DISSEMINATED ACTINOMYCETOSIS WITH PNEUMONIA, LEFT GLUTEAL, LEFT EYE, AND BRAIN ABSCESSES IN A PATIENT WITH SJÖGREN AND INTERSTITIAL LUNG DISEASE

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: A localized or disseminated infection by an aerobic gram-positive beaded filamentous branching actinomycete Nocardia is called Nocardiosis. Its presence is ubiquitous, causing infection in immunosuppressed and healthy individuals. An increased incidence is due to the greater use of immunosuppressants and improved diagnostic processes. On average, 500-1,000 new cases occur in USA [1] CASE PRESENTATION: 86-year-old female with hypertension, diabetes, Sjogren's, and interstitial lung disease (ILD) on 10 mg prednisone came to the eye clinic for left blurry eye pain for three days. A recent ILD flare was treated with a steroid burst. Eye exam showed acute left eye endophthalmitis with bilateral chorioretinal infiltrates (Figure A1-2). A white cell count was normal with neutrophilia and an absolute lymphocyte count of 903 cells/mm3. Human immunodeficiency virus, syphilis, endemic fungal, and Quantiferon testing and blood cultures were negative. Echocardiogram was normal, while prednisone was held. Computed tomography (CT) of the chest, abdomen, and pelvis revealed interstitial pneumonia, new left lower lobe consolidation, left gluteal and right paraspinal muscle abscess, and left gluteal biopsy showed acid-fast filamentous microorganisms with culture positive for Nocardia farcinica resistant to ceftriaxone, clarithromycin, and tobramycin (Figure B1-4). Magnetic resonance imaging (MRI) brain revealed multiple ring-enhancing lesions in the right midbrain, left cingulate gyrus, parietofrontal and temporal lobe (Figure C1-3). On the 14th day, the left eye revealed a small subretinal abscess. An initial regimen of meropenem and bactrim was changed to amikacin and imipenem for six weeks at discharge. A week later, she was back in intensive care in a comatose state with worse MRI brain changes and placed on comfort care DISCUSSION: Disseminated disease is common in males and often presents with brain lesions, with N. farcinica being the frequent subspecies causing it due to its predilection for brain and skin tissue with an increased mortality rate [2-4]. N. farcinica is resistant to multiple antibiotics, including third-generation cephalosporins. A frequent site of the abscess is the parietofrontal lobe [5]. Mortality in multiple abscesses is higher than with a solitary abscess (66% vs. 33%) [6]. Inappropriate empirical therapy has higher mortality at 31% than an appropriate therapy (10%) [7]. Concomitant involvement of lungs, brain, eye, and muscles is rare. Due to a lower incidence, it is not considered at initial diagnosis CONCLUSIONS: In chronic respiratory disease patients on low-dose steroids, the onset of new visual or nervous system symptoms is a concern for disseminated nocardiosis with a recent history of steroid burst, lymphopenia, and neutrophilia REFERENCE #1: Beaman BL, Burnside J, Edwards B, Causey W. Nocardial infections in the United States, 1972-1974. J Infect Dis. 1976;134(3):286-9 REFERENCE #2: Kramer MR, Uttamchandani RB. The radiographic appearance of pulmonary nocardiosis associated with AIDS. Chest. 1990;98(2):382-5 REFERENCE #3: Sabuncuoğlu H, Cibali Açikgo Z Z, Caydere M, Ustün H, Semih Keskil I. Nocardia farcinica brain abscess: a case report and review of the literature. Neurocirugia (Astur). 2004;15(6):600-3 DISCLOSURES: No relevant relationships by Andres Bran, source=Web Response No relevant relationships by CARLA CARUSO, source=Web Response No relevant relationships by Paragkumar Patel, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response No relevant relationships by ANTONY RAWINDRARAJ, source=Web Response