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Yamamoto H, Kuroda H, Hiramoto N, Hasuike T, Doi A, Nishioka H. Successful maintenance treatment of disseminated nocardiosis with cerebral abscess in a severely immunocompromised patient allergic to trimethoprim-sulfamethoxazole using moxifloxacin and high-dose minocycline: A case report. J Infect Chemother 2024:S1341-321X(24)00121-1. [PMID: 38670455 DOI: 10.1016/j.jiac.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 03/08/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024]
Abstract
Nocardiosis in patients after allogeneic hematopoietic stem cell transplantation (HSCT) is rare, but is associated with a significant mortality risk. Although trimethoprim-sulfamethoxazole (TMP/SMX) remains the cornerstone of nocardiosis treatment, optimal alternative therapies for patients intolerant to TMP/SMX are not well-established. Herein, we report a case of disseminated nocardiosis with bacteremia and multiple lesions in the lungs and brain caused by Nocardia farcinica, in a 60-year-old man who had previously undergone allogeneic HSCT and was receiving immunosuppressants for severe chronic graft-versus-host disease. The patient received atovaquone for the prophylaxis of Pneumocystis pneumonia because of a previous serious allergic reaction to TMP/SMX. The patient was initially treated with imipenem/cilastatin and amikacin, which were later switched to ceftriaxone and amikacin based on the results of antimicrobial susceptibility testing. After switching to oral levofloxacin and a standard dose of minocycline, the patient experienced a single recurrence of brain abscesses. However, after switching to oral moxifloxacin and high-dose minocycline, the patient did not experience any relapses during the subsequent two years and seven months of treatment. In treating nocardiosis with brain abscesses, it is crucial to select oral antibiotics based on the antimicrobial susceptibility test results and pharmacokinetics, especially when TMP/SMX is contraindicated. A combination of oral moxifloxacin and high-dose minocycline could be a promising alternative therapy.
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Affiliation(s)
- Hiroshi Yamamoto
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Hirokazu Kuroda
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Nobuhiro Hiramoto
- Department of Hematology, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Toshikazu Hasuike
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Asako Doi
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Hiroaki Nishioka
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
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Margalit I, Lebeaux D, Tishler O, Goldberg E, Bishara J, Yahav D, Coussement J. How do I manage nocardiosis? Clin Microbiol Infect 2021; 27:550-558. [PMID: 33418019 DOI: 10.1016/j.cmi.2020.12.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Nocardiosis is a rare infection that is often difficult to treat and may be life-threatening. There is no consensus on its management. OBJECTIVES Our aim was to provide the current evidence for the diagnosis and management of individuals with nocardiosis, and to propose a management approach for this uncommon infection. SOURCES We systematically searched the medical literature on nocardiosis for studies published between 2010 and 2020 and describing ten or more individuals. CONTENT Nocardiosis, a primarily opportunistic infection which may occur in immunocompetent persons, most commonly involves the lungs and frequently disseminates to other sites including the central nervous system. The reference standard for Nocardia species identification is molecular biology, and the preferred method for antibiotic susceptibility testing (AST) is broth microdilution. Monotherapy seems appropriate for patients with primary skin nocardiosis or non-severe pulmonary disease; we reserve a multidrug regimen for more severe infections. Species identification and AST results are often missing at initiation of antibiotics. Trimethoprim-sulfamethoxazole is the preferred agent for initial therapy, because Nocardia is very often susceptible to this agent, and because it has been the keystone of nocardiosis treatment for years. Linezolid, to which Nocardia is almost always susceptible, may be an alternative. When combination therapy is required, the repertoire of companion drugs includes third-generation cephalosporins, amikacin and imipenem. Therapeutic modifications should take into account clinical response to initial therapy and AST results. Treatment duration of 6 months is appropriate for most situations, but longer durations are preferred for disseminated nocardiosis and shorter durations are reasonable in low-risk situations. Secondary prophylaxis may be considered in selected individuals with permanent immunosuppression. IMPLICATIONS We hereby provide the clinician with an easy-to-use algorithm for the management of individuals with nocardiosis. We also illuminate gaps in evidence and suggest future research directions.
