Pulmonary Nocardiosis in Suspected Tubercilosis Patients… Susan MM. et al. 293 REVIEW Pulmonary Nocardiosis in Suspected Tuberculosis Patients: A Systematic Review and Meta-Analysis of Cross-Sectional Studies Susan Mansuri Mehrabadi1, Mina Taraghian2, Aliyar Pirouzi3, Azad Khaledi3, 4*, Alireza Neshani5, Somaye Rashki4 OPEN ACCESS ABSTRACT Citation: Susan Mansuri Mehrabadi, Mina Taraghian, Aliyar Pirouzi, Azad BACKGROUND: nocardiosis is an opportunistic infectious disease khaledi, Alireza Neshani, Somaye Rashki. Pulmonary Nocardiosis in in immunocompromised patients. The most common form of Suspected Tuberculosis Patients: A nocardiosis infection in humans is pulmonary nocrdiosis caused by Systematic Review and Meta-Analysis of inhaling Nocardia species from the environment. Thus, this study Cross-Sectional Studies. Ethiop J Health Sci.2020; aimed to evaluate the pulmonary nocardiosis in patients with 30(2):293.doi:http://dx.doi.org/10.4314/ejhs suspected tuberculosis using systematic review and meta-analysis. .v30 i2.17 Received: November 5, 2019 METHODS: We conducted a systematic search for cross-sectional Accepted: November 11, 2019 studies focused on the pulmonary nocardiosis among patients with Published: March 1, 2020 pulmonary tuberculosis based on the Preferred Reporting Items for Copyright: ©2020 Susan MM., et al. This is an open access article distributed Systematic reviews and Meta-analysis (PRISMA) published from under the terms of the Creative Commons January 2001 to October 2019. The search was conducted in Attribution License, which permits unrestricted use, distribution, and MEDLINE/PubMed, Web of Science, Scopus, Cochrane Library, reproduction in any medium, provided the Google Scholar, Science Direct databases, and Iranian databases. original author and source are credited. Medical subject headings (MeSH) and text words were searched: Funding: Nil Competing Interests: The authors “pulmonary nocardiosis”, “nocardiosis”, OR “nocardial declare that this manuscript was approved infection”, “pulmonary nocardial infections/agents”, AND by all authors in its form and that no “pulmonary tuberculosis”, OR “pulmonary TB”, AND “Iran”. competing interest exists. Affiliation and Correspondence: Two of the reviewers enrolled independently articles published in 1Medical Student, Department of English and Persian languages according to the inclusion and the Medicine, Kazeroun Branch, Islamic Azad University, Kazeroun, exclusion criteria. Comprehensive Meta-Analysis software (Version Iran 3.3.070) was used for meta-analysis. 2Department of Microbiology, RESULTS: Only 4 studies met the eligibility criteria. The School of Basic Sciences, Hamedan Branch, Islamic Azad University, pulmonary nocardiosis prevalence varied from 1.7% to 6.7%. The Hamedan, Iran combined prevalence of nocardiosis among patients with suspected 3Cellular and Molecular Gerash pulmonary tuberculosis in Iran was 4.8% (95% CI: 3-7.3, Q=5.8, Research Center, Gerash University of Medical Sciences, Gerash, Iran Z=12.7). No heterogeneity was observed between studies because 4Infectious Diseases Research I2 was 48.3. N. cyriacigeorgica and N. asteroides were reported as Center, Department of Microbiology and Immunology, the prevalent isolates, respectively. Faculty of Medicine, Kashan CONCLUSIONS: This review showed in patients suspected TB University of Medical Sciences, when they were negative in all diagnosis laboratory tests, Kashan, Iran 5Department of Microbiology and nocardiosis cases which be considered. Virology, Faculty of Medicine, KEYWORDS: Nocardia infection, nocardiosis, Pulmonary Mashhad University of Medical Tuberculosis, Pulmonary Nocardioses Sciences, Mashhad, Iran *Email: [email protected] DOI: http://dx.doi.org/10.4314/ejhs.v30i2.17 294 Ethiop J Health Sci. Vol. 30, No. 2 March 2020 INTRODUCTION affects predominantly people of between 20 and 60 years of age (19). The prevalence of the disease in Nocardiosis is an opportunistic infectious disease Iran is not known and often has been reported as a in immunocompromised individuals and in people case report. In the USA, the annual incidence rate with healthy immune systems is reported as a case of the disease was reported between 500-1000 (1-4). The nocardiosis spectrum consists of cases (16). In most cases, Nocardia infections are pulmonary, cutaneous, subcutaneous, cerebral, not diagnosed quickly because of a lack of specific cutaneous lymphatic or systematic diseases (3-5). clinical symptoms (20,21). The most common form of nocardiosis infection in Since these organisms are slow to grow, the humans is a pulmonary form caused by inhaling rapid and accurate diagnosis of them from other Nocardia species from the environment. So far, organisms for the treatment of severe infections