A life-threatening case of disseminated nocardiosis due to Nocardia brasiliensis
A 67-year-old Caucasian man was referred to the emergency department complaining for dyspnea and fever. The symptoms had started 5 days earlier. The patient had a history of successfully treated non-Hodgkin lymphoma (NHL) 7 years earlier, and was diagnosed with autoimmune hemolytic anemia, unrelated to NHL recurrence, 3 months before admission. He was put on steroids (64 mg) while no prophylaxis with trimethoprim-sulfamethoxazole was given. When he was first seen his was on tapered doses of methylprednisolone (20 mg) and oral cyclosporine. On physical examination the patient was somnolent, his temperature was 38,5°C, blood pressure was 85/45 mmHg and pulse 120/min. Skin examination revealed the presence of intracutaneous nodular lesions (1.5 cm in diameter) on the forehead as well on both forearms [Figures , ], with absence of regional lymphadenopathy. In chest examination crepts were present in both hemithoraces. His arterial blood gases revealed significant hypoxemia (PO2: 56 mmHg in room air). Respiratory and circulatory support was administered, and although hemodynamic stability was achieved, he developed respiratory failure necessitating intubation and admission to the Intensive Care Unit (ICU).\nLaboratory workup revealed: hemoglobin 8.2 g/dL, total leucocyte count 8.410/mm3 (94% neutrophils), platelet count 100.000/mm3 and C-reactive protein was elevated at 83.2 mg/dl (normal <0.5). Serum chemistries were within normal limits.\nChest X-rays demonstrated opacity in both lung fields []. A contrast-enhanced computed tomography chest scan showed subsegmental consolidation in right posterior upper segment, right-sided septal thickening, air bronchograms and irregular nodules with cavitation prominent in the anterior upper of the left lobe [].\nPurulent bronchial secretions were collected by bronchoscopy and sent for stains and culture along with material from dermal lesions sampled by needle aspiration.\nDirect Gram stain of skin and bronchial secretions revealed the presence of Gram-positive long, obviously branching, thin and finely beaded rods []. Modified Ziehl-Nielsen stain using 1% sulfuric acid as decolorizer, showed the true partially acid-fast nature of the organism. Specimens were cultured using the standard procedure on blood, chocolate, and Sabouraud dextrose agar, on Lowenstein-Jensen medium and in MGIT960 tubes. After 3 days of incubation all cultures grew white colonies, chulky in consistency [] with a pungent musty-basement odor. Acid-fast stain of material from a positive MGIT960 tube showed delicate, branching, acid-fast filaments []. The presence of Nocardia spp was suspected and the organism was further identified using molecular techniques.\nOf note, our patient was HIV negative and the blood cultures taken were sterile.\nThe patient was initially treated with imipenem-cilastatin and linezolid. His clinical course was uneventful, with a rapid improvement in lung function leading to extubation 3 days later, accompanied by involution of the subcutaneous nodules. Ten days after his admission to the ICU he was discharged to the ward. He was subsequently treated with intravenous trimethoprim-sulfamethoxazole after sensitivity determination was available (TMP-SMX, 10 mg/kg/day of TMP). He was disharged 3 weeks later with on oral TMP-SMX (160/800 mg b.i.d).