Primary cerebral nocardiosis in a renal transplant recipient: a case report

Multiple nocardial abscesses secondary to anti‑neutrophil cytoplasmic antibody‑associated vasculitis in an elderly patient: A case report and literature review

A nocardial abscess is a relatively rare opportunistic infection that typically occurs after immunosuppressive treatment and is a clinical challenge. In the present study, the case of a 69-year-old patient with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, and lung and kidney involvement, was reported. The patient received systemic glucocorticoid and cyclophosphamide treatment for 6 months, after which a large encapsulated abscess appeared on magnetic resonance imaging and CT in the subcutaneous tissue of the left hip and lung, respectively, and the pus culture showed Nocardia. Orthopedic abscess incision and ultrasound-guided thoracic puncture drainage were performed, and the lesion was completely absorbed after 1 month of treatment with linezolid and compound sulfamethoxazole. Tests for ANCA were negative, and renal function and urine tests were completely normal after 1 year of follow-up. Furthermore, a literature review performed for the present study retrieved a few reports of successful treatment of multiple nocardial abscesses secondary to ANCA-associated vasculitis in elderly patients in a short period of time. Therefore, the present case report and literature review have been reported to improve awareness of this rare disease, so as to facilitate its early diagnosis and treatment.

Nocardiosis in Kidney Disease Patients under Immunosuppressive Therapy: Case Report and Literature Review

The increased use of novel and powerful immunosuppressive drugs in kidney diseases may concomitantly expose the patients to higher risk of opportunistic infections, some of which still remain underdiagnosed thus mishandled. As such, we recently had a less prepared encounter of pulmonary nocardial infection in an ANCA-associated renal vasculitis patient under steroid therapy. Despite the use of broad-spectrum antimicrobials including micafungin, the infection was still unbridled and eventually culminated in lethal brain abscess. We thus chose to renew the knowledge of the clinical features, imaging manifestations, differential diagnosis, specific laboratory tests and unique treatment about this rare infection in kidney diseases patients under immunosuppressive therapy. In addition, CT images of easily confused pulmonary lesions superimposed on kidney diseases were also retrieved from our depository. Moreover, impaired renal function as a risk factor for infection and pharmacological options for the treatment were also focused. By sharing our hard-learnt experience and reviewing the literatures, our report may contribute to the awareness among the clinicians in general and nephrologists in particular of this rare disease in susceptible patients and facilitate a swift thus life-saving treatment.

"Primary" nocardial brain abscess in a renal transplant patient

Background

Intracranial abscesses are rare among transplant recipients, and Nocardia is responsible for less than 2 % of them. Nocardiosis, a chronic infection and is difficult to treat. Primary infection involves lungs and eventually disseminates. Primary nocardial abscesses are rare and we report a case from Sri Lanka.

Case presentation

A 38 year old Sri Lankan, who has received his 2nd ABO matched live donor transplantation, which was complicated with perinephric hematoma and massive transfusion syndrome. He presented with fever, worsening headache and papilledema. An urgent magnetic resonance image (MRI) showed an occipital abscess with midline shift. Craniotomy and drainage followed by 3 week course of imipenem and levofloxacin, which rendered him symptom free. After 12 months he has stayed recurrence free. Imaging and bacteriology of the respiratory tract failed to demonstrate Nocardia infection.

Conclusion

Isolated (Primary) nocardial brain abscess are rare, and have an excellent response to medical therapy. We achieved a good response from a relatively short course of antibiotics (not using sulfonamides, due to allergy), where long courses of antibiotic had been the norm.