1 Introduction
Nocardiosis is an opportunistic, localized or disseminated infection, which mimics as a mycobacterium tuberculosis infection (Chopra et al., 2001). Nocardiosis most commonly presents as pulmonary disease and lesions in other sites are usually as secondary infections (Luce, 2010). The predominant predisposing factor that contributes the Nocardiosis includes: HIV infection, hematological malignancy, transplantation and immune suppressive drugs or steroids. Nocardia spp. belonging to the aerobic actinomycetes, is Gram- positive, partially acid-fast, slow growing saprophytic bacteria leads Nocardiosis. Generally, the infection transfer through the inhalation or from traumatic inoculation from skin surfaces, leading pulmonary or disseminated infection (Andalibi et al., 2015). In addition to this, exhibits broad clinical manifestations such as lymphocutaneous syndrome, brain abscess, keratitis, osteomylities and so on. There are more than 90 Nocardia species, and nearly 33 of which are pathogenic to humans. Nocardia asteroides is the commonest isolates that encountered in respiratory speciemens (Malladi et al., 2010).

Furthermore, the co-infection of Candida albicans is also dependent to above predisposing factors, the development of invasive disease with Candida albicans is dependent on multiple factors, such as colonization and efficient host defense at the mucosa (van de Veerdonk et al., 2010). Candida albicans are generally considered as normal flora of cutaneous and mucocutaneous and rarely incriminated as an agent of infection (Bannoehr et al., 2009). However, Wright et al. And Wenzel et al. suggested Candida albicans as a causative agent of nearly 60% nosocomial infection so their presence could not be neglected as normal flora. Herein, we present the case of Nephrotic syndrome Patient treated with corticosteroids, developed a primary pulmonary Nocardiosis with Candidosis and then cutaneous involvement.

2 Case study
2.1 Patient Information
A 62 years patient with a history of steroid treated nephrotic syndrome, hypertension, and habitual smoker with a recent history of returned from southern California USA. The combination of long term steroid therapy, chronic lungs disease has been suggested as primary important combination of risk for the infection. With a reference, to the report published by CDC Jan 2013, In United States it has been estimated of about 500-1000 new cases of nocardiosis occurs every year of which 60% are associated with the pre-existing immune compromise. Since, the patient had a history of returning from USA the patient might have acquired infection from USA.

2.2 Chief complain
The patient was presented to Emergency department (TUTH) along with the chief complain of shortening of breathe, dry cough, lethargy, low grade fever, restlessness, slight swelling of limbs, suggestive renal infection. As previous history of hypertension and nephrotic syndrome, admitted to Intensive care Unit in 24^th December, 2015 under Nephro consultant.

2.3 Relevant history including past interventions and outcomes
Pulmonary nocardiosis was not diagnosed previously; but the steroid treated nephrotic syndrome, hypertensive history of patient, habitual smoking behavior and recent returned from endemic region could be a predisposing factors which contributes in transmission of infection via respiratory route following cutaneous involvement (Imran and Ullah, 2009).

2.4 Physical Exam
Bp 130/100 mmHg, Pulse 87/min, SPo2 87% via nasal, Normal urine output steroid induced hypoglycemic state and mild swellings of limbs was noted.

2.5 Diagnostic assessment
On screening, Radiological findings showed the bilateral pneumonia with parapneumonic effusion and collection of abscesses in right mid intramuscular plane in anteriolateral aspects of right mid-thigh.

Moreover, laboratory findings reveals slight elevation of leucocytes count (12 740 cumm) with DLC (90N, 10L) in CBC, albumin trace in urine re/me, pleural tapping with total leucocytes count of 3 400 cells/cumm predominantly monomorphs (80%), sugar 8.3 mmol/liter, LDH 601 U/L, and ADA 18.2U/L.

