0
Chest Infections |

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

Lauren Lee, MD; Dana Blyth, MD; Thomas Raj, MD; Charles Borders, MD; Samantha Butler, MD; Alexander Brown, MD; Murray Clinton, MD; Michael Osswald, MD
Author and Funding Information

San Antonio Military Medical Center, Department of Medicine, Schertz, TX


Chest. 2015;148(4_MeetingAbstracts):155A. doi:10.1378/chest.2268489
Text Size: A A A
Published online

Abstract

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

No Product/Research Disclosure Information


Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Figures

Tables

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543