Critical Care |

A Rare Cause of ARDS and Bacteremia FREE TO VIEW

Praveen Bondalapati, MD; Ruchi Bansal, MD; Pramil Vaghasia, MD; Liziamma George, MD
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New York Methodist Hospital, Brooklyn, NY

Chest. 2013;144(4_MeetingAbstracts):281A. doi:10.1378/chest.1705187
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SESSION TITLE: Critical Care Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Infectious complications in immunocompromised patients carry high mortality and are often difficult to identify and treat. We report a case of Nocardia farcinica bacteremia in a patient receiving chemotherapy for multiple myeloma.

CASE PRESENTATION: A 71 year old female with h/o Multiple Myeloma on chemotherapy with bortezomib and dexamethasone was admitted with fever, chills, cough and progressive lethargy. On admission, she was febrile, tachycardic, and tachypneic. Lung exam revealed left sided rales. Laboratory examination was significant for leukocytosis of 21,000 per microliter. Chest x-ray revealed a left upper lobe opacity. She was treated with broad spectrum antibiotics after blood cultures were drawn. Her condition then worsened and she developed acute respiratory distress sydrome (ARDS) on day 2 requiring intubation and mechanical ventilation and multiple vasopressors. On day 4, blood cultures drawn on admission grew Nocardia species and she was started on trimethoprim-sulfamethoxazole (TMP-SMZ), Imipenem and Amikacin. In spite of aggressive management, she expired from multi-organ failure. Nocardia was subsequently identified as N. farcinica.

DISCUSSION: Nocardia is an aerobic gram positive, partially acid-fast bacterium found ubiquitously in soil and water(1) and its isolation from blood is rare(2). There are about 50 different species of Nocardia identified, of these N. farcinica constitute 19%(3). N. farcinica is characterized by its high resistance to conventional antibiotics and propensity to cause disseminated infection. It is associated with high mortality ranging from 31% to 39%(2). In a recent review, out of 67 cases of Nocardia farcinica from 2000 to 2012, 88% were in immunocompromised patients. Most common risk factors include immunosuppression with steroids or chemotherapy (61%), solid organ transplant (12%), COPD (9%) and malignancy (8%)(2). N. farcinica isolates are resistant to ampicillin, cefixime, tobramycin, and third generation cephalosporins. They are usually susceptible to Amikacin, Dapsone and TMP-SMZ(1,3). The treatment of choice for Nocardia is TMP-SMX. Other antibiotics like Imipenem, Amikacin and Linezolid have also been tried.

CONCLUSIONS: Nocardia should be considered in the differential diagnosis in a patient with immunocompromised conditions especially those being treated with steroids and chemotherapy and in transplant recipients. Since isolation of Nocardia is difficult, empiric treatment against it should be considered if there is no response to conventional empiric broad spectrum regimens.

Reference #1: Lerner PI. Nocardiosis. Clinical Infect Dis 1996; 22:891-903

Reference #2: Budzik JM et al. Disseminated Nocardia farcinica: literature review and fatal outcome in an immunocompetent patient. Surg Infect. 2012 Jun;13(3):163-70

Reference #3: Wallace RJ Jr, Tsukamura M, Brown BA, et al. Cefotaxime resistant Nocardia asteroides strains are isolates of the controversial species Nocardia farcinica. J Clin Microbiol 1990; 28:2726-2732

DISCLOSURE: The following authors have nothing to disclose: Praveen Bondalapati, Ruchi Bansal, Pramil Vaghasia, Liziamma George

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