Pulmonary Nocardiosis: A Rare and Serious Complication of TNF Alpha Blockers in Children

Abstract

Purpose: Nocardiosis is a rare and serious complication of treatment with tumor necrosis factor alpha blockers. We present a case of pulmonary infection by Nocardia pseudobrasilliensis associated with infliximab treatment for Crohn's disease in an adolescent. A sixteen year old male patient with a history of Crohn's disease treated with 6-mercaptopurine, inflixmab, and prednisone presented with a two-week history of fever, productive cough, dyspnea, chest pain, anorexia and weight loss. Chest X-ray revealed a 2 × 2 cm pulmonary nodule in the left anterior upper lobe. CT scan of the chest confirmed the presence of the nodule in the left anterior upper lobe, abutting the left carotid and subclavian arteries with a central area of necrosis. Routine blood and sputum cultures with stains for acid-fast bacilli were negative. Percutaneous biopsy of the nodule demonstrated necrotic material with questionable hyphae. Gram stain of the specimen was negative. Due to insufficient specimen, fungal and mycobacterial cultures were not sent. The patient was treated with caspofungin and amphoptercin B but remained febrile. Repeat chest CT demonstrated an increase in the size of the nodule with a central area of necrosis. Wedge resection of the lesion was performed and the specimen was sent for fungal, mycobacterial, bacterial cultures and PCR for Aspergillus, histoplasmosis, and blastomyces. Nocardia pseudobrasilliensis was identified on fungal culture. The patient was started on high-dose trimethoprim/sulfamethoxazole. Immunosuppressive therapy was discontinued and systemic steroids ware subsequently weaned. His gastrointestinal symptoms were managed by bowel rest and total parentral nutrition. The patient remained asymptomatic following treatment, with complete resolution of the nodule on a follow up CT scan. This case illustrates the diagnostic and therapeutic challenges faced in patients with inflammatory bowel disease that are infected with opportunistic organisms. Early recognition and treatment are necessary for prevention of disseminated disease and favorable outcomes.Figure: [1259]