Asunto(s)
Amiloidosis de Cadenas Ligeras de las Inmunoglobulinas , Linfoma de Células B de la Zona Marginal , Linfoma Folicular , Humanos , Linfoma Folicular/complicaciones , Linfoma Folicular/patología , Yeyuno/patología , Células Plasmáticas/patología , Linfoma de Células B de la Zona Marginal/patologíaRESUMEN
BACKGROUND Nocardia infections have rarely been reported in hematopoietic stem cell transplantation (HSCT) patients, who usually receive the prophylactic use of sulfamethoxazole/trimethoprim (ST) against Pneumocystis jiroveci. However, the ST prophylaxis, sensitive to Nocardia species, sometimes induces renal toxicities. Therefore, alternative prophylactic or therapeutic drugs are required for nocardiosis in HSCT patients. CASE REPORT A 34-year-old Japanese man with acute mixed phenotypic leukemia with t(9; 22) received allogenic peripheral blood HSCT from a haplo-identical sibling donor. He developed graft versus host disease (GVHD) with grade II, and was treated with prednisolone and cyclosporine A with concurrent ciprofloxacin, fluconazole, valacyclovir, and ST. However, the prophylactic ST was ceased because of its renal toxicity. He developed a pulmonary nodular lesion with elevated ß-D-glucan and Aspergillus galactomannan antigen. Repeated blood and sputum culture isolated no pathogens. Voriconazole treatment administered once improved these lesions and laboratory findings. One month later, he presented with right pleuritic chest pain and multiple ring-enhancing cavitation lesions along the ribs. A needle biopsy demonstrated Nocardia elegans, which is an extremely rare infection induced by Nocardia species, in the cavitation lesions, shown by 16S rRNA gene sequencing. He was started on doripenem and liposomal amphotericin B, and a subsequent treatment kept him free from Nocardia elegans infection, without any adverse effects, while continuing the cyclosporine A and prednisolone treatment for chronic GVHD. CONCLUSIONS Clarithromycin has fewer adverse effects than ST. This case suggests that clarithromycin is an appropriate alternative and prophylactic therapy for patients with nocardiosis and ST toxicities.
Asunto(s)
Trasplante de Células Madre Hematopoyéticas , Nocardiosis , Nocardia , Adulto , Claritromicina/uso terapéutico , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Humanos , Masculino , Nocardia/genética , ARN Ribosómico 16SAsunto(s)
Células Clonales/patología , Infecciones por Virus de Epstein-Barr/patología , Herpesvirus Humano 4/aislamiento & purificación , Linfadenopatía Inmunoblástica/virología , Linfoma de Células T/virología , Células Madre Neoplásicas/patología , Células Plasmáticas/virología , Anciano de 80 o más Años , Antígenos CD/análisis , Antígenos de Neoplasias/análisis , Linfocitos B/patología , Linfocitos B/virología , Médula Ósea/patología , Células Clonales/virología , Diagnóstico Diferencial , Infecciones por Virus de Epstein-Barr/sangre , Resultado Fatal , Reordenamiento Génico de Cadena Pesada de Linfocito B , Reordenamiento Génico de la Cadena beta de los Receptores de Antígenos de los Linfocitos T , Humanos , Linfadenopatía Inmunoblástica/sangre , Linfadenopatía Inmunoblástica/diagnóstico , Linfadenopatía Inmunoblástica/patología , Ganglios Linfáticos/patología , Linfoma de Células B Grandes Difuso/diagnóstico , Linfoma de Células T/sangre , Linfoma de Células T/diagnóstico , Linfoma de Células T/patología , Masculino , Células Madre Neoplásicas/virología , Células Plasmáticas/patología , Linfocitos T/patología , Linfocitos T/virologíaRESUMEN
Nocardiosis, sometimes presenting with multiple granulomatous lesions, is a rare opportunistic infection occurring in immunocompromised patients. However, its immunological features remain largely unaddressed. We investigated the immunological characteristics of human nocardiosis and examined the component cells of the granulomatous lesions. A 66-year-old man with diffuse large B-cell lymphoma presented with fever and multiple nodules in the lung during chemotherapy. The blood culture formed white colonies, but their characterization was difficult by routine microbiological laboratory methods. Matrix-assisted laser desorption ionization-time of flight mass spectrometry identified the colonies as Nocardia otitidiscaviarum. Meanwhile, the patient suddenly experienced an epileptic seizure without a brain abscess. His cerebrospinal fluid (CSF) showed neutrophilic pleocytosis (108/mm3). The conventional agar culturing failed to isolate colonies, but culturing with brain-heart infusion agar generated colonies. These colonies were completely concordant with those from the blood, as confirmed by 16S rRNA gene sequencing. Therefore, the patient had developed meningitis through sepsis induced by N. otitidiscaviarum. His CD4-positive T-lymphocyte counts were low, and oligoclonal CD8-positive αß T-lymphocytes were present in the blood prior to the first and after three cycles of chemotherapy. He had bone marrow granulomatous lesions comprising lymphoma and CD8-positive αß T-cells. Treatment with sulfamethoxazole/trimethoprim relieved all of his symptoms. The combined analysis by microbiological and molecular methods determined the cause of his epileptic seizure. His immunological characteristics, including low CD4-positive or CD8-positive αß T-lymphocytes, may have contributed to the unusual clinical presentations by N. otitidiscaviarum, which rarely involves the central nervous system.