V SRINIVASA1, G KAN1, V MANICKAM1, V SRIVASTAVA1
1Townsville Hospital Renal unit, Townsville, Douglas, Australia
Background:Nocardia is an opportunistic pathogen causing infection in immunocompromised hosts. The incidence of Nocardia in renal transplant patients is uncommon with an estimated incidence rate of 0.7 to 3.6% reported in the literature. Disseminated Nocardia is rare in renal transplant patients and has a high mortality rate.
Case Report:We report the case of a 57-year-old indigenous male with disseminated Nocardia infection post renal transplantation, whose past medical history included CMV colitis. His medications included tacrolimus mycophenolate and prednisolone. His presenting features were fevers and cough and imaging of his chest revealed right sided consolidation with pleural effusion. He was treated with ceftriaxone and azithromycin but clinically was not improving. Melioidosis was suspected and he was subsequently commenced on meropenem. Pleural fluid and sputum analysis surprisingly yielded Nocardia species and he was started on Bactrim. Furthermore, MRI brain showed multiple cerebral abscesses and imaging of his right humerus was suggestive of an abscess. Antibiotic susceptibility testing later identified that he was meropenem resistant and ciprofloxacin was commenced instead.
Conclusions:This case highlights several teaching points.Pulmonary nocardiosis should be in the differential diagnosis of any immunocompromised patient who presents with pneumonia not resolving with conventional antibiotics. In patients diagnosed with pulmonary nocardiosis cerebral MRI should be performed as 20-35% of cases have CNS dissemination. Potential risk factors for infection include tacrolimus therapy, prolonged use of corticosteroids and previous CMV infection.
Management with antibiotic therapy is difficult due to risk of potential drug interactions with immunosuppressive therapy.
Dr. Vinay Srinivasa is a advanced trainee currently working at the Townsville hospital.
He is in his final year of advanced training for general medicine and is currently doing his first year of renal advanced training at Townsville hospital. He is aiming to be a dual specialist in both nephrology and general medicine
He has a special interest in Glomerulonephritis and hypertension