When Opportunity Strikes: A Case of a 67-year-old with History of Cardiac Transplant Developing New-onset Seizures

Abstract

Introduction Many known risks are associated with cardiac transplantation. Although dangers surround the transplant itself, immunosuppression increases the vulnerability to infection and malignancy. Without expertise in transplant medicine, diagnosing and managing patients with complications of immunosuppression can become challenging. Case Description : A 67-year-old male 4 months post orthotopic heart transplant (OHT), without induction therapy, tolerating appropriate immunosuppression and antimicrobial prophylaxis presented to an outside hospital (OSH) for new-onset seizures and fevers of up to 104° F. At the OSH he was started on Keppra and underwent a brain MRI showing enhancing masses with edema, suspicious for metastatic disease with primary lung carcinoma, as the patient had a known lung nodule pre-OHT. The OSH called us for transfer, however, the patient refused due to wanting to stay near his home to take care of his cats. However, he continued to deteriorate despite being on steroids and anti-epileptics and on day 3, he agreed to be transferred to our facility. Transthoracic echocardiogram showed normal ejection fraction, no vegetations or abscess or evidence of graft dysfunction. Repeat MRI at our institution revealed 3 ring-enhancing lesions within the supratentorial parenchyma consistent with cerebral abscesses. CT scan showed a 2.5 cm pulmonary nodule in the left lingula. Lumbar puncture indicated white blood cells and predominant neutrophils. He was originally scheduled for a lung biopsy, but pre-procedure CT revealed the lung nodule decreased in size, suggesting an infectious etiology. He began IV Meropenem and Bactrim since all evidence was suggestive of infection and not malignancy. Brain biopsy revealed the lesions were abscesses and culture demonstrated gram-positive filamentous rods, consistent with Nocardia. Linezolid was added to his current antibiotic regiment for better broader coverage. Bacterial speciation detected Nocardia cyriacigeorgica. The patient continued to improve after antibiotic initiation and was discharged to rehab. Conclusion : Immunosuppressed patients are susceptible to opportunistic infections, such as that of N. cyriacigeorgica, especially in the first year following OHT. These infections can lead to clinical manifestations that may be mistaken for malignancy at centers lacking expertise in transplant medicine. Transplant patients should be aware of the risks of chronic immunosuppression therapy and counseled to return to the implanting center for serious conditions.