Dr GHIA SPANGENBERG1,3, Dr RAJIV JUNEJA1,3, Prof DAVID GORDON1,2, A/Prof JORDAN LI1,3
1Renal Unit, Flinders Medical Centre, Bedford Park, Australia, 2Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Bedford Park, Australia , 3College of Medicine and Public Health, Flinders University, Bedford Park, Australia
Background:
Nocardia is a gram-positive bacterium capable of causing both local and systemic opportunistic infection in immunocompromised patients. The most common clinical presentation is pulmonary infection. Presentation with an intramuscular abscess without disseminated nocardiosis is rare.
Case Report:
A 67-year-old male with polycystic kidney disease received a renal transplant three years prior complicated by cytomegalovirus viraemia and persistent neutropaenia with subsequent cessation of mycophenolate. His immunosuppressants at the time of presentation included tacrolimus and prednisolone.
He presented with swelling of the right bicep muscle in the vicinity of an intravenous cannula inserted at the time of left radiocephalic fistula ligation. Ultrasound confirmed a 10x20x20mm intramuscular fluid collection which was managed conservatively and presumed to be a haematoma from intravenous cannulation and in the setting of anticoagulation for a pulmonary embolism.
He represented two-weeks later with increasing pain and swelling without constitutional symptoms. Computer tomography (CT) was suggestive of an intramuscular abscess. Surgical incision and drainage was performed with intraoperative samples showing gram-positive bacilli resembling Nocardia spp., treated initially with meropenem and linezolid. CT of the brain, chest, abdomen and pelvis showed no other focus of infection. The Nocardia was identified as N. pseudobrasiliensis which was resistant to carbapenems. Therapy was changed to trimethoprim/sulfamethoxazole (SXT) and ciprofloxacin however SXT was not tolerated. He was subsequently treated with 6-months of ciprofloxacin and azithromycin with a good clinical response and no recurrence to date.
Conclusions:
Nocardia requires consideration in the differential diagnosis of atypical infections in the immunocompromised kidney transplant recipient. The antimicrobial susceptibilities of Nocardia are variable depending on species with carbapenem resistance recently described in N. pseudobrasiliensis and this should be considered when initiating antimicrobial therapy.
Biography:
My name is Ghia Spangenberg and I am a third year General Medicine Advanced Trainee with an interest in Nephrology.