Infectious Disease Reports 2014; volume 6:5327 A complicated case Introduction Correspondence: Chad J. Cooper, Department of of an immunocompetent Internal Medicine, Texas Tech University Health patient with disseminated Nocardia species are aerobic, gram positive Sciences Center, 4800 Alberta Ave, El Paso, TX nocardiosis filamentous branching bacteria that have the 79905, USA. potential to cause localized or disseminated Tel. +1.915.543.1009. E-mail: [email protected] Chad J. Cooper, Sarmad Said, infection. Nocardia species are ubiquitous in the environment as saprophytic components in Maryna Popp, Haider Alkhateeb, Key words: nocardia, lung abscess, brain abscess, dust, soil, water, decaying vegetation and stag- Carlos Rodriguez, septic emboli. nant matter.1 Nocardiosis mainly affects Mateo Porres Aguilar, Ogechika Alozie immunocompromised patients, although Contributions: the authors contributed equally. Department of Internal Medicine, Texas rarely immunocompetent individuals could Tech University Health Sciences Center, also be affected. The predominant form of Conflict of interests: the authors declare no El Paso, TX, USA nocardiosis is dependent on the species and potential conflict of interests. the geographical location.2 The majority of nocardiosis cases are caused by the N. aster- Received for publication: 28 January 2014. oides complex and N. brasiliensis. In the tropi- Revision received: 17 February 2014. Accepted for publication: 25 February 2014. Abstract cal climate cutaneous and lymphocutaneous infections caused by N. brasiliensis (myce- This work is licensed under a Creative Commons toma) predominate. In the temperate climate Nocardia species are aerobic, gram positive Attribution NonCommercial 3.0 License (CC BY- zone, pulmonary infections with N. asteroides NC 3.0). filamentous branching bacteria that have the complex will be more prevalent.2 The major potential to cause localized or disseminated risk factor for nocardia infection is being ©Copyright C.J. Cooper et al., 2014 infection. Nocardiosis is a rare disease that immunocomprised, specifically those with cell- Licensee PAGEPress, Italy usually affects immunocompromised patients Infectious Disease Reports 2014; 6:5327 mediated immunity defects.3 The main causes and presents as either pulmonary, cutaneous doi:10.4081/idr.2014.5327 of immunocompromise are hematopoietic only or disseminated nocardiosis. Forty-two year- stem cell or solid organ transplantation, HIV old hispanic male presented to our care with infection, chemotherapy, malignancy or gluco- extremity pain for 3 weeks, located at the bilateral lower extremity weakness, frontal corticoid therapy. Risks factors for pulmonary upper thighs with radiation down the legs. He headache, subjective fever, nausea, and vomit- nocardiosis are alcoholism and chronicuse lung also complained of a non-radiating severe, ing. Brain computed tomography (CT) disease. frontal, throbbing headache for one week, revealed multiple hyperdense lesions with Nocardiosis is a rare disease that usually associated with occasional episodes of diplop- vasogenic edema in the frontal, parietal and causes one of three clinical manifestations. ia, without a stiff neck or photophobia. Four left temporal lobes. Chest CT demonstrated Pulmonary nocardiosis is the most common days prior he developed bilateral lower extrem- bilateral cavitary nodules in the lung and right manifestation nocardiosis. Pulmonary infec- ity weakness and could not walk or stand on hilar lymphadenopathy. Brain magnetic reso- tion is acquired through the inhalation of the his own. Other complaints included nausea, nance imaging revealed multiple bilateral organism from dust or soil. Other sites of vomiting and a low-grade fever of 37.7°C. No supratentorial and infratentorial rim enhanc- nocardial dissemination include skin, subcuta- recent travel abroad or sick contacts. He had ing lesions involving the subcortical gray- neous tissues, and the central nervous sys- no medical problems or previous surgical white matter interface with vasogenic edema. tem.4 Disseminated disease is defined by the interventions. He admitted to a 20 pack year Patient was started on empiric therapy for presence of two or more organs infected by history of smoking and chronic alcohol intake unknown infectious etiology with no response. nocardia. Disseminated nocardiosis is charac- of four 8 oz cans of beer every day for the last He eventually expired and autopsy findings terized by hematogenous spread of microbes twenty years. He currently worked as a con- revealed a right hilar lung abscess and multi- into brain, eye, bone, joint, heart, kidney, skin struction worker. All vital signs were stable on ple brain abscesses. Microscopic and culture or other organs and