Abstract
The management of potentially life-threatening brain nocardiosis in an elderly renal transplant recipient with the relevant specific antimicrobial agents while still continuing anti-rejection immunosuppressive therapy poses major clinical, pharmaceutical and logistical problems. This is a case of a 70-plus year old Caucasian male renal transplant recipient on maintenance immunosuppression, who developed a left flank abscess that was later complicated by the onset of personality changes from brain nocardiosis. The evolution of the diagnosis, treatment and recovery in this case presentation highlight the need for microbial susceptibility testing, the need for pharmacovigilance to monitor drug intolerance and drug resistance as well as other overarching treatment strategies including a close collaboration between Infectious Diseases and Transplant Medicine specialties in the management of this complicated case.
Highlights
The management of potentially life-threatening brain nocardiosis in an elderly renal transplant recipient with the relevant specific antimicrobial agents while still continuing anti-rejection immunosuppressive therapy poses major clinical, pharmaceutical and logistical problems.Case Report A 74-year old Caucasian diabetic hypertensive male with a cadaveric renal allograft from 2011, on maintenance immunosuppression (Myfortic 540 mg/d, Prednisone 5 mg/d, tacrolimus 2 mg BID) developed a left flank abscess while spending the winter in Florida in February 2012
The flank abscess improved and since the patient was to return up north to Wisconsin, he was switched to oral minocycline after 14 days of IV ceftriaxone
He was discharged after twelve days on IV amikacin 560 mg every 12 hours, IV ceftriaxone 2 g every 12 hours, and oral moxifloxacin 400 mg/d
Summary
The management of potentially life-threatening brain nocardiosis in an elderly renal transplant recipient with the relevant specific antimicrobial agents while still continuing anti-rejection immunosuppressive therapy poses major clinical, pharmaceutical and logistical problems. As at October 2014, the patient had remained otherwise asymptomatic nearly a year after completing the oral moxifloxacin course He has continued to do well, off antifungals and has continued immunosuppression with Prednisone 5 mg daily, tacrolimus 1 mg every 12 hours (50% of original dose from April 2012), mycophenolic acid 360 mg in am, 180 mg in pm, and his current serum creatinine was 1.4 mg/dL as at August 2015. 5. Six months into antimicrobial therapy, in October 2012, whilst on IV ceftriaxone and oral moxifloxacin, he developed severe generalized exfoliative dermatitis which rapidly resolved following the discontinuation of IV ceftriaxone. Six months into antimicrobial therapy, in October 2012, whilst on IV ceftriaxone and oral moxifloxacin, he developed severe generalized exfoliative dermatitis which rapidly resolved following the discontinuation of IV ceftriaxone He subsequently was continued only on oral moxifloxacin for another 12 months to complete therapy of the brain nocardiosis
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