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Invasive Pulmonary Nocardiosis With Extrapulmonary Joint Extension After Allogeneic Hematopoietic Stem Cell Transplant for Chronic Lymphocytic Leukemia FREE TO VIEW

Lauren Lee, MD; Dana Blyth, MD; Thomas Raj, MD; Charles Borders, MD; Samantha Butler, MD; Alexander Brown, MD; Murray Clinton, MD; Michael Osswald, MD
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San Antonio Military Medical Center, Department of Medicine, Schertz, TX

Chest. 2015;148(4_MeetingAbstracts):155A. doi:10.1378/chest.2268489
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SESSION TITLE: Infectious Disease Cases - Student/Resident

SESSION TYPE: Student/Resident Case Report Slide

PRESENTED ON: Monday, October 26, 2015 at 11:00 AM - 12:00 PM

INTRODUCTION: Nocardiosis is a rare, potentially life-threatening opportunistic infection, but perhaps less common in HSCT patients with the use of trimethoprim/sulfamethoxazole (TMP/SMX) for PCP prophylaxis. We report a unique case of invasive pulmonary nocardiosis with supraclavicular (SC) joint extension in a post-allogeneic HSCT patient.

CASE PRESENTATION: A 67 year-old male, living in Albania, with chronic lymphocytic leukemia presented with a non-productive cough and CMV viremia following a matched-unrelated donor HSCT. High-dose corticosteroids, tacrolimus, and mycophenolate mofetil were initiated for grade III graft-versus-host disease (GVHD). Rising creatinine and pancytopenia prompted atovaquone use in lieu of TMP/SMX for PCP prophylaxis. He was afebrile and CXR revealed no infiltrates. Increasing shoulder pain prompted further imaging. Chest CT revealed a 7-cm apical consolidation with an anterior mediastinum confluent fluid collection extending along his subclavian chest port into his SC joint. Bronchoalveolar lavage revealed no bacterial growth. Negative fungal and mycobacterial stains necessitated a CT-guided lung biopsy. Lung tissue culture revealed chalky colonies of beaded, filamentous gram-positive rods. GMS staining of histopathology samples were consistent with Nocardia sp. Empiric therapy with extended-duration IV TMP/SMX, imipenem/cilastatin, and amikacin ensued until speciation revealed imipenem-resistant N. abscessus. This, along with TMP/SMX intolerance, prompted amoxicillin/clavulanate maintenance therapy. Contiguous extension into surrounding tissues, port, and SC joint necessitated port removal and fluid collection drainage.

DISCUSSION: Nocardiosis primarily involves a localized pulmonary infection or disseminated disease in HSCT patients. High-dose corticosteroids, preceding CMV reactivation, and GVHD are well-established risk factors and a functional cellular immune system is essential for infection clearance.While nocardiosis is uncommon in HSCT patients, even rarer is contiguous extrapulmonary joint invasion with only two prior reported cases.

CONCLUSIONS: While improved antimicrobial prophylaxis has reduced the incidence of infections, they remain a leading cause of HSCT non-relapse mortality. TMP/SMX is often used for PCP prophylaxis, but adverse effects may result in use of alternative agents. Astute clinicians must consider nocardiosis in immunosuppressed patients with cavitary lung lesions and, therefore, request appropriate diagnostic testing and prolonged culture incubation, particularly in HSCT patients who are not receiving daily TMP/SMX, as it may provide a degree of Nocardia protection.

Reference #1: Lebeaux, P. et al. Nocardiosis in transplant recipients. Eur J Clin Microbiol Infect Dis (2014) 33: 689-702

DISCLOSURE: The following authors have nothing to disclose: Lauren Lee, Dana Blyth, Thomas Raj, Charles Borders, Samantha Butler, Alexander Brown, Murray Clinton, Michael Osswald

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