tissues.5 Nocardiosis has admission and within normal range. Physical findings from tissue sample during autopsy the ability to disseminate any organ, most examination demonstrated somnolent but revealed nocardia wallacei speciesNon-commercial with mul- commonly the central nervous system (CNS) arousable patient in no acute distress. The tidrug resistance. The cause of death was stat- and has a tendency to relapse or progress complete neurological and lung examination ed as systemic nocadiosis (nocardia pneu- despite being given the appropriate therapy.6 were unremarkable except hypereflexia of the monitis and encephalitis). The presence of We are presenting a case of an immunocom- right brachioradialis and right biceps and a simultaneous lung and brain abscesses is a petent patient with risk factors of chronic alco- decrease of muscle strength of bilateral lower reliable indication of an underlying Nocardia hol abuse and environmental exposure as a extremities. All other body systems of physical infection. An increased awareness of the vari- construction worker that developed dissemi- examination were unremarkable. ous presentations of nocardiosis and a high nated nocardiosis. This case was further com- Initial laboratory work up (Table 1) was index of clinical suspicion can help in a rapid plicated by the inability to obtain a tissue sam- remarkable for mild hyponatremia, mild diagnosis and improve survival in an other- ple to characterize the nocardia species and transaminase elevation and hyperbilirubine- wise fatal disease. This case highlights the give the appropriate therapy. mia. The ammonia level was in the upper nor- importance of obtaining a tissue biopsy for mal range. Urinalysis, urine toxicology screen definitive diagnosis on the initial presentation and alcohol level, hepatitis serology panel and when an infectious process is considered in HIV were negative. Chest x-ray on admission the differential diagnosis and early treatment Case Report was unremarkable. Computer tomography can be initiated. (CT) of the brain (Figure 1A) on admission Forty-two year-old Hispanic male presented revealed multiple intraaxial hyperdense with severe and constant bilateral lower lesions with surrounding vasogenic edema in [Infectious Disease Reports 2014; 6:5327] [page 9] Case Report the frontal, parietal and left temporal lobes. Table 1. Initial laboratory work up. Hematogenous spread was suggested by the White blood cell count 10.05×103 UL (4.5-11.0×103/UL) presence of several lesions at the gray-white junction. Chest-CT (Figure 1B) on admission Hemoglobin 16.0 g/dL (12.0-15.0 g/dL) demonstrated bilateral cavitary nodules in the Hematocrit 43.4% (36.0-47.0%) lung and right hilar lymphadenopathy. Our dif- Platelet count 233×103/UL (150-450×103/UL) ferential diagnosis included metastatic versus Sodium 130 mmol/L (135-145 mmol/L) infectious etiology. We therefore started the Potassium 4.4 mmol/L (3.5-5.1 mmol/L) patient on empiric antibiotics of vancomycin 1 Serum glucose 137 mg/dL (70-100 mg/dL) gram every 12 hours, ceftriaxone 2 grams every 12 hours, and dexamethasone 6mg IV BUN 15 mg/dL (7-22 mg/dL) every 8 hours for cerebral edema. We then pro- Creatinine 0.8 mg/dL (0.60-1.30 mg/dL) ceeded to obtain a MRI of the brain (Figure 2) AST 66 IU/L (15-37 IU/L) which revealed multiple bilateral supratentori- ALT 66 IU/L (12-78 IU/L) al and infratentorial rim enhancing lesions Alkaline Phosphatase 104 IU/L (50-136 IU/L) involving the subcortical gray-white matter Ammonia 45 umol/L (10-40 umol/L) interface, superficial and deep white matter tracts, brainstem and cerebellum associated with vasogenic edema. These findings were more likely associated with an infectious etiol- ogy causing septic emboli. The initial blood and urine cultures on admission were nega- tive. The pulmonary service was consulted on the second hospital day for bronchoscopy for bron- Table 2. Cerebrospinal fluid studies. only choalveloar lavage (BAL). Bronchoscopy Appearance Clear and colorless revealed normal airway anatomy with diffusely erythematous mucosa and clear secretions. White blood cell count 18/uL BAL was obtained from the left upper lobe and Neutrophils use64% cytology report had no significant findings. Lymphocytes 25% The BAL cultures were negative for fungal, Monocytes 11% bacteria and mycobacteria. AFB stain was per- Red blood cell count 1/uL formed on the BAL and was also negative. The infectious disease service was also consulted Protein 37 mg/dL on the second hospital day and recommended Glucose 55 mg/ dL a PPD, Quaniferon Gold, coccidiodies serology, Corresponding serum glucose 128 mg/ dL aspergillus antigen, toxoplasma IgG antibody, Cerebrospinal fluid serology serum crytococcal antigen and a lumbar punc- Cryptococcal antigen Negative