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A3608 - From Toe to Head! A Case of Disseminated Nocardiosis Presenting as Foot Drop!
Author Block: A. M. Pasha1, P. K. Sinha2, M. Ehtesham2; 1Pulmonary and Critical Care Medicine, Providence-Providence Park Hospital, Southfield, MI, United States, 2Pulmonary-Critical Care, Providence-Providence Park Hospital, Southfield, MI, United States.
INTRODUCTION: Nocardia species are ubiquitous microorganisms that are opportunistic pathogens in immunocompromised hosts. Disseminated Nocardiosis is a rare and life threatening illness that is challenging to diagnose and treat. We describe a case of Disseminated Nocardiosis presenting primarily as foot drop.
CASE DESCRIPTION: A 54 year old Caucasian male presented with a two week history of right ankle weakness and gait imbalance. He also complained of fifty pound weight loss over six months. Patient had undergone renal transplant four years earlier due to polycystic kidney disease. Therefore, he had been taking Tacrolimus since then. Examination revealed tender nodules on the skin of his forehead, neck and arms. Examination also revealed a right foot drop. Computed Tomography (CT) scan showed multiple lesions in the brain. A subsequent Magnetic Resonance Imaging (MRI) of his brain showed 6 ring-enhancing lesions with surrounding vasogenic edema. A CT of his chest showed multiple lung nodules that were more prominent on the right side. Bronchoscopy with right lower lobe transbronchial biopsy revealed gram positive, branching, filamentous, weakly acid-fast bacilli, consistent with Nocardia species. However,a few enlarged cells with viral inclusion bodies were also seen suggestive of Cytomegalovirus (CMV) co-infection. Patient was started on Ganciclovir and Meropenam. The organism was identified as Nocardia abscessus on the final culture report. Patient was then transitioned to a 12 month course of Trimethoprim-Sulfamethoxazole. MRI brain was repeated 3 months into therapy and demonstrated significant improvement in the lesions.
DISCUSSION: Nocardiosis is a rare opportunistic infection that affects 0.04 to 3.5% of solid organ transplant recipients. The risk is highest in the first year following transplant and co-infections such as CMV have been reported in 20 to 64% of cases. CMV has significant immunomodulatory effects which increase the risk of subsequent viral, bacterial and fungal infections. Furthermore, Calcineurin inhibitors such as Tacrolimus cause inhibition of T cell activation leading to increased risk of Nocardiosis which can disseminate to organs such as the skin, brain and lungs. However, foot drop is a highly unusual presentation of Disseminated Nocardiosis. Antimicrobial therapy is directed by the susceptibility profile and consists of Trimethoprim-Sulfamethoxazole, Carbapenams or Linezolid. Due to the high recurrence rate, therapy should be continued for 6 to 12 months. Diagnosis can be difficult due to the slow growing nature of this organism. Hence, a high index of suspicion is often required for timely intervention.