Bittar et al. Journal of Medical Case Reports 2010, 4:84 http://www.jmedicalcasereports.com/content/4/1/84 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Nocardia farcinica lung infection in a patient with cystic fibrosis: a case report Fadi Bittar1, Nathalie Stremler2, Jean-Pierre Audié3, Jean-Christophe Dubus2, Jacques Sarles2, Didier Raoult1, Jean-Marc Rolain1* Abstract Introduction: Respiratory tract infections are the major causes of morbidity and mortality in patients with cystic fibrosis. Nocardia are rarely implicated in these infections and few reports of the involvement of this species are found in the literature. Case presentation: We describe a case of lung infection followed by chronic colonization of trimethoprim and sulfamethoxazole resistant Nocardia farcinica in a patient with cystic fibrosis. The chronic colonization of this uncommon bacterium in patients with cystic fibrosis was proved using a newly developed real-time polymerase chain reaction assay, which indicates that this bacterium, despite treatment, is difficult to eradicate. Conclusion: Our case report confirms that this organism can be recovered in persons with cystic fibrosis. Its eradication is necessary especially if the patient is to undergo lung transplantation. Introduction Since the early description of cystic fibrosis (CF), pul- monary infection has been recognized as having the greatest role in morbidity and mortality leading to pre- mature death in 90% of patients reported [1,2]. It has been demonstrated that accurate antimicrobial treat- ment is of great importance in avoiding the rapid destruction of the lung function of patients and in the spread of multidrug-resistant and/or highly virulent pathogens [1]. Case presentation In February 2007, a 15-year-old Caucasian French boy with CF (ΔF508, M1V heterozygote genotyping pattern) was admitted to the CF center in Marseille, France. He presented with fever (39°C), fatigue, haemoptysis, bron- chial syndrome, and respiratory decompensation. His chest X-ray showed multiple bilateral bronchial thicken- ing. He has had a history of persistent colonization of the respiratory tract since childhood with Staphylococcus aur- eus and Haemophilus influenzae. He also had a primary * Correspondence: jean-marc.rolain@univmed.fr 1Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes (URMITE), CNRS-IRD, UMR 6236, Faculté de Médecine et de Pharmacie, Université de la Méditerranée, Boulevard Jean Moulin, 13385 Marseille cedex 5, France colonization with Pseudomonas aeruginosa at the age of 10 and with Aspergillus fumigatus and Candida albicans at the age of 13. Our patient received inhaled fluticasone (1500 μg/day) on several occasions in 2006. On admission, his laboratory tests showed a white blood cell count of 25.63 × 109/L with 87% polymorpho- nuclear cells (PMNs). His C-reactive protein (CRP) was at 92 mg/L. A direct Gram-staining of his sputum taken at the time of his admission showed the presence of many polymorphonuclear leukocytes without squamous cells. The presence of Gram-positive branching filamen- tous bacilli and Gram-positive cocci was also noted. A standard culture and conventional identification of his sputum sample yielded 104CFU/ml of S. aureus, 104CFU/ml of Nocardia sp. that was isolated from Columbia colistin-nalidixic acid (CNA) agar (BioMér- ieux, Marcy l’Etoile, France) after three days of incuba- tion. Accurate identification at species level was achieved after 16S rDNA amplification and sequencing [3] leading to the discovery of N. farcinica (GenBank accession number AB162795, 100%). The sequence of our isolate has been deposited in GenBank under acces- sion number EU861514. The phylogenetic position of N. farcinica (strain 7400458) among closely related bac- teria is presented in Figure 1. Using the disk diffusion method we found out that the isolate was resistant to © 2010 Bittar et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.