Chest Infections |

Renal Transplant+Lung Mass: Cancer? FREE TO VIEW

Pooja Desa; Ketan Buch
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University of Kentucky, Lexington, KY

Chest. 2014;146(4_MeetingAbstracts):135A. doi:10.1378/chest.1964227
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SESSION TITLE: Infectious Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

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

INTRODUCTION: A mass is a pulmonary lesion >3cm in size concerning for malignancy, but an infection must be ruled out. Occam’s razor may be irrelevant- an immunocompromised host can have multiple opportunistic pathogens.

CASE PRESENTATION: 52 year old male farmer with renal transplant on immunosuppressant’s presented with three weeks of fever, productive cough and pleuritic chest pain. Crackles were appreciated over the right with a decrease in breath sounds at the right base. Labs revealed an elevated white blood cell count. Sputum showed partially acid fast filamentous branching rods consistent with Nocardia. Blood culture and subsequent sputum samples showed coccobacilli with short filaments consistent with Rhodococcus. Chest imaging revealed an 8cm right upper lobe mass with effusion and enlarged, necrotic mediastinal lymph nodes.

DISCUSSION: Nocardia and Rhodococcus are soil borne organisms acquired by inhalation. Increased incidence of these infections has been due to a rise in immunocompromised hosts and novelties in methods of detection. Chest CT reveals nodules or masses in more than 80% of Norcardia cases. Gram stain reveals gram positive beaded branching filaments that are partially acid fast. The laboratory must be alerted Nocardia is suspected since it is slow growing. Sulfonamides are treatment of choice. Exposure to domesticated horses may play a role in Rhodococcus acquisition. It is a non-motile intra-cellular weakly acid fast gram positive rod. Pulmonary disease is present in 80%. Cavitary upper lobe pneumonia is common with bacteremia in >80% of immunocompromised patients. Macrolides, rifampicin, aminoglycosides and imipenem are treatment choices.

CONCLUSIONS: Immunocompromised hosts are at risk for rare opportunistic infections but to our knowledge this is the first reported case of concomitant Nocardia and Rhodococcus infection in a renal transplant patient. There must be a high index of suspicion for multiple infections occurring simultaneously.

Reference #1: X Yu, F Han, H Wu, Q He, W Pent, Y Wang, H Huang, H Li, R Wang, J Chen. Nocardia infection in kidney transplant recipients: case report and analysis of 66 published cases. Transpl Infect Dis 2011: 13: 385-391

Reference #2: D Weinstock, A Brown. Rhodococcus equi: An Emerging Pathogen. Clinical Infectious Diseases 2002; 34:1379-85

Reference #3: K Blackmon, J Ravenel, J Gomez, J Ciolino, D Wray. Pulmonary Nocardiosis Computed Tomography Features at Diagnosis. J Thorac Imaging 2011; 26: 224-229

DISCLOSURE: The following authors have nothing to disclose: Pooja Desa, Ketan Buch

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