370

CORRESPONDENCE Nocardiosis in Patients with AIDS

Correspondence: Dr. Charles E. Cherubin, Infectious Diseases Section, Department of Veterans Affairs Medical Center, IIII East End Boulevard, Wilkes-Barre, Pennsylvania 18711.

Clinical Infectious Diseases

1992;15:370

This article is in the public domain.

Reply SIR-Cherubin, in criticizing that my letter [I] is missing several case reports, seems to overlook that the article [2] which my letter is addressing already reviews the literature that he is now quoting again. Furthermore, my letter is in fact pointing out that nocardiosis in patients with AIDS is " . . . not as rare as one would assume given the 14 cases described in this article" [2]. Within the spectrum ofnocardiosis, infection with Nocardia brasiliensis-the main topic of my letter-is unarguably particularly uncommon. The incidence of nocardiosis that was reported from two centers with a large population of patients with AIDS [2, 3] was small. It is not evident why these two studies should not represent the clinical reality found in most centers for the treatment of AIDS. Furthermore, if Cherubin finds it worthwhile to report a single, complex-but essentially not untypical-case of nocardial infection in a human immunodeficiency virus-positive Correspondence: Dr. Harry J. Sieratzki, Department of Child Health, Royal Hospital for Sick Children, St. Michael's Hill, Bristol BS2 8BJ, United Kingdom.

Clinical Infectious Diseases 1992;15:370 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1502-0020$02.00

Charles E. Cherubin Infectious Diseases Section, Department of Veterans Affairs Medical Center, Wilkes-Barre, Pennsylvania

References I. Sieratzki HJ. Nocardia brasiliensis infection in patients with AIDS. Clin Infect Dis 1992; 14:977-8. 2. Kim J, Minamoto GY, Grieco MH. Nocardial infection as a complication of AIDS: report of six cases and review. Rev Infect Dis 1991; 13:624-9. 3. Kramer MR, Uttamchandani RB. The radiographic appearance of pulmonary nocardiosis associated with AIDS. Chest 1990;98:382-5. 4. Bonacini M. Nocardia brasiliensis peritonitis in a patient with AIDS. Am J Gastroenterol 1990;85: 1432-3. 5. Cherubin CEo Case report: pleurocerebral nocardia in an HIV-positive patient. IDINDN 1991;10:85-6. 6. Telzek E, Hii J, Polsky B, KiehnT, Armstrong D. Nocardia infection in the acquired immunodeficiency syndrome. Diagn Microbiol Infect Dis 1989; 12:517-9. 7. Rodriguez JL, Berrio JL, Pitchenik AE. Pulmonary nocardiosis in the acquired immunodeficiency syndrome. Diagnosis with bronchoalveolar lavage and treatment with non-sulphur containing drugs. Chest 1986;90:912-4. 8. Lynn W, White M, Weber J. Nocardia, mycobacteria and AIDS [letter]. AIDS 1989;3:766-7. 9. Gaspar G, Alia I. Ewuines G, Ballesteros P. Primary cutaneous nocardiosis and human immunodeficiency virus infection [letter]. Med Clin (Bare) 1989;92:73-80.

patient [4], does this not give a certain indication of how relatively rarely he himself observes nocardiosis among his own patients with AIDS? It may be that many cases of nocardiosis in patients with AIDS are, as he says, "inadvertently being treated with other possible diagnoses in mind." The available data, however, do rather suggest that Nocardia, despite a general predilection for immunocompromised patients, causes significant disease in patients with AIDS much less frequently than do other opportunistic organisms.

Harry J. Sieratzki Department of Child Health, Royal Hospital for Sick Children, Bristol, United Kingdom

References I. Sieratzki HJ. Nocardia brasiliensis infection in patients with AIDS. Clin Infect Dis 1992; 14:977-8. 2. Kim J, Minamoto GY, Grieco MH. Nocardial infection as a complication of AIDS: report of six cases and review. Rev Infect Dis 1991; I3:624-9. 3. Kramer MR, Uttamchandani RB. The radiographic appearance of pulmonary nocardiosis associated with AIDS. Chest 1990;98:382-5. 4. Cherubin CEo Case report: pleurocerebral nocardia in an HIV-positive patient. IDINDN 1991;10:85-6.

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SIR-In his recent letter, Sieratzki [I] speculates that it is surprising that nocardiosis in patients with AIDS has been reported so infrequently. In addition to the review by Kim et al. [2], the case presented by Sieratzki [I], and the two other cases [3, 4] that he found in the literature, there are actually several other cases [5-9]. Aside from missing case reports, a misapprehension apparently is at work that produces Sieratzki's surprise: the incidence of the disease is reflected by its appearance in the literature. Sporadically occurring disease is seldom reported after the first cluster ofcase reports. Unless there is something new to say, why report it? Further, I would postulate another possible reason for misapprehension. Many of the antimicrobial agents used to treat infections in patients with AIDS (e.g., trimethoprim-sulfamethoxazole) are active against Nocardia. Since the terminal clinical picture of patients with AIDS is one infection after another, it is likely that many such patients are inadvertently being treated with other possible diagnoses in mind. In the case that I reported [5], this clearly occurred. Nevertheless, we should be aware that the literature is not a mirror ofcurrent clinical reality: Staphylococcus aureus endocar-

ditis in the intravenous drug user has not been the subject of recent reports, but I have not noticed that it has ceased to occur.

Nocardiosis in patients with AIDS.

370 CORRESPONDENCE Nocardiosis in Patients with AIDS Correspondence: Dr. Charles E. Cherubin, Infectious Diseases Section, Department of Veterans Af...
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