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Affiliation(s)
- Ili Margalit
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel.
| | - David Lebeaux
- Université de Paris, Paris, France; Service de Microbiologie, Unité Mobile d'Infectiologie, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Ori Tishler
- Department of Internal Medicine F-Recanati, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Elad Goldberg
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel; Department of Internal Medicine F-Recanati, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Jihad Bishara
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Julien Coussement
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
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Goto M, Marushima A, Tsuda K, Takigawa T, Tsuruta W, Ishikawa E, Matsumaru Y, Matsumura A. Ruptured Mycotic Cerebral Aneurysm Secondary to Disseminated Nocardiosis. Asian J Neurosurg 2020; 15:1072-1075. [PMID: 33708692 PMCID: PMC7869307 DOI: 10.4103/ajns.ajns_283_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 09/01/2020] [Indexed: 11/24/2022] Open
Abstract
We report a case of a ruptured mycotic cerebral aneurysm caused by Nocardia infection. A 22-year-old immunocompromised woman with adult-onset Still's disease developed a subarachnoid hemorrhage (SAH). Digital subtraction angiography revealed a small aneurysm at the M2-3 bifurcation of the right middle cerebral artery. Cardiac ultrasonography showed vegetation at the posterior cardiac wall, suspecting infective endocarditis (IE). Gram-positive filamentous bacteria were observed in the necrotic tissue surrounding the aneurysm obtained during trapping surgery. Long-term blood culture showed that the cause of her cerebral mycotic aneurysm was nocardiosis. A mycotic ruptured cerebral aneurysm is an important cause of SAH in immunocompromised patients. Early diagnosis of IE, detection of gram-positive rods by Gram staining, and long-term culture to identify the bacteria is crucial in diagnosing nocardiosis.
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Affiliation(s)
- Masayuki Goto
- Department of Neurosurgery, University of Tsukuba Hospitals, Tsukuba, Japan
| | - Aiki Marushima
- Department of Neurosurgery, University of Tsukuba Hospitals, Tsukuba, Japan
| | - Kyoji Tsuda
- Department of Neurosurgery, University of Tsukuba Hospitals, Tsukuba, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, University of Tsukuba Hospitals, Tsukuba, Japan
| | - Wataro Tsuruta
- Department of Neurosurgery, University of Tsukuba Hospitals, Tsukuba, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, University of Tsukuba Hospitals, Tsukuba, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, University of Tsukuba Hospitals, Tsukuba, Japan
| | - Akira Matsumura
- Department of Neurosurgery, University of Tsukuba Hospitals, Tsukuba, Japan
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4
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Restrepo A, Clark NM. Nocardia infections in solid organ transplantation: Guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation. Clin Transplant 2019; 33:e13509. [PMID: 30817024 DOI: 10.1111/ctr.13509] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/12/2019] [Indexed: 12/29/2022]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of Nocardia infections after solid organ transplantation (SOT). Nocardia infections have increased in the last two decades, likely due to improved detection and identification methods and an expanding immunocompromised population. The risk of developing nocardiosis after transplantation varies with the type of organ transplanted and the immunosuppression regimen used. Nocardia infection most commonly involves the lung. Disseminated infection can occur, with spread to the bloodstream, skin, or central nervous system. Early recognition of the infection and initial appropriate treatment is important to achieve good outcomes. Species identification and antimicrobial susceptibility testing are strongly recommended, as inter- and intraspecies susceptibility patterns can vary. Sulfonamide is the first-line treatment of Nocardia infections, and combination therapy with at least two antimicrobial agents should be used initially for disseminated or severe nocardiosis. Trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis may be helpful in preventing Nocardia infection after SOT.
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Affiliation(s)
- Alejandro Restrepo
- Division of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Nina M Clark
- Division of Infectious Diseases, Department of Medicine, Loyola University Stritch School of Medicine, Maywood, Illinois
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Shrestha S, Kanellis J, Korman T, Polkinghorne KR, Brown F, Yii M, Kerr PG, Mulley W. Different faces of Nocardia infection in renal transplant recipients. Nephrology (Carlton) 2016; 21:254-60. [PMID: 26820918 DOI: 10.1111/nep.12585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2015] [Indexed: 11/29/2022]
Abstract
AIM Nocardia infections are an uncommon but important cause of morbidity and mortality in renal transplant recipients. The present study was carried out to determine the spectrum of Nocardia infections in a renal transplant centre in Australia. METHODS A retrospective chart analysis of all renal transplants performed from 2008 to 2014 was conducted to identify cases of culture proven Nocardia infection. The clinical course for each patient with nocardiosis was examined. RESULTS Four of the 543 renal transplants patients developed Nocardia infection within 2 to 13 months post-transplant. All patients were judged at high immunological risk of rejection pre-transplant and had received multiple sessions of plasmaphoeresis and intravenous immunoglobulin before the onset of the infection. Two patients presented with pulmonary nocardiosis and two with cerebral abscesses. One case of pulmonary nocardiosis was complicated by pulmonary aspergillosis and the other by cytomegalovirus pneumonia. All four patients improved with combination antibiotic therapy guided by drug susceptibility testing. At the time of Nocardia infection all four patients were receiving primary prophylaxis with trimethoprim/sulphamethoxazole (TMP/SMX) 160/800 mg, twice weekly. CONCLUSION Plasmaphoeresis may be risk factor for Nocardia infection and need further study. Nocardia infection may coexist with other opportunistic infections. Identification of the Nocardia species and drug susceptibility testing is essential in guiding the effective management of patients with Nocardia. Intermittent TMP-SMX (one double strength tablet, twice a week) appears insufficient to prevent Nocardia infection in renal transplant recipients.
