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Nocardia farcinica Pneumonia in a Palliative Care Unit.

A 75-year-old Japanese man with hepatocellular carcinoma involving multiple metastases of the lung was admitted to the palliative care unit of our hospital with a 1-week history of a low grade fever, cough and dyspnea. He was administered betamethasone (1 mg per day). A chest X-ray showed bilateral infiltration with multi-nodular lesions (Picture 1). Gram’s staining of the sputum revealed Grampositive rods with characteristic long and branching filaments (Picture 2A). Kinyoun staining was also positive (Picture 2B). Molecular identification by a sequence analysis of the 16S rRNA gene identified the isolate as Nocardia farcinica. The isolate was susceptible to trimethoprimsulfamethoxazole, amikacin, ciprofloxacin and imipenem. Therefore, the patient was treated with imipenem and ciprofloxacin because a smaller number of blood samples would be required due to the lack of side effects associated with these antibiotics. Nocardia species are aerobic, Grampositive rods belonging to the order Actinomycetales, and the duration of the treatment for Nocardia infections is at least one year for immunocompromised patients (1). Although patients diagnosed with pneumonia in the palliative care unit can be treated empirically to avoid investigation and minimize pain, Gram staining is necessary for an accurate diagnosis and treatment, even in the palliative care unit. Furthermore, obtaining sputum samples is not highly invasive and thus does not create any patient discomfort.