2.6 Microbiological Approaches
AFB staining shows acid fast branching, filamentous bacteria suggestive Nocardia spp. (Figure 1). Gene Xpert excludes Mycobacterium tuberculosis. Furthermore, in AFB culture Nocardia spp. along with Candida albicans grown on LJ media after 72 hours of incubation at 37°C. The Sputum sample was inoculated in SDA and on LJ Media with and without decontamination by 4% NaoH. No growth seen from sample after decontaminating with 4% NaoH and this indicates possible inhibitory action of 4% NaoH. Nocardial spp. grown cultural media was confirmed with conventional techniques (phenotypic characteristic:- colonies are chalky, matt, dry, crumbly, adherent or velvety in appearances; 0.5 to 1.0 mm in diameter with fine intertwining, branching filaments with delicate aerial hyphae (Hall, 2013). Gram staining: Gram positive branching hyphae, AFB staining: acid fast positive branching hyphae, biochemical interpretations:- catalase (Positive), Nitrate reduction (Positive), Urea hydrolysis test (Positive), Bile esculine (Positive), Simmon’s citrate (Negative), No gelatin liquefaction and casein hydrolysis seen, Incubated in Temperature variation:- Incubation with temperature variation was done at 46°C and 10°C, no growth seen at 10°C but the growth seen at 46°C) as Nocardia asteroids (Figure 2). The antibiotic sensitivity test was performed by Kirby Bauer disc diffusion method following CLSI guidelines. The isolate was found to be sensitive for Cotrimoxazole, Cefotaxime, Ceftriaxone, Colistine, Erythromycin, Gentamycin, Imipenem, Amikacin, Linozolid, and Tobramycin (Figure 3). Later, phenotypically and characteristically similar type of organism grown from abscess. Hence, the isolate was confirmed as Nocardia asteroides with conventional techniques, since molecular analysis and sequencing are not accessible.

Similarly, for Candida albicans gram staining, Germ tube test was performed and then sub cultured on chrome agar (Hi Media). The germ tube test shows sprouting fungal hyphae and light green color colonies appears on chrome agar (Hi Media) (Figure 4).
 

2.7 Diagnostic reasoning and challenges
Sputum and Abscesses culture shows no significant growth after 24 hours of incubation at 37°C; since the saprophyte (Nocardia asteroides) was slow grower always there is a possibilities of missing although isolates are viable/ pathogenic microbes, therefore  frequent culture of specimens remained as option (Amatya et al., 2011). Pulmonary nocardiosis mimics as that of Mycobacterium tuberculosis, fungal invasion; diagnostic approaches are crucial for absolute prognosis. Rapid Gene Xpert analysis excluded the possibilities of Mycobacterium Tuberculosis co infection.

2.8 Interventions
The pleural tapping and abscess drainage was found to be an aid for diagnostic /prognostic approach, no need for surgical consultations. Initial Pleural tapping with total leucocytes count of 3400 cells /cumm predominantly monomorphs (80%), sugar 8.3 mmol/liter, LDH 601 U/L, and ADA 18.2U/L. The patient was treated with tab Sulfamethoxazole (Co trim DS), Cefexime 400 mg, Candid mouth paint LA tds, vitamin B and vitamin D was supplemented. Patient recovered sequentially, Radio-imaging report shows minimal free fluid seen in pleural cavity with nearly 3 ml of collection from right thigh abscess. Pleural fluid with markedly reduced total leucocytes count (1 700 cumm, sugar 5.2 mmol/liter, LDH 356U. Sequentially, patient achieved progressive changes/recovery, hence discharged on 13^th January, 2016 with same antibiotic therapy for six month with an advice of periodic follow up.

2.9 Follow-up and Outcomes
Patient undergoes quite satisfactory improvement clinically and symptomatically, with a normal CBC, normal biochemical test and normal urine re/me. X ray with very less fluid accumulated in Pleural cavity and in cutaneous membrane. No distinct adverse effect of drugs was noted. No drug allergy noted.

3 Discussion
Nocardia asteroides is associated with invasive and systemic disease occurs as an acute, subacute or chronic infectious disease with Pulmonary, cutaneous and in disseminated forms (Dar et al., 2009). Generally, the organism transmits via inhalation, deposit in lungs and then disseminates to other sites (Baldi et al., 2006). Nocardia spp. contain tuberculostearic acids like Mycobacterium spp, but in contrast they possess short-chain (40 to 60 carbon) mycolic acids and characteristic branching on Gram staining (Patil et al., 2012). These are facultative intracellular pathogens with an ability to grow in macrophages by their ability to produce catalase and superoxide dismutase (Bannoehr et al., 2009). The predominant clinical presentation of pulmonary nocardiosis, almost 90% found caused by members of the Nocardia asteroides complex (Imran and Ullah, 2009). However, Nocardia brasiliensis causes 3% to 9% and N farcinica is being recognized with increasing frequency (Marrie, 1994).

