Reactions 1680, p283 - 2 Dec 2017 Fatal disseminated Nocardia farcinica bacteraemia: case report 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 202×10 /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 - Italy 803284495 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680
Reactions Weekly – Springer Journals
Published: Dec 2, 2017
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