Nocardia Liver Abscess – An Uncommon Infection Post Liver Transplant

Abstract

Background: Nocardiosis is a rare, localised or disseminated, bacterial infection caused by aerobic actinomyces. It commonly affects immunocompromised hosts. With increasing load of post transplant patients the world over, this infection has been reported with increasing frequency.Case Report: A 59-year-old gentleman underwent living donor liver transplant for ethanol related ESLD in our hospital. Immediate post OP period was uneventful. After 6 weeks post transplant he presented with abdominal pain and low grade fever. General examination was unremarkable except for minimal tenderness over right hypochondrium. His baseline laboratory evaluation revealed hemoglobin 8.7 gm%, leukocyte count 7170/cumm, platelets 176,000/cmm. Liver function revealed total bilirubin 0.46 mg/dL, AST 14 μ/L, ALT 25 μ/L, albumin 2.6 g/L, alkaline phosphatase 74 μ/L, GGT 78 μ/L and INR 1.2. Tacrolimus level 6 mg/dL. Ultrasound abdomen revealed well-defined thin walled hypoechoic lesion in segment VII measuring 53 mm × 58 mm liver abscess. CT scan of abdomen showed a 6.2 cm × 6 cm × 5.9 cm size multiloculated hypodense collection in segment VII of right lobe with perilesional edema. He underwent percutaneous drainage of collection, which revealed purulent aspirate. Microbiological examination of aspirates showed pus cells and occasional gram-positive branching filaments. Modified acid-fast stain was positive. Culture revealed Nocardai spp. MALDI-TOF test was positive for Nocardia farcinica. He was treated with trimethoprime-sulfamethoxazole, amikacin and imipenem for 2 weeks. He was kept on low immunosuppression. His fever subsided over next few days. Repeat ultrasound scan revealed collapsed abscess cavity with small remnant collection. He was discharged on oral antimicrobials and is under regular follow up.Conclusion: Nocardiosis should be suspected as a likely cause of liver abscess in the setting of immunocompromised patients. Long-term treatment with trimethoprime-sulfamethoxazole for up to 6 months improves survival.Conflicts of InterestThe authors have none to declare. Background: Nocardiosis is a rare, localised or disseminated, bacterial infection caused by aerobic actinomyces. It commonly affects immunocompromised hosts. With increasing load of post transplant patients the world over, this infection has been reported with increasing frequency. Case Report: A 59-year-old gentleman underwent living donor liver transplant for ethanol related ESLD in our hospital. Immediate post OP period was uneventful. After 6 weeks post transplant he presented with abdominal pain and low grade fever. General examination was unremarkable except for minimal tenderness over right hypochondrium. His baseline laboratory evaluation revealed hemoglobin 8.7 gm%, leukocyte count 7170/cumm, platelets 176,000/cmm. Liver function revealed total bilirubin 0.46 mg/dL, AST 14 μ/L, ALT 25 μ/L, albumin 2.6 g/L, alkaline phosphatase 74 μ/L, GGT 78 μ/L and INR 1.2. Tacrolimus level 6 mg/dL. Ultrasound abdomen revealed well-defined thin walled hypoechoic lesion in segment VII measuring 53 mm × 58 mm liver abscess. CT scan of abdomen showed a 6.2 cm × 6 cm × 5.9 cm size multiloculated hypodense collection in segment VII of right lobe with perilesional edema. He underwent percutaneous drainage of collection, which revealed purulent aspirate. Microbiological examination of aspirates showed pus cells and occasional gram-positive branching filaments. Modified acid-fast stain was positive. Culture revealed Nocardai spp. MALDI-TOF test was positive for Nocardia farcinica. He was treated with trimethoprime-sulfamethoxazole, amikacin and imipenem for 2 weeks. He was kept on low immunosuppression. His fever subsided over next few days. Repeat ultrasound scan revealed collapsed abscess cavity with small remnant collection. He was discharged on oral antimicrobials and is under regular follow up. Conclusion: Nocardiosis should be suspected as a likely cause of liver abscess in the setting of immunocompromised patients. Long-term treatment with trimethoprime-sulfamethoxazole for up to 6 months improves survival. Conflicts of InterestThe authors have none to declare. The authors have none to declare.