Chronic nocardiosis, Morgellons?

My lab is certified by CLIA and the College of American Pathologists for blood parasitology.  I examine blood for bloodborne parasites: Plasmodium (malaria), Babesia, Trypanosomes – flagellates, microfilaria. Today I became aware of a bacterium which may appear in the blood but is not bloodborne. Nocardia. I have a patient with this infection. I have been treating her for a long time.  We think Nocardia infection it is chronic along with tickborne pathogens. The bacterium is found in soil and water and is ubiquitous, there are numerous species, some not yet speciated/characterized. We (the patient and me) have thought she suffers with chronic nocardiosis.  She has a clear, documented history of Nocardia: positive pulmonary infiltrate and positive blood culture. This is a slow growing organism. Texts say this rarely seen organism cultures slowly, 3-5 days. Her culture was positive only after 28 days. Nocardia infections is thought to primarily occur in patients with impaired immunity. She lacked clear evidence of immune dysfunction. The bacteria forms lesions in the skin, lungs and brain. Generally, IV antibiotics are recommended initially followed by oral therapy. Standard sources say skin infection is always curable, lung infection is usually curable and brain infection is curable half the time. Texts don’t address chronic nocardiosis, but I haven’t done a literature search.

This bacterium takes on an unusual appearance.  We are accustomed to rods, cocci and spirochetes.  Microscopically these appear as fungal-like filamentous structures.  The filaments vary in length.  Over the years I seen similar things I thought they were contaminants or artifacts and most likely were (not using the same stain).  Perhaps I missed something.  Of course, this was not on my radar.  Images are startling. Images of clumped filamentous structures, looking not like bacteria at all but rather the dense threads seen with Morgellons appear. The images, if correct (I have not validated them) can be found on google images. I know for a fact that some images on google images are incorrect.

Then there are patient images of skin lesions of the cutaneous form of the disease. Some look horrible.  Some clearly resemble lesions seen with Morgellons.

The chest X rays and brain MRIs are distinct from those seen with tickborne disease.

Again, this organism is found on skin and in the lungs and brains. In severe cases it may also appear in blood, gram stains. I don’t know if it also appears in Giemsa stains I perform.

I wonder if some cases of Morgellons are misdiagnosed nocardiosis. I wonder if Lyme immunosuppression plays a role in the pathogenesis of the disease.  Antibiotics recommended are some of the same ones used for Lyme but not exactly the same ones. The initial early treatment recommended is IV Bactrim.

Lyme and biliary disease

Most readers have some familiarity with the liver and gallbladder.  The biliary (bile duct) system includes the gallbladder and a collection of ducts coming from the liver which join to enter the first part of the small intestines, the duodenum, the first part of the small intestines (bowel) just below the stomach. 


The liver is best known as our body’s detoxification organ (along with kidneys). The liver “metabolizes,” alters and excretes medicines and other substances. 


The liver makes bile, a yellow viscous fluid stored in the gallbladder, located directed under the liver. The gallbladder contracts with meals. Bile made of bile acids, from cholesterol, aid in the digestion of fat (an emulsifier) but has many other functions.  


The liver detoxifies medications and toxins through a system of enzymes with names like cytokine P450. Toxins and medications may end up in bile. 

Adsorption of medications may be dependent on something called the enterohepatic recirculation of bile.

Most bile is recycled from the gut which is considered 95% efficient. A particular bile acid molecule may be used 20 times before it is replaced. This is not necessarily a bad thing. The process of repeated cycling may enhance the function of therapeutic drugs and delay their excretion. For liver toxins this works the other way.  Proper functioning of the enterohepatic system depends in part on a healthy gut flora and specific bacterial enzymes.  Higher doses of antibiotics may be required because disruption of normal flora and necessary enzymes caused by the antibiotic(s). 

The use of bile acid sequestrants to remove unknown toxins like cholestyramine is not supported by scientific evidence. 

Some antibiotics promote the production of biliary cholesterol sludge and gall stones, primarily Rocephin, the popular intravenous drug used to treat Lyme disease.  Cholecystitis (gall bladder attacks) with or without the presence of gall stones is a common occurrence. 

Lyme anecdotally can attack the biliary system. Cases of positive Lyme PCR/DNA from gallbladder tissues are known to me but there are no published reports to date. 

Published reports have established Lyme liver disease in the form of granulomatous hepatitis. 
Tests like sonogram, HIDA/CCK scan and others may be used diagnostically for problems with gallbladder and bile ducts.  Negative test results do not rule out gallbladder/biliary disease. 

I am treating a patient with primary biliary cholangitis (PBC). Generally, the disorder is considered autoimmune, “idiopathic,” which of course means the patient is pathological and the doctor is an idiot. Some European literature (this patient is European) connects Lyme with this enigmatic illness. The patient has a clear history of Lyme. No such connection is made in the U.S. PBC is now a treatable disease. 

Bile via an array of ducts ultimately empties into the common bile duct. Bile the empties into the duodenum into a structure called the Ampulla of Vater. The flow of bile is regulated by a muscle called the sphincter of Oddi. 

After cholecystectomy, (surgical removal of the gallbladder), prior gallbladder pain may seem to recur. The bile ducts may become dilated. When a medical workup excludes a left-over stone stuck in bile duct, liver disease, pancreatic disease and other rare diseases, the diagnosis may be post-cholecystectomy syndrome or sphincter of Oddi dysfunction.

These syndromes are more common in Lyme patients, many of whom suffer with gallbladder disease and biliary tract disease and have had their gallbladders removed. 

The diagnosis is commonly missed or not taken seriously. The disorder can be disabling. Effective medical therapy, in my recent experience, is available but overlooked.