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Affiliation(s)
- Shailendra Shrestha
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia.,Department of Internal Medicine, Nobel Medical College and Teaching Hospital, Biratnagar, Nepal
| | - John Kanellis
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Tony Korman
- Department of Infectious Disease and Microbiology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Fiona Brown
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Ming Yii
- Department of Vascular Surgery, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - William Mulley
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
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6
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Clark NM, Reid GE. Nocardia infections in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:83-92. [PMID: 23465002 DOI: 10.1111/ajt.12102] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- N M Clark
- Division of Infectious Diseases, Department of Medicine, Loyola University Stritch School of Medicine, Maywood, IL, USA.
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8
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First case of cerebral abscess due to a novel Nocardia species in an immunocompromised patient. J Clin Microbiol 2012; 51:696-700. [PMID: 23224088 DOI: 10.1128/jcm.00762-12] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We report the first case of cerebral abscess due to a novel species of Nocardia in a heart transplant patient and describe the antimicrobial susceptibility of this isolate. As our patient was intolerant to trimethoprim-sulfamethoxazole, we also discuss alternative therapeutic options in brain abscess due to Nocardia sp.
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Yu X, Han F, Wu J, He Q, Peng W, Wang Y, Huang H, Li H, Wang R, Chen J. Nocardia infection in kidney transplant recipients: case report and analysis of 66 published cases. Transpl Infect Dis 2011; 13:385-91. [PMID: 21824241 DOI: 10.1111/j.1399-3062.2011.00607.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Nocardiosis is a rare but life-threatening opportunistic infection, especially in immune compromised patients, including kidney transplant recipients. Primary pulmonary infection is the most common clinical pattern, and can easily result in disseminated Nocardia infection if treatment therapy is not adequate at the beginning. In this article, we report a new case of disseminated nocardiosis (lungs, skin, and pericardium) after renal allograft transplantation. We also review the English literature published from 1980 to 2010 and analyze the clinical characteristics of nocardiosis in kidney transplant recipients.
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Affiliation(s)
- X Yu
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, China Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, Zhejiang, China
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10
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Nocardial brain abscess. J Clin Neurosci 2010; 17:250-3. [DOI: 10.1016/j.jocn.2009.01.032] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2008] [Revised: 12/28/2008] [Accepted: 01/04/2009] [Indexed: 11/19/2022]
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Frank M, Woschnagg H, Mölzer G, Finsterer J. Cerebellar nocardiosis and myopathy from long-term corticosteroids for idiopathic thrombocytopenia. Yonsei Med J 2010; 51:131-7. [PMID: 20046527 PMCID: PMC2799960 DOI: 10.3349/ymj.2010.51.1.131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 05/09/2008] [Accepted: 05/14/2008] [Indexed: 11/30/2022] Open
Abstract
Infection of the central nervous system with Nocardia sp. usually manifests as supratentorial abscesses. Supratentorial and cerebellar abscesses from infection with Nocardia sp. following immunosuppression with long-term corticosteroids for idiopathic thrombocytopenia (ITP) have not been reported. An 83 years-old, human immunodeficiency virus (HIV)-negative, polymorbid male with ITP for which he required corticosteroids since age 53 years developed tiredness, dyspnoea, hemoptysis, abdominal pain, and progressive gait disturbance. Imaging studies of the lung revealed an enhancing tumour in the right upper lobe with central and peripheral necrosis, multiple irregularly contoured hyperdensities over both lungs, and right-sided pleural effusions. Sputum culture grew Nocardia sp. Neurological diagnostic work-up revealed dysarthria, dysphagia, ptosis, hypoacusis, tremor, dysdiadochokinesia, proximal weakness of the lower limbs, diffuse wasting, and stocking-type sensory disturbances. The neurological deficits were attributed to an abscess in the upper cerebellar vermis, myopathy from corticosteroids, and polyneuropathy. Meropenem for 37 days and trimethoprime-sulfamethoxazole for 3 months resulted in a reduction of the pulmonary, but not the cerebral lesions. Therefore, sultamicillin was begun, but without success. Long-term therapy with corticosteroids for ITP may induce not only steroid myopathy but also immune-incompetence with the development of pulmonary and cerebral nocardiosis. Cerebral nocardiosis may not sufficiently respond to long-term antibiotic therapy why switching to alternative antibiotics or surgery may be necessary.
