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Int J Infect Dis. 2019 Feb 4. pii: S1201-9712(19)30059-1. doi: 10.1016/j.ijid.2019.01.046. [Epub ahead of print]

Granulomatous hepatitis by Nocardia species - An unusual case.

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Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India.
Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India. Electronic address:


We wish to report a case of granulomatous hepatitis due to Nocardia. A 63year old immunocompetent patient presented with persistent fever, weight loss and malaise. Radiology suggested enlarged liver with dense diffuse to multiple tiny micronodular areas of parenchymal involvement, possibly granulomatous. Liver biopsy showed necrotizing granulomas and anti-tubercular therapy was initiated, but the patient showed no improvement. A repeat liver biopsy showed similar histopathology, however PCR for Mycobacterium tuberculosis was negative, while MGIT 960 culture grew filamentous gram-positive bacilli, acid-fast by 1% H2SO4, identified biochemically as Nocardia spp. 16SrRNA sequencing confirmed Nocardia spp. A diagnosis of granulomatous hepatitis due to Nocardia spp was made. Treatment based on drug sensitivity testing was initiated, resulting in a resolution of symptoms. History revealed that stray dogs adopted by patient's family had skin lesions, likely canine distemper (two newborn pups died recently). Nocardia is known to co-infect animals with distemper. It could be the possible source of zoonotic infection to our case. Nocardia spp is seldom reported from sites other than the lungs, skin or brain, the current case highlights the involvement of liver. Due to the granulomatous tissue response, it could be a differential diagnosis of tuberculosis (TB) in such cases.


Granulomatous hepatitis

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