NOCARDIOSIS PRESENTING LIKE A METASTATIC LUNG CANCER

Abstract

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Nocardia is a gram-positive, weakly acid-fast, branching rod which is ubiquitous environmental saprophytes that cause localized or disseminated disease in both immunocompetent and immunocompromised patients. We present here a case of a 55-year-old male who was found to have right middle lobe lung abscess as well as right cerebellar abscess secondary to disseminated Nocardiosis from the pulmonary source. CASE PRESENTATION: A 55-year-old male with a past medical history of hypertension, hyperlipidemia, migraines, 30 pack-year smoking history, and emphysematous COPD presented to the hospital with 5 days of cough productive of clear sputum, headache and multiple episodes of emesis. He also reported 30 pounds weight loss over the last 1 year due to poor appetite. On presentation, he was hypoxic and tachypneic requiring 5 liters of oxygen by nasal cannula. Physical examination showed a cachectic male with decreased breath sounds bilaterally and crackles in the right lower lung field. The neurological exam showed nystagmus with right-sided gaze and square wave jerks as well as dysdiadochokinesia. Labs showed elevated WBC count at 17.6*10^3 with Neutrophilic pleocytosis. Chest CT showed right middle lobe lung mass, multiple bilateral pulmonary nodules as well as right lower lobe pneumonia. CT head showed right-sided cerebellar mass. Hence an emergent MRI was obtained to assess the mass which showed a large multiseptated cerebellar mass measuring 4.7 * 5.8 * 3.2 cm with mild vasogenic edema centered in the right cerebellar hemisphere crossing midline and producing severe stenosis of the fourth ventricle and resultant obstructive hydrocephalus. The patient was taken to the Operating room STAT and when the right cerebellum was entered a green-tinged fluid started draining which was sent for a culture that grew Nocardia cyriacigeorgica. The patient also had a bronchoscopic biopsy of the right-sided lung mass a day later which also grew the same organism. The patient was initially treated with Intravenous vancomycin, ceftriaxone and levofloxacin for broad-spectrum coverage for pneumonia and after the cultures grew Nocardia was switched to intravenous trimethoprim-sulfamethoxazole and meropenem after infectious disease consultation. However, he failed to respond to the therapy and was made comfort care and passed away. DISCUSSION: Disseminated disease with Nocardia involving brain and lung has been reported in both immunocompromised and immunocompetent patients. However, most of the cases reported in the literature are of elderly patients or immunocompromised patients. As the population of the United States is aging with many patients on immunomodulators it is imperative to raise awareness about disseminated nocardiosis CONCLUSIONS: Physicians must be aware that disseminated nocardiosis can mimic the presentation of metastatic lung carcinoma: early surgical intervention in brain abscess improves outcomes. Reference #1: Karan M, Vučković N, Vuleković P, Rotim A, Lasica N, Rasulić L. Acta Clin Croat. 2019 Sep;58(3):540-545. doi: 10.20471/acc.2019.58.03.20. Reference #2: Schlaberg R, Huard RC, Della-Latta P. Nocardia cyriacigeorgica, an emerging pathogen in the United States. J Clin Microbiol. 2008. Jan;46(1):265–73. 10.1128/JCM.00937-07 Reference #3: Lee GY, Daniel RT, Brophy BP, Reilly PL. Surgical treatment of nocardial brain abscesses. Neurosurgery. 2002. Sep;51(3):668–71, discussion 671–2. 10.1097/00006123-200209000-00010 DISCLOSURES: No relevant relationships by Fazal Raziq, source=Web Response No relevant relationships by Muhammad Usama, source=Web Response