HIV combined with skin infection of Nocardia brasiliensis: A rare case report

  1. YUN XING
  2. Shilu Li

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Abstract

Introduction. The HIV virus can attack and gradually damage the human immune system, causing the host to be unprotected when infected. Nocardia is a type of opportunistic pathogenic bacteria that can easily cause infections in patients with chronic wasting diseases, immune dysfunction, and the use of immunosuppressants. Nocardia can invade various tissues and parts of the body, causing corresponding clinical symptoms. There are few reports of HIV patients being infected with Brazilian Nocardia.   Case presentation. This article reports a case of an HIV patient with concurrent infection with Brazilian Nocardia. A patient with HIV developed a lump on the surface of their left skin without any obvious cause. Due to improper disinfection and treatment methods, the condition worsened, and they subsequently sought medical attention at our hospital. A series of laboratory related tests are conducted clinically based on the patient's medical history, symptoms, and signs. Based on the test results, a reasonable treatment plan was adopted clinically, ultimately achieving satisfactory treatment outcomes for patients.   Conclusion . HIV patients are prone to various types of infections, even rare bacteria, as their immune function decreases. With the popularity of new identification methods such as mass spectrometry, laboratories should pay attention to traditional staining methods and use microscopes to detect pathogens.

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  1. Access Microbiology

    The reviewers have highlighted major concerns with the work presented. Please ensure that you address their comments. The paper is poorly structured and written, which has prevented a proper assessment of the research done.

  2. Access Microbiology

    Comments to Author

    Many thanks for authors for their contribution. They have responded to initial reviewers' comments adequately but I do believe the manuscript can be significantly improved. There are quite a few grammatical errors throughout and a thorough proof-read is recommended. The 'Case Report' could also be structured better. Some specific suggestions; ABSTRACT Line 27 - '…laboratory related tests were…' Please maintain proper tenses INTRODUCTION Line 42 - '…bacterium can invade various bodily tissues, causing…' CASE REPORT Line 62 - 'Yellow water' is not appropriate. Water is a very specific term, consider 'fluid' instead Line 65 - The patient was treated with disinfection, what disinfection? Line 65 - '…and an intravenous cefazolin effusion at the clinic…' Line 68 - 'Five years prior, the patient went to a private clinic for penicillin because…' Line 69 - '…HIV acquisition…' Line 69 - You mention the HIV viral load here, was this the HIV viral load at that time or currently? If it is his current viral load, it should not be placed here but further down the manuscript with his current laboratory results. Line 70 - '…long term antiretroviral treatment with tenofovir and ribavirin.' From Line 71 your structure is incredibly poor with no sentence structure. Please rectify. Listing things is not appropriate. Consider subheadings. For example; - Past Medical and Surgical History A previous cholecystectomy was performed in 2021, with no reported blood transfusions, intravenous drug use or underlying chronic medical conditions. - Examination Line 73 - A 3cmx4cm pustule with an overlying brown scab was observed on the dorsum of the left hand, with associated erythema, swelling, warmth and tenderness. Line 75 - 'A linear blanching erythema…' Line 76 - Omit 'which could fade when pressed' - This is 'blanching' - Investigations This part of the manuscript is incredibly difficult to read. Your results are not easy to follow. Consider a Table with Test/Value/Reference Range. That way, a reader can easily understand what the values mean. Are they elevated? Listing them in isolation is poor. Also consider separating them out into Biochemistry, Haematology, Microbiology. Also, you report on syphilis serology, please put the interpretation as to what the result means. Line 88 - Please start new paragraph Again, this entire section is poorly structured. Words are just put together. Please rewrite. Sentence structure is weak. Your information should tell a story, your paragraph seems like it was meant to be bullet points. Consider reviewing other Case Reports to see how to structure if you are having difficulty. Your information is good but just presented poorly. Line 94 - Again, Baiduobang ointment is mentioned. Please consider explaining what this is. Not everyone would know what this is. Line 95 - '…left back…' - I presume you mean 'dorsum of the left hand'? Line 97 - '…quail egg sized…' - Please stop using these descriptions of sizes. They are not standardised. I personally have no idea the size of a standard quail egg. Use metric units. DISCUSSION Line 114 - '…bacteria and is weakly acid…' Line 128-138 - This information is irrelevant in your Discussion. You are just re-quoting your Case Report. Omit. Line 140 - 'If the scientists…' Line 141 - Omit 'do not pay attention to observation'. Are you implying that a scientist may neglect appropriate observations? Line 150 - New paragraph Line 153 - 'Our patient…formed locally…his hand…' Line 158 - Do not use etc. and please restructure the rest of the manuscript. Overall the information presented is important but the manuscript is written extremely poor and requires a significant re-write.

    Please rate the quality of the presentation and structure of the manuscript

    Very poor

    To what extent are the conclusions supported by the data?