more than 50 species of Nocardia have been and as well as prevention of brain abscess identified. Of which, the important pathogenic formation is essential. The use of molecular species include N. brasiliensis, N. asteroids methods compared to culture have the high speed, complex, N. pseudobrasiliensis, N. transvalensis, accuracy, sensitivity, and specificity in the and N. otitidiscaviarum (6). Nocardia is a Gram- identification of Nocardia species(22). There is the positive, obligatory aerobic, catalase-positive, non- motility, and relative acid-fast microorganism. It is lack of comprehensive data on the prevalence of pulmonary nocardiosis in Iran. The present study slow-growing and in the culture and tissue thus aimed to evaluate the pulmonary nocardiosis environment often forms filaments that convert in suspected tuberculosis patients using systematic easily to coccus and bacillus forms (7). The main review and meta-analysis of cross-sectional studies. site of Nocardia species is soil, but it is also found in water, sewage and organic residues of plants (8). METHODS AND MATERIALS However, the geographic prevalence of each species may change tremendously over the world, Search strategy: We conducted a systematic and some are rare (9). These opportunistic bacteria search for cross-sectional studies focused on the are facultative intracellular, which with suppressing pulmonary nocardiosis among patients with the immune system, are capable of replacing in pulmonary tuberculosis based on the Preferred different parts of the body including the lungs (10). Reporting Items for Systematic reviews and Meta- Also, they tend to expand to blood circulation and analysis (PRISMA) published from January 2001 cause brain abscesses and skin infections; if they to October 2019. A systematic literature search was are miss-diagnosed and unless timely treated will conducted in MEDLINE/PubMed, Web of Science, be fatal (11). Since patients with immune- Scopus, Cochrane Library, Google Scholar, and deficiency, Hematological malignancies, organ Science Direct databases. Medical subject headings transplant recipients, AIDS, prolonged (MeSH) and text words were searched within titles, consumption of corticosteroids, chronic alcoholism abstracts, and keywords. The search strategy was and diabetes that are deficient in T-cells, are as follows: “pulmonary nocardiosis”, susceptible to pulmonary nocardiosis (12). Some “nocardiosis”, OR “nocardial infection”, patients with nocardiosis usually have a chronic “pulmonary nocardia infections/agents”, AND underlying pulmonary disease and often under “pulmonary tuberculosis”, OR “pulmonary TB”, Long-term treatment with high doses of AND “Iran”. We included articles published in corticosteroids (13). Clinical signs and radiological English and Persian languages. Two reviewers, features of pulmonary nocardiosis are similar to A.K and AN, conducted the literature search. The that of pulmonary tuberculosis, but its progress is reference sections of retrieved studies were faster than tuberculosis having a period of several checked to find further relevant studies. months (14,15). Pulmonary lesions caused by Inclusion and exclusion criteria: All parts of the pulmonary nocardiosis are predominantly local and studies were read to check them against the have no clinical symptoms, and are associated with eligibility criteria. The inclusion criteria were: a) abscess and sometimes pneumonia (16-18). cross-sectional design, and b) assessing infection of Nocardiosis has a worldwide distribution and Nocardia and pulmonary TB. Studies published DOI: http://dx.doi.org/10.4314/ejhs.v30i62.17 Pulmonary Nocardiosis in Suspected Tubercilosis Patients… Susan MM. et al. 295 before 2001, case reports, abstracts, editorials, was used to calculate total effects. Cochran’s Q and literatures reporting inadequate data, case series, I square (I2) tests were used for assessing sources congress articles, meeting reports, letters to editors, of heterogeneity among studies. Publication bias articles published in languages other than English was checked by Egger’s regression asymmetry test. and Persian, duplicate publications, all review RESULTS forms were excluded. This peer-review process was performed independently by two reviewers Study selection: In total, 234 relevant articles were (AK, AN). Finally, discrepancies between two recognized via the initial literature search reviewers were resolved by involving a third (Figure1). About 111 records were excluded due to reviewer. duplications. Fifty-six studies were removed due to Quality evaluation: In the assessment process of the irrelevant titles. Then, abstracts 67 remained the qualities of studies, an appraisal tool for Cross- records were screened. It resulted in the exclusion