Since, Candida albicans was supposed as normal flora of cutaneous and mucocutaneous and rarely incriminated as an agent of infection (Bannoehr et al., 2009). However, Wright et al. and Wenzel et al. suggested Candida albicans as a causative agent of nearly 60% nosocomial infection so could not be neglected as normal flora and hence taken as possible pathogen. Although 16S ribosomal RNA sequence-based identification of Nocardia species is the gold standard, this technology was not available in our laboratories during the study period. Nocardia isolates were identified using a combination of traditional standard biochemical test, growth characteristics, and antimicrobial susceptibility patterns.

This case report would be a Clinical practice guideline for diagnosing the case having much similarity with malignancy, fungal invasion and Tuberculosis. Furthermore, limits chance of misdiagnosis with better prognostic approaches. Hence, it would be an assists for Clinician as well as Microbiologist in clinic-microbial interpretation.

4 Conclusion
The clinical symptoms and radiological findings are nonspecific and hence microbiological investigations enlighten the case as pulmonary nocardiosis co-infection along with Candida albicans and cutaneous involvement. Furthermore, suggests proper antimicrobial therapy and case management. This case report would be a Clinical practice guideline for diagnosing the case having much similarity with malignancy, fungal and Tuberculosis. And, limits chance of misdiagnosis due to lack of suspicion, non-specific clinicoradiological presentation, diagnostic intricacies, and lack of systematic reporting have hindered the true estimation of its incidence and better prognosis. Furthermore, it would be an assists for Clinician as well as Microbiologist in clinic-microbial interpretation.

In Nepal rare incidence of Nocardia keratitis mimicking fungal keratitis and herpes simplex viral keratitis was reported (Bajracharya and Gurung, 2012). Another case study was done from KIST medical college, Nepal but the isolate was Nocardia brasiliensis in an immunocompetent patient (Amatya et al., 2011). Despite, ours is Nocardia asteroides in a nephrotic syndrome patient under corticosteroid therapy with primary pulmonary and cutaneous involvement.

5 Informed Consent
Written informed consent was obtained from patient for publications of this Case report.

6 Abbreviation
ADA: Adenosine deaminase

AK: Amikacin

AST: Antibiotic sensitivity test

BA: Blood Agar

CA: Chocolate agar

CBC: Complete blood cell count

CDC: Centre for Disease Control and Prevention.

COT: Cotrimoxazole

CTX: Cefotaxime

CTR: Ceftriaxone

CL: Colistine

DLC: Differential leucocytes count

ERYTHRO: Erythromycin

GEN: Gentamycin

IMP: Imipenem

IOM: Institute of Medicine

LDH: lactate dehydrogenase

LJ media: Löwenstein-Jensen media

LZ: Linezolid

MHA: Muller Hilton Agar

NaoH: Sodium hydroxide

N brasiliensis: Nocardia brasiliensis

N farcinica: Nocardia farcinica

TC: Total count

TUTH: Tribhuvan University Teaching Hospital

TOB: Tobramycin  

7 Competting Interest
The author declare that they have no competing interest.

8 Authors Contributions
Mr. Priyatam Khadka: Performed out the presumptive tests, (AFB stain, Gramstain, Fluorescence stain, Germ tube test, and studied Morphological features, biochemical characteristics and Susceptibility pattern of antibiotics), Performed out Gene Xpert test, Drafted Manuscript and designing the frame work of Case report. Mr. Shyam Kumar Mishra Participated in presumptive test, proof reading of manuscript and design, report analysis and interpretation of data. Prof. Dr. Dibya Sing Shah participated in Clinical examination and treatment, management of patient, Review the case and suggest the drug of choice for patient with clinical interpretations. Prof. Dr. Basistha Prasad Rijal participated in design manuscript and co-ordinate authors provide guideness and supervise the overall case report analysis and Clinical interpretation of data.

9 Acknowledgement
It’s an honor to acknowledge and extend my sincere gratitude to my supervisor, Prof. Dr. Basistha Psd. Rijal, Head of department of Microbiology, TUTH and Assistant Lecturer Shyam kumar Mishra, IOM, for their excellent guidance and support. Under their excellence and expertise I was encouraged and inspired in every moment during case presentation. Dear sir this work wouldn’t have been possible in your absence and I will always remain indebted to you.

I will always grateful to Mr. Ramesh Bahadur Basnet (Senior Medical technologist of Mycobacteriology section, TUTH), Hari Psd Kattel (Medical Technologist of Bacteriology section, TUTH). And special thanks goes to my brother Pratap Khadka, and Januka Thapaliya for their technical support. Last but not least, I owe more than thanks to my parents, sisters and brother, the pillars of my strength.

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