothorax DOI: 10.1177/0218492317705286
journals.sagepub.com/home/aan

Ryo Fujimoto, Mitsugu Omasa, Hiroyuki Ishikawa and

Minoru Aoki

Abstract
While some cases of nocardial pneumonia develop secondary empyema, tension pyopneumothorax is a very rare and
lethal complication. A 74-year-old man who exhibited thrombocytopenia during steroid therapy for autoimmune hepa-
titis, presented to our department with a nocardial tension pyopneumothorax. He underwent a left lower lobectomy
after chest drainage, and was discharged without any complication other than reoperation to remove a postoperative
hematoma.

Keywords
Anti-infective agents, Lung abscess, Nocardia infections, Pneumonectomy, Pneumothorax, Thrombocytopenia

Introduction
Nocardial lung abscess is an opportunistic infection
with a poor prognosis. Antimicrobial susceptibility pat-
terns differ among Nocardia species, making species
identification important for treatment.1 In recent
years, linezolid has emerged as an attractive drug for
nocardial infection. However, common severe side-
effects include myelosuppression which is the most sig-
nificant reason for discontinuation.2 Pyopneumothorax
due to nocardial lung abscess is rare because pleural
adhesions form early in the disease process. Surgical
treatment for nocardial lung abscess has been
reported.3 However, to the best of our knowledge,
this is the first report describing surgical treatment for
pyopneumothorax due to Nocardia.
Case report
A 74-year-old man who had been treated with cortico-
steroid therapy for autoimmune hepatitis with unex-
plained thrombocytopenia, presented with dyspnea.
Chest drainage for a left tension pneumothorax
(Figure 1a) showed a purulent pleural effusion. Chest
computed tomography showed a cavity lesion, 31 mm
in diameter, in the left lower lobe (Figure 1b). Bacterial
cultivation of the pleural effusion showed Nocardia
pseudobrasiliensis which was sensitive to trimetho-
prim-sulfamethoxazole and amoxicillin-clavulanate
in susceptibility tests. With a diagnosis of left tension
pyopneumothorax caused by perforation of the nocar-
dial abscess, the patient was treated initially with oral
trimethoprim-sulfamethoxazole. After a platelet trans-
fusion for thrombocytopenia and confirmation of exist-
ing non-disseminated nocardiosis, surgical treatment
was undertaken to remove the perforated lower lobe.
Intraoperative findings showed a 5-mm fistula in the
left lower lobe with a massive purulent discharge
and an easy hemorrhagic tight pleural adhesion to the
diaphragm and chest wall around the lower lobe
(Figure 2). A left lower lobectomy was performed
with pedicled intercostal muscle wrapping of the bron-
chial stump, and the thoracic cavity was cleaned (oper-
ation time 4 h 49 min). Due to dense fibrous adhesion of
the left lung to the chest wall, adhesiotomy was accom-
panied by a tendency for severe bleeding. To obtain
optimal hemostasis, transfusion of 16 units of fresh
frozen plasma and 30 units of platelet concentrate
was necessary. The estimated blood loss was 2375 mL,
Department of Thoracic Surgery, Nishi-Kobe Medical Center, Hyogo,
Japan
Corresponding author:
Mitsugu Omasa, Department of Thoracic Surgery, Nishi-Kobe Medical
Center, 5-7-1 Kojidai, Nishi-ku, Kobe, Japan.
Email: omasa@kuhp.kyoto-u.ac.jp
2 Asian Cardiovascular & Thoracic Annals 0(0)
Figure 1. (a) Preoperative chest computed tomography showing tension pneumothorax and an air-fluid level in the left thoracic
cavity. (b) Preoperative chest computed tomography showing a cavity lesion measuring 31 mm in the left lower lobe.
Figure 2. Intraoperative findings of the left lower lobe with
a massive purulent discharge. The ruptured cavity lesion is
indicated (arrow).
and 18 units of packed red blood cells were transfused.
The patient was transferred to the intensive care unit
and discharged 19 days after the operation with no
complication other than a reoperation for postopera-
tive hematoma. At one year after the operation, he
had no recurrence, and continued to undergo preventa-
tive treatment with oral antibiotics (amoxicillin-
clavulanate).
Discussion
Oral corticosteroid therapy for chronic obstructive pul-
monary disease can lead to a high risk of pulmonary
nocardiosis, an opportunistic infection.1 Nocardia aster-
oides is considered the most common species in pulmon-
ary nocardiosis,1 and Nocardia pseudobrasiliensis in
this case represents a relatively rare species. The latter
often invades the lungs through the respiratory tract in
immunosuppressed patients.4 Approximately 40% of
pulmonary nocardiosis cases present as disseminated
nocardiosis with a high affinity for the central nervous
system. Pulmonary nocardiosis has a high mortality
rate (41%), and disseminated nocardiosis is a poten-
tially lethal disease.1 Thus appropriate antibiotic
therapy based on susceptibility testing of the pathogen
is of primary importance.1 Trimethoprim-sulfamethox-
azole is used to treat all forms of nocardiosis. However,
sulfamethoxazole-resistant strains of Nocardia, includ-
ing Nocardia pseudobrasiliensis, have been reported in
immunocompromised patients. In this case, trimetho-
prim-sulfamethoxazole was administered before the
results of susceptibility testing were known. The anti-
biotic regimen was changed to amoxicillin-clavulanate
because the patient suffered loss of appetite due to
trimethoprim-sulfamethoxazole. In addition, linezolid
has emerged as an attractive drug for nocardial infec-
tion in recent years. However common severe side-
effects included myelosuppression which was the most
significant reason for discontinuation.2 Therefore,
linezolid was not administered to our patient with
severe thrombocytopenia.
Although chest drainage can be curative for second-
ary nocardial empyema,5 surgical treatment should be
performed for pyopneumothorax that develops from
erosion of a nocardial lung abscess in the thoracic
cavity. However, there has been no report of surgical
treatment for nocardial pyopneumothorax, which high-
lights the rapid deterioration and lethality of this situ-
ation. Surgical treatment is required for nocardial
pyopneumothorax, as with other bacterial species and
pyopneumothorax,6 with the exception of cases with
only minor fistulas.7 Lobectomy is recommended with-
out delay for non-disseminated nocardial pyopneu-
mothorax because of the deadly nature of Nocardia.
Fujimoto et al.
Appropriate concomitant postoperative antibiotic ther-
apy should be continued for 6–12 months.1 Lobectomy
with appropriate antibiotic treatment was effective in
this case of nocardial tension pyopneumothorax.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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