Disseminated Nocardia farcinica infection in immunocompromised patient
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IMAGES IN INFECTION
Disseminated Nocardia farcinica infection in immunocompromised patient Alexandre E. Malek1,2 · George M. Viola1 · Garret T. Seiler2 · Ariel D. Szvalb1 Received: 19 November 2019 / Accepted: 17 February 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
A 72-year-old female with a past medical history of myelodysplastic syndrome recently transformed to acute myeloblastic leukemia presented with 3-day history of progressive shortness of breath, productive cough and fever as high as 101.8 °F. She was receiving decitabine, venetoclax and midostaurin chemotherapy, as well as levofloxacin, valacyclovir, plus posaconazole prophylaxis. Physical exam was unremarkable. Laboratory studies showed white blood cell count of 500 cells/uL, absolute neutrophils count 340 cells/uL, absolute lymphocyte count 10 cells/uL, C-reactive protein 290 mg/L and procalcitonin 0.72 ng/mL. A chest computed tomography scan revealed multiple nodules surrounded by ground glass attenuation (halo sign) (Fig. 1a). On day 3 post admission, blood cultures from the central venous catheter and a peripheral vein yielded a filamentous Grampositive rod (Fig. 1b) also positive for periodic acid-Schiff stain (Fig. 1c), with subsequent cultures growing Nocardia
farcinica identified by 16 S ribosomal DNA sequencing. Additional microbiologic studies including bronchoalveolar lavage culture, serum Aspergillus antigen and endemic mycoses serologies were negative for other bacterium and fungi. Despite lack of any neurological symptoms, a brain magnetic resonance imaging showed multiple ring-enhancing lesions in the supratentorial and infratentorial regions (Fig. 1d). Intravenous trimethoprim/sulfamethoxazole (5 mg TMP/kg every 8 h) and linezolid (600 mg every 12 h) were started but unfortunately the patient expired. Nocardiosis is an opportunistic infection with the ability to disseminate, particularly to the lungs and central nervous system [1, 2]. Its incidence and antibiotic resistance profile are evolving [1, 3]. Early clinical suspicion, diagnosis, and antimicrobial susceptibility testing in the immunocompromised patient are critical to avoiding a poor prognosis [4].
* Alexandre E. Malek [email protected] 1
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
Division of Infectious Diseases, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center At Houston, Houston, TX, USA
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Fig. 1 a Noncontrast chest computed tomography imaging with axial view revealing multifocal central and peripheral macronodular opacities with halo sign (arrow). b Blood culture revealing a filamentous Gram-positive rod-shaped bacteria (arrow) on Gram staining (× 1000 magnification). c Blood culture showing positive periodic acid-Schiff
stain (arrow) with thin beaded branching filamentous bacteria ( × 500 magnification).
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