Reactions 1680, p283 - 2 Dec 2017
Fatal disseminated Nocardia farcinica bacteraemia:
A 91-year-old man developed fatal disseminated Nocardia
farcinica bacteraemia following treatment with prednisone
[route not stated].
The man was admitted with a complaints of fatigue,
anorexia, weight loss of 10kg in few weeks and arthralgia, on
July 2012. He had a history of myelodysplastic syndrome
(MDS), complicated by autoimmune haemolytic anaemia
since March 2012. He was on treatment with prednisone
25 mg/day, cutting down the dosage by half every week to
treat MDS. Few days prior to the admission, he had completed
his prednisone therapy. On admission, his examination
revealed a low-grade fever, fatigue, non-productive cough,
bilateral basal crackles and wheezes at chest auscultation. His
blood pressure was at 118/78mm Hg, heart rate was
82 beats/minute, respiratory rate was 20 breaths/minute and
oxygen saturation was 95%. Two sets of blood cultures were
drawn from the different peripheral sites at the same time.
Laboratory tests revealed haemoglobin level at 10.2 g/dL,
leucocytes count at 11.3×10
/µL, platelet count at
/µL, sedimentation rate of 42 mm/h, creatinine level
at 1.95 mg/dL, albumin level at 2.7 g/dL and gamma globulin
level of 29.5% with two monoclonal bands in gamma region. A
chest X-ray demonstrated multiple nodular acinar opacities in
both lungs with diffuse interstitial thickening. A presumptive
diagnosis of community-acquired pneumonia was made.
The man was treated with ceftriaxone. Despite treatment,
his condition slightly worsened over the next couple of days.
The level of consciousness decreased and he experienced low-
grade fever episodes every day. On day 4, the aerobic bottle of
the first blood culture was found to be positive. Gram staining
of positive bottle showed branching Gram-positive rods. On
the basis of these findings, Nocardia spp. bacteraemia was
suspected. His ceftriaxone therapy was switched to
cotrimoxazole [trimethoprim/sulfamethoxazole] and linezolid.
The positive blood culture was subcultured and incubated.
Two days later, very small colonies were observed on
Columbia blood agar and were identified by MALDITOF MS as
Nocardia farcinica, with a score of 1.879. On day 5, N. farcinica
identification was confirmed by conventional biochemical
tests. Ciprofloxacin was added to the therapy. On day 10, his
level of consciousness deteriorated to a state of light coma,
difficult to awaken, with worsened shortness of breath.
Oxygen saturation was 89%, hence, oxygen therapy was
initiated via nasal cannula. A brain CT scan revealed multiple
enhancing focal lesions in the frontal regions, midbrain and in
the cerebellum. A chest CT scan revealed multiple nodular
lesions and bilateral pleural effusion. However, he was
suffering from psychosis and was in coma, was uncooperative
when awakened. Hence, thoracentesis could not be
performed. On day 18 of hospitalisation, he died due to
Nocardia farcinica bacteraemia.
Author comment: "Most of the patients with N. farcinica
infection had predisposing factors like hematologic
malignancies, treatment with corticosteroids, solid tumors,
bone marrow or solid organ transplantation, HIV infection,
chronic pulmonary, and renal diseases."
Leli C, et al. Fatal nocardia farcinica bacteremia diagnosed by matrix-assisted laser
desorption-ionization time of flight mass spectrometry in a patient with
myelodysplastic syndrome treated with corticosteroids. Case Reports in Medicine
2013: 16 Apr 2013. Available from: URL: http://doi.org/10.1155/2013/368637 -
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