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Affiliation(s)
- N M Clark
- University of Illinois at Chicago, Section of Infectious Diseases, Chicago, IL, USA.
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Kennedy KJ, Chung KHC, Bowden FJ, Mews PJ, Pik JHT, Fuller JW, Chandran KN. A cluster of nocardial brain abscesses. ACTA ACUST UNITED AC 2007; 68:43-9; discussion 49. [PMID: 17586220 DOI: 10.1016/j.surneu.2006.08.067] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Accepted: 08/04/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND Nocardia species are aerobic Gram-positive bacteria that are ubiquitous in the environment. Infection usually occurs through inhalation or direct cutaneous inoculation of the organism. It has been reported that infection is more common in warm, dry climates. Cerebral nocardiosis is an uncommon clinical entity, representing only 2% of all cerebral abscesses. It is an illness associated with significant morbidity and mortality. CASE DESCRIPTIONS We report 4 cases of nocardial brain abscesses presenting to TCH, Australia, within a 1-year period. All 4 cases occurred in men without any significant underlying immunocompromise. In 3 of the cases, the diagnosis was only established after craniotomy. All cases were given prolonged antimicrobial therapy. After more than 8 months of follow-up, there have been no deaths or treatment failures. There has been only one other case of nocardial brain abscess at TCH over the past 15 years. We review the current literature on cerebral nocardiosis. CONCLUSION Nocardial brain abscesses are uncommonly encountered at our institution. This cluster of 4 cases over a 1-year period has therefore led us to postulate that the severe drought may be aiding in the transmission of the bacteria. The cases also emphasize the propensity of nocardial infections to mimic other conditions, particularly malignancy, which may lead to delays in appropriate surgical treatment and antimicrobial therapy. The diagnosis requires a high clinical index of suspicion, with early tissue and microbiological diagnosis. Prolonged antimicrobial therapy is required to prevent relapse of the infection.
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Affiliation(s)
- Karina J Kennedy
- Department of Infectious Diseases, The Canberra Hospital, Australian Capital Territory 2606, Australia.
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Dahan K, El Kabbaj D, Venditto M, Pastural M, Delahousse M. Intracranial Nocardia recurrence during fluorinated quinolones therapy. Transpl Infect Dis 2006; 8:161-5. [PMID: 16913975 DOI: 10.1111/j.1399-3062.2006.00130.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nocardia infection is a well-recognized complication in renal transplant recipients and other immunocompromised hosts. It is mostly a primary pulmonary infection, which can disseminate to other organs in half of the cases. Nocardiosis is a life-threatening infection. Therefore, an efficient long-lasting treatment must be rapidly administered. We report 1 case of disseminated nocardiosis with pulmonary involvement, brain lesions, and bone lesions in a renal transplant patient, who was treated with stereotactic aspiration in association with high dose of trimethoprim/sulfamethoxazole (TMP/SMX) and imipenem, changed, after 3 weeks to moxifloxacin. First, clinical manifestations decreased after surgical drainage and combination therapy with the 2 antimicrobial agents, but later the patient developed a recurrence of brain lesions during treatment with quinolones. Consequently, the patient was again treated with TMP/SMX and imipenem, after which the patient recovered. It is surprising that moxifloxacin was efficient in vitro and the antimicrobial concentration in the central nervous system was high, yet the nocardial abscess recurred under this therapy.
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Affiliation(s)
- K Dahan
- Service de Néphrologie, Hôpital Foch, Créteil, France.
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