SESSION TITLE: Critical Care Student/Resident Case Report Posters IV
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Nocardia is a gram positive branching filamentous organism and it can disseminate to any organ. Nocardia bacteremia is rare, even in severely immunocompromised patients with underlying malignancies.
CASE PRESENTATION: A 51-year-old male presented to the emergency room with productive cough, shortness of breath and left-sided pleuritic chest pain of 2 weeks duration. His past medical history was significant for chronic granulomatous disease of unclear etiology on multiple biopsies (thought to be Sarcoidosis).He was being treated with prednisone and Methotrexate since 4-5 years. On physical exam, he was febrile, tachycardic, hypotensive and was saturating 94% on 3 liters of nasal cannula with decreased breath sound and dullness to percussion on left side. CT chest was suggestive of left sided loculated hydropneumothorax .He underwent video assisted thoracic surgery with drainage and partial decortications. He was started on Oral Bactrim and Linezolid based on gram positive branching rods on day 7of hospitalization. CDC reported his final blood culture as Nocardia veteran. Sputum and pleural fluid cultures were also positive for Nocardia. He developed thrombocytopenia due to Linezolid and could not tolerate Bactrim due to nausea. Antibiotics were switched to Ceftriaxone and Imipienem. Later in the course of hospitalization, he developed VII,IX and X cranial nerve palsy. MRI of the brain showed rim-enhancing lesion in the posterior left temporal gyrus .Biopsy of laryngeal wall was obtained which was positive for Herpes simplex virus. He had a complicated course and eventually he succumbed to death.
DISCUSSION: Although Nocardia species can be recovered in most blood culture systems, this rarely occurs despite frequent hematogenous dissemination.(1) The lungs are the primary site of nocardial infection in more than two-thirds of cases. Presence of another bacteremia should not lead to consider the gram positive rods as contaminant. Species identification is essential due to different susceptibilities and resistance to the antibiotics.(2) Mortality rate of almost 85% have been reported in disseminated form of the disease.
CONCLUSIONS: This case emphasizes that Nocardia bacteremia is critical because of limited antibiotic choices for successful therapy and increased mortality seen with delayed recognition of disseminated disease
Reference #1: 1)Nocardiosis: a case series and a mini review of clinical and microbiological features M.J. Agterof1*, T. van der Bruggen2, M. Tersmette2, E.J. ter Borg3, J.M.M. van den Bosch4, D.H. Biesma1; Netherlands journal of medicine
Reference #2: 2) Infection caused by Nocardia farcinica: case report and review. Eur J Clin Microbiol Infect Dis 2000;19(3):205-12. Torres OH, Domingo P, Pericas R, Boiron P, Montiel JA, Vazquez G.
Reference #3: 3) Kontoyiannis DP, Ruoff K, Hooper DC.Report of 4 cases and review of the literature.Infectious Disease Division, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
DISCLOSURE: The following authors have nothing to disclose: Tasneem Shah, Arunima Rajbhandary, Paras Dedhia, Urooj Fatima
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