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Chest Infections |

Rhodococcal Emphysema Thoracis: A Case Report of Rhodococcus equi Present With Loculated Pleural Effusion

nittha oer-areemitr, MD
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phramongkutklao hospital, Bangkok, Thailand


Chest. 2015;148(4_MeetingAbstracts):153A. doi:10.1378/chest.2232109
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Abstract

SESSION TITLE: Infections Global Case Reports

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: An Rhodococcus equi has been identified as a pathogen since 1923 when it was isolated from the lung of a foal diagnosed of pneumonia in Sweden.The first case of human Rhododcoccal infection was reported in 1967 from lung specimen of an immunocompromised young man who worked in stockyard. Since 1980s, the incidence of Rhodococcal infection had been increasing markedly attributed to an increase in incidence of HIV infection and organ transplantation. The common presentation of Rhodococcal infection is pulmonary infection. Although pleural effusion may also be encountered in Rhodococcal pulmonary infection, however, empyema thoracis has been considered as a rare condition. We, here, reported a HIV-infected patient presenting with Rhodococcal empyema.

CASE PRESENTATION: We report a case of a-24-year old woman, a worker, who suffered from high graded fever, dry cough and pleuritic chest pain for one month. The physical examination found temperature 38.5 c, decreased breath sound and tenderness at anterolateral part of right chest wall. Chest x-ray revealed loculated pleural effusion. We performed ultrasound-guided thoracenthesis and 3 ml of frank pus was obtained. Numerous intracellular and extracellular coccobacilli were identified by Gram's and Kinyoun's stains respectively, thus, suggestive of Rhodococcal infection. In additional, her blood test for anti-HIV was positive. Rhodococcal empyema thoracis was diagnosed and we suggested her to do thoracotomy but she denied. So she was given intravenous ceftriaxone, vancomycin and oral rifampicin. Nevertheless, her clinical and chest x-ray were dramatically improve. The result of pus culture was Rhodococcus equi. Unfortunately, at the end of second week of antibiotics, she developed new onset of fever, generalized maculopapular rash and transaminitis, drug hypersensitivity was suspected which possible caused by rifampicin and/or vancomycin. After discontinuation of both antibiotics, her fever subsided with good clinical improvement. Ciprofloxacin and clarithromycin were started and she got along with these two antibiotics without any adverse effect. After continue antibiotics for 6 weeks, her clinical was very good and chest x-ray showed minimal blunt costophrenic angle. We desired to discontinue antibiotics and started antiretroviral therapy. To this day, she is in good clinical and no IRIS was detected.

DISCUSSION: Rhodococcal empyema thoracis was uncommon in HIV infection. We report a case of empyema thoracis from R. equi as the first presentation of AIDs in young female from Kanchanaburi province, Thailand. R. equi is found in domestic animal eg., horse, sheep, etc., and also found in soil in all continents except Antarctica.[i]This patient had never been direct contact to those animals but she lived in the house where 10 kilometers away from the sheep farm. Although contact with those animal may be a risk factor in R. equi infection but only one-third of all patients with R equi infection have a history of exposure to those animals.

CONCLUSIONS: R. equi was susceptible to vancomycin, amikacin, rifampicin, imipenem, ciprofloxacin and erythromycin.Her clinical was significantly improved after receiving vancomycin and rifampicin. Even second-line drugs, clarithromycin and ciprofloxacin, were used, the patient had very good response and complete resolution without surgery.

Reference #1: Magnusson H. Spezifische infektiose pneumonie beim fohlen: Ein neuer eitererreger beim pferd [in German]. Arch Wiss Prakt Tierheilkd. 1923;50:22-38.

Reference #2: Weinstock DM, Brown AE. Rhodoccus equi: An emerging pathogen. Clin Infect Dis. 2002;34:1379-1385

Reference #3: Gray KJ, French N, Lugada E, Watera C, Gilks CF. Rhodococcus equi and HIV-1 infection in Uganda. J Infect 2000; 41:227-231

DISCLOSURE: The following authors have nothing to disclose: nittha oer-areemitr

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