Chest Infections |

An Infectious Case of a Solitary Pulmonary Nodule FREE TO VIEW

Timothy Hauser, MD; Joel Nations, MD
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Walter Reed National Military Medical Center, Bethesda, MD

Chest. 2014;146(4_MeetingAbstracts):134A. doi:10.1378/chest.1992334
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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: The etiology of pulmonary nodules can vary widely including malignancy, infection or inflammation. History and risk factors can sometimes lead the workup in the wrong direction. We present a case of an 82 year old male with a left upper lobe nodule.

CASE PRESENTATION: An 82 year old male is evaluated for a pulmonary nodule noted on pre-operative chest x-ray. The patient had developed amiodarone induced thyrotoxicosis and failed corticosteroid therapy prompting the need for thyroidectomy. A CT scan revealed a solitary 2.5 x 2.2cm nodule. His history is significant for 6 months of steroid use, a 30 pack year history and COPD. A PET scan confirmed avidity of the nodule, in addition to a 1 x 1 cm left deltoid avid lesion. Ultrasound guided FNA of the deltoid lesion revealed neutrophils but no malignant cells or organisms. Bronchoscopy of the LUL nodule was nondiagnostic. CT guided biopsy of the pulmonary nodule and a core biopsy of the deltoid lesion both showed no malignant cells but had weakly acid fast positive filamentous bacteria consistent with nocardia. Cultures revealed nocardia cyriacigeorgica. The patient was treated with oral trimethoprim sulfamethoxazole (TMP-SMX) and intravenous ceftriaxone.

DISCUSSION: Nocardiosis is a risk in immunosuppression including corticosteroids alone. One case series showed that nearly 2% of lung transplant recipients developed nocardia infection. 39% of patients with nocardia infection present with pulmonary disease alone, while disseminated nocardiosis can occurs in up to 32%. Pulmonary manifestations of nocardia include pulmonary nodules, interstitial infiltrates, reticulonodular pattern, and pleural plaques. TMP-SMX has variable efficacy as a prophylactic agent depending on the dose and frequency with daily dosing being shown to be more effective than three times weekly dosing.

CONCLUSIONS: Opportunistic infections are a growing concern in the medical community with the increase in immunosuppressive therapies. Currently there are no guidelines regarding prophylactic therapy for most immunosuppressed patients.

Reference #1: Wilson, John W. Nocardiosis: Updates and Clinical Overview. Mayo Clinic Proceedings. 2012; April:87(4):403-407

Reference #2: Beaman BL, Beaman L. Nocardia species: host-parasite relationships. Clin Microbiol Rev. 1994:7(2):213

Reference #3: Poonyagariyagorn HK et al. Challenges in the diagnosis and management of Nocardia infections in lung transplant recipients. Transpl Infect Dis 2008; 10(6): 403-8

DISCLOSURE: The following authors have nothing to disclose: Timothy Hauser, Joel Nations

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