    Strongly support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    No

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  3. Version published to 10.1099/acmi.0.000782.v2 on Access Microbiology
  4. Access Microbiology

    The reviewers have highlighted major concerns with the work presented. Please ensure that you address their comments. The language used is poor, which can cause ambiguity at times. Please carefully rewrite it. We offer a discounted translation service, Editage (https://www.editage.com/; see https://www.microbiologyresearch.org/prepare-an-article#13 for more information)

  5. Access Microbiology

    Comments to Author

    Dear Editor, Many thanks for inviting me to review this case report. This is an interesting case and highlights the risk of opportunistic infections in patients living with HIV, as well as difficulties with laboratory diagnosis of certain pathogens. I have some comments and queries that I believe would strengthen this case report. Overall this is an interesting case. The description of the case is good. However, the grammar and syntax of the article text could be improved. I would suggest that the case should be presented in the past tense throughout. Specifically, I would suggest the follow edits/clarifications: 1. Throughout the article, the bacterium should be referred to as Nocardia brasliniensis or N. brasliniensis rather than Brazilian Nocardia. The name of the bacterium should be italicised. 2. It would be more correct to say "patient with HIV" rather than "HIV patient". See lines 23, 31, 44, 48, 119, 122. 3. Line 24: Suggest change "left skin" to "dorsum of left hand". 4. In the first sentence of the introduction (line 38), "AIDS virus" should be changed to "human immunodeficiency virus". I would also suggest clarifying that this risk to the host immune system is for patients with untreated HIV. 5. Line 43: State the corresponding symptoms associated with each system. 6. Line 55: I am not familiar with the size of a mung bean and am not sure that this is a widely recognised size comparison. Suggest that the authors change this to a metric measurement (e.g. size in centimetres). 7. Lines 55 and 57: Suggest change "ago" to "prior to presentation". 8. Line 60: Remove quotation marks from "cephalosporin". Could the authors name the oral cephalosporin? 9. Line 63: Suggest change "They are not coming to out hospital for treatment" to "The patient was referred to our hospital for further management". 10. Line 64: The source of the patient's HIV exposure is unclear from this statement. Suggest that authors should clarify this. I also note that the authors state that the patient has no history of blood transfusion, which appears to contradict the possible blood exposure as the original source of the patient's HIV. 11. Line 65: The authors state that the patient is on long-term oral medication. I would suggest referring to this as "antiretroviral treatment (ART)" for clarity. Was the patient compliant with medication? Was any resistance testing carried out if the patient had been on long-term ART and was compliant with medication? Was a viral load checked? 12. Line 68: Suggest change "the left back" to "the dorsum of the left hand". 13. Lines 72-82: Suggest that the authors should tabulate the blood results for ease of understanding and give the normal reference range for each test. Was a HIV viral load checked? 14. Line 80: I am more familiar with absolute CD4 count for monitoring HIV response and so perhaps the authors could include this information here. 15. Line 81: Regarding the Syphilis serology - was the Syphilis IgM and RPR tested? Is the result consistent with active or previous Syphilis? Was the patient ever treated for Syphilis in the past? 16. Line 87: Suggest change "the left back" to "the dorsum of the left hand". 17. Line 88: Suggest the full antibiotic name trimethoprim/sulfamethoxazole for the first reference to this antibiotic. 18. Line 93: Regarding the referral for HIV treatment - was this patient's HIV considered untreated upon initial presentation, which would explain the risk of opportunistic infection. 19. Line 107: It is my opinion that Figure 4 does not add any significant value to the presentation of the results and so the authors should consider removing this figure. 20. Line 122: Suggest delete the word "anti". 21. Line 123: Suggest delete arrow and change the sentence to "...a low T4/T8 ratio." 22. Line 125-128: The blood results should not be repeated in the discussion. Suggest summarise the interpretation of the significant results rather than repeating the actual values. 23. Line 132: Was the patient treated for only 7 days? Nocardia infection would usually require a long treatment course. 24. Line 155: Suggest change "regrets" to "limitations".

    Please rate the quality of the presentation and structure of the manuscript

    Satisfactory

    To what extent are the conclusions supported by the data?

    Strongly support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    No

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  6. Access Microbiology

    Comments to Author

    Many thanks for your contribution. Your case is indeed interesting but would benefit greatly from an English review for the many grammatical errors throughout. The case can also be better structured - use paragraphs. Please revise! Some specific comments; The term, "Brazilian Nocardia," is used repeatedly throughout the manuscript; surely the authors mean Nocardia brasiliensis and this should be amended. Line 64 - The patient was infected with HIV after being exposed to the patient's blood 5 years ago? How? A needle-stick injury? Please elaborate. Line 65 - The medications are stated but clarity on his viral load here would be helpful in setting the clinical picture, is he Undetectable? Line 68 - I presume you mean the back of the left hand Laboratory test results would be much better presented in a Table or list, incorporated into the text makes it very difficult to appreciate Line 84 - Is it routine to do acid fast staining? Or was this done because of the branching nature of the Gram? Line 88 - What is Baiduobang? Line 88 - Do not abbreviate SMZ-TMP as not all readers would know what antibacterial that stands for. How long was he treated with the antibacterial? Only 7 days? Was the patient assessed for any other manifestations of opportunistic infections?

    Please rate the quality of the presentation and structure of the manuscript

    Good

    To what extent are the conclusions supported by the data?

    Strongly support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    No

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  7. Version published to 10.1099/acmi.0.000782.v1 on Access Microbiology