A 28-YEAR-OLD FEMALE WITH RIGHT UPPER LOBE MASS

Abstract

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Nocardia represents a prevalent pathogen associated with high morbidity and mortality in the immunocompromised. Nocardiosis has been increasing in incidence in the U.S. with 500-1000 annual cases. Here, we present a 28-year-old female with SLE who presents with a lung mass. CASE PRESENTATION: A 28-year-old female with significant history of SLE with cardiorenal involvement on immunosuppressive agents, pulmonary hypertension and end stage renal disease on hemodialysis who presents with productive cough, dyspnea, fever, weight loss, and rash. Vital signs were temperature of 39.3°C, heart rate of 122 beats/min, blood pressure of 150/97 mmHg, respiratory rate of 24 breaths/min, and 100% oxygen saturation on nasal cannula 2 liters. Physical exam was significant for a systolic murmur radiating to axilla, decreased and coarse breath sounds bilaterally, raised centrally indented vesicular, non-erythematous rash located over right medial thigh. Labs were significant for positive ANA and anti-double stranded-DNA, leukocytosis, proteinuria, and negative cultures. Chest X-ray noted a right upper lobe peri-hilar mass. CT Thorax showed a right loculated pleural effusion, and a right upper lobe mass. Patient was started on intravenous steroids, empiric antibiotics and antivirals. CT guided percutaneous biopsy of right upper lobe anterior mass showed filamentous bacteria which finalized as N. farscinica and patient was started on linezolid due to trimethoprim-sulfamethoxazole (TMP-SMX) resistance and allergy. MRI brain was negative for dissemination. Patient was discharged on acyclovir for a herpetic rash, and linezolid for Nocardiosis. Upon follow-up, patient was switched to intravenous antibiotics due to intolerance to linezolid. DISCUSSION: N. farscinica most commonly affects the lung with half of cases disseminating to the brain. A major virulence factor is resistance to phagocytosis. Risk factors are defective cell-mediated immunity, diabetes, alcoholism and chronic lung disease. Radiographic findings can be lung masses, consolidation, pleural effusion, or nodules usually in upper lobes. In immunocompromised patients, TMP-SMX or intravenous amikacin, imipenem, meropenem, and linezolid are agents that can be used for management for at least 12 months. CONCLUSIONS: Nocardia is ubiquitous, but remains an under-diagnosed pathogen that is overlooked in the work up for lung masses in the immunocompromised. The non-specific clinical presentation, lack of available diagnostic testing coupled with poor yield from cultures and variable radiographic findings is what makes Nocardiosis a diagnostic dilemma. Reference #1: Wilson, J. (2012). Nocardiosis: Updates and Clinical Overview. Mayo Clinic Proceedings, 87(4), pp.403-407. Reference #2: Lerner P. Nocardiosis. Clinical Infectious Diseases. 1996;22:891-905 Reference #3: Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ, Jr. Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy. Clin Microbiol Rev. 2006;19:259-282. DISCLOSURES: No relevant relationships by Ali Chaudhry, source=Web Response No relevant relationships by Wael Nasser, source=Web Response No relevant relationships by Sachin Patel, source=Web Response