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Klebsiella urinary tract infection, bacteraemia and pulmonary Nocardia ignorata infection with dissemination to soft tissue: case report A 66-year-old man developed Klebsiella urinary tract infection, Klebsiella bacteraemia and pulmonary Nocardia ignorata infection with dissemination to soft tissue following immunosuppression therapy with tacrolimus and unspecified steroids post cardiac transplantation [routes and dosages not stated; times to reactions onsets not clearly stated]. The man, whose medical history was notable for ischaemic cardiomyopathy, underwent implantation of a left ventricular assist device. However, this was complicated by Enterococcus faecalis device infection and extended spectrum β-lactamase-producing (ESBL) Klebsiella urosepsis. Therefore, he underwent left ventricular assist device explantation, followed by orthotopic cardiac transplantation. During this time, he started receivingimmunosuppression therapy with tacrolimus and unspecified steroids. Concomitantly, for Pneumocystis prophylaxis, he received cotrimoxazole [trimethoprim/sulfamethoxazole] which was later changed to atovaquone. However, he subsequently developed tamponade requiring a pericardial window, accompanied by an ESBL Klebsiella urinary tract infection. The man received meropenem for the Klebsiella urinary tract infection. However, 6 weeks later, he developed ESBL Klebsiella bacteraemia, which was again treated with meropenem. Six months posttransplant, he presented with complaints of cough and dysponea for 10 days. Chest CT scan revealed bilateral nodules with bronchiectasis, cavitation and spiculation. He was initially treated with meropenem and doxycycline. The results of severe acute respiratory syndrome coronavirus-2 swab test, sputum cultures, respiratory pathogen panel and fungal studies were nondiagnostic. He underwent a venous duplex scan because of severe left calf pain, which showed a nonvascular mass. He reported no trauma, recent travel or soil contact. The abscess was aspirated, revealing branching Gram-positive beaded rods. The isolate was subsequently identified as Nocardia ignorata. Brain MRI was unremarkable. His respiratory status and leg pain rapidly improved. He was discharged on long-term cotrimoxazole [trimethoprim/ sulfamethoxazole] and doxycycline. Due to renal insufficiency, cotrimoxazole was replaced with moxifloxacin after 2 weeks. Chest radiograph results showed improvement 3 months later [not all outcomes stated]. Muggia VA, et al. Nocardia ignorata infection in heart transplant patient. Emerging Infectious Diseases 26: 2788-2789, No. 11, Nov 2020. Available from: URL: http:// 803517834 doi.org/10.3201/eid2611.202756

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