Chest Infections |

Nocardia in a Remitting Multiple Myeloma Patient Diagnosed by a Lung Mass Core Biopsy FREE TO VIEW

Samer AlSamman, MD; Christopher Hayner, MD; Stephen Blatt, MD
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Good Samaritan Hospital, Cincinnati, OH

Chest. 2014;146(4_MeetingAbstracts):165A. doi:10.1378/chest.1962888
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SESSION TITLE: Infectious Disease Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Nocardiosis is a bacterial infection caused by gram positive aerobic actinomycetes. Diagnosing Nocardiosis can be challenging and easily missed because of disease rarity, diversity of presentations, and inadequacy of specimens obtained by non-invasive means.

CASE PRESENTATION: A 64 year old man presented with an episode of seizures. Several days prior, he had headache, nausea and vomiting. He suddenly developed generalized tonic clonic seizures for 1-2 minutes, and then went unconscious. He has no history of seizures or neurological disease. He was given IV doses of Levetiracetam, then he woke up, with no focal neurological deficits. His past medical history is significant for Diabetes, chronic HCV carrier, multiple myeloma in remission with undetectable paraprotien, and autologous stem cell transplant a year ago, and currently on daily Linalidomide. Two month ago, he had right lower lobe infiltrate with exudative pleural effusion, but negative sputum and effusion cultures, and was treated as a pneumonia with oral levofloxacin. His physical and neurological exam was normal except for decreased breath sounds over the right lower lobe. CBC and BMP were normal. Head CT scan showed Hypodensity in left posterior temporoparietal region, and a Head MRI showed multiple areas of abnormal T2 and FLAIR signal and one area in the left parieto-occipital lobe demonstrates enhancement. CSF cell count, AFB, bacterial and fungal cultures were negative. Chest CT showed 6 pulmonary nodules in the right lung, the largest measures 5.8 x 4.2 cm, and small right pleural effusion. A transthoracic core biopy of the largest mass was done, cytology was negative for malignancy, but there was gram positive branching rods, turned to be Nocardia Farcinica on culture. IV Ceftriaxone and Bactrim were started and after 2 days meropenem was substituted for Ceftriaxone as patient continued to be free of seizures.

DISCUSSION: This case demonstrates how disseminated nocardia can present. About 64% of cases occur in the immunocompromised, particularly those with impaired cell mediated immunity. Multiple myeloma itself affects the humoral immunity more than the cell mediated, while medications used to treat it like Linalidomide impaire the cellular immunity. Disseminated Nocardiosis occurs in 32% of cases, 44 % of them have CNS involvement because of nocardia’s special tropism for neural tissue. Diagnosis was not possible in our patient with the non-invasive methods.

CONCLUSIONS: Suspect nocardia in patients who present with brain, soft tissue or cutaneous lesions, and concurrent or recent pulmonary process. Cultures obtained by invasive techniques significantly increases the positive predictive value. Bactrim is usually part of multiple prolonged antimicrobial regimens but some strains can be resistant.

Reference #1: Pamukçuoğlu M, et al. Brain abscess caused by Nocardia cyriacigeorgica in two patients with multiple myeloma: novel agents, new spectrum of infections.Hematology. 2013 Jul 31.

DISCLOSURE: The following authors have nothing to disclose: Samer AlSamman, Christopher Hayner, Stephen Blatt

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