Successful Liver Retransplantation in a Patient With Disseminated Aspergillosis and Nocardiosis: A Case Report.

BACKGROUND: Clinical guidelines list active fungal infection and sepsis as contraindications to liver transplantation due to the risk of worsening infection with immunosuppression postoperatively. Mortality from systemic opportunistic infections in transplant recipients is high, approaching 100% for disseminated aspergillosis. However, the optimal duration of treatment required before transplant is unclear. Additionally, delaying surgery while the infection is treated risks death from hepatic decompensation and physical deconditioning, preventing progression to transplantation. CASE REPORT: Here, we present a patient who underwent successful repeat liver transplantation for recurrent autoimmune hepatitis and graft rejection while undergoing treatment for disseminated aspergillosis and nocardiosis. He had pulmonary, hepatic, and central nervous system involvement. He had received 2 months of antimicrobials but had ongoing radiologic evidence of infection when listed for retransplantation. He remains well and infection-free 1 year postoperatively. CONCLUSION: Few cases of successful liver transplantation in the setting of disseminated aspergillosis have been reported previously. To our knowledge, this is the first successful liver transplant in a patient with disseminated nocardial infection.

Nocardia brain abscess in a patient with diabetes: a case report.

BACKGROUND: Nocardia are aerobic Gram-positive bacilli that can invade multiple organ systems, including the brain and lungs. It is most frequently found in patients who are immunocompromised. Invasive nocardial disease is a potentially life-threatening infection that can pose a diagnostic challenge. CASE PRESENTATION: Our case details a 76-year-old Indian woman with poorly-controlled diabetes mellitus admitted for confusion and falls. Imaging revealed intracranial abscesses and necrotic masses in the mediastinum and lungs. The suspected diagnosis was tuberculosis; however, she underwent extensive workup without a final diagnosis. Ultimately, a craniotomy with partial brain abscess resection was performed. Dura matter samples revealed Nocardia farcinica. CONCLUSIONS: This case illustrates the importance of considering Nocardia in patients with brain abscesses, particularly in those with immunocompromised states and demonstrates the diagnostic challenges that may arise in definitively making this diagnosis. Invasive procedures may be needed for diagnostic confirmation.

A rare case of isolated cauda equina Nocardia farcinica infection.

Nocardia is a Gram-positive, partially acid-fast, catalase-positive, and urease-positive bacterium that grows aerobically. We present an extremely rare case of cauda equina syndrome due to isolated intramedullary Nocardia farcinica infection. A 44-year-old male presented with low backache and gradually progressive weakness in bilateral lower limbs followed by paraplegia. He was found to have a well-defined, sharply demarcated ring-enhancing lesion located from T11-T12 to L3 vertebral body. He underwent laminectomy and decompression. The histopathological examination revealed a Gram-positive filamentous organism that looks like Nocardia. The culture report was suggestive of Nocardia farcinica. He was then treated with antibiotics and had a remarkable clinical and radiological improvement.

A clinical case report of brain abscess caused by Nocardia brasiliensis in a non-immunocompromised patient and a relevant literature review.

BACKGROUND: Brain abscess due to the Nocardia genus is rare and usually found in immunocompromised patients. The most common subtype implicated is Nocardia farcinica while brain abscess due to Nocardia brasiliensis is comparatively rare. Diagnosis of brain abscess is based mainly on bacteriological culture from pus collected at the site of