Disseminated Nocardia Nova Infection

Geeta Arora, MD; Mark Friedman, MD; Richard P. MacDermott, MD

Disclosures

South Med J. 2010;103(12):1269-1271. 

In This Article

Case Report

A 61-year-old woman presented with a five week history of fevers (t-max of 104.0°F), left leg pain, and a dry cough. She had a history of ulcerative colitis (UC) for three years, and had been maintained in remission on azathioprine 100 mg daily. Prednisone had recently been started at 100 mg daily for treatment of a disease flare, and had been gradually tapered to 30 mg daily at the time of admission. She denied any other changes in medications, sick contacts, headaches, or trauma. She did report having extensively cleaned her very moldy basement one week prior to the onset of her symptoms.

On physical examination the patient had left lower extremity swelling, which was tender to palpation. Also noted was a 0.25 cm papule on her right wrist, and a 1 x 1 cm scalp lesion. Labs consisted of an elevated white blood cell count of 12,000 (normal: 4,000–9,000) with 29% bands. Computed tomography (CT) scan of the chest showed multiple cavitary lesions in both lung fields (Fig. 1, A and B). The CT scan of the abdomen revealed irregular heterogeneous low-density lesions measuring 1.4 cm in the upper pole of the right kidney, and 1.7 cm in the upper pole of the left kidney. There were irregular heterogeneous low-density lesions in the head and tail of the pancreas measuring 1.4 cm and 8 mm (Fig. 2). The head CT scan was positive for three ring enhancing lesions (Fig. 3). The patient was offered a bronchoscopy, but refused. A Doppler ultrasound of her left leg swelling showed a hypoechoic density. Magnetic resonance imaging of her left leg revealed a cystic 12.1 cm mass.

Figure 1.

A. There were several cavitary lesions involving both lung fields. This image depicts the largest lesion. It is in the right lower lobe, and measures 2.4 × 2.3 cm. B. An area of nodular density involving a segment of the left lung lobe.

Figure 2.

Low density lesions in the head and tail of the pancreas measuring 1.4 cm and 8 mm, respectively.

Figure 3.

There were three distinct, ring-enhancing, central necrotic lesions seen in the computed tomography scan of the head. This shows a 12 × 13 mm right temporoparietal enhancing lesion with little surrounding edema and no mass effect. In addition, there was a 1 cm lesion in the right occipitoparietal junction and a 1 cm lesion within the inferior left cerebellar hemisphere.

The area of swelling on the left leg was incised, drained, and cultured. Cultures grew out Gram-positive acid-fast bacilli on a standard nonselective media. This resulted in the identification of Nocardia nova. Cultures of biopsies of both the wrist and scalp lesions were also positive for Nocardia nova. The patient was treated with double-strength trimethoprim and sulfamethoxazole, six tablets three times a day. This was gradually tapered over the course of a year. Follow-up CT scans of the head and abdomen seven months after initiation of therapy showed complete resolution of all previously observed lesions. The azathioprine was discontinued. The patient's prednisone was tapered and discontinued. The patient remains in remission two years following successful treatment of her disseminated Nocardia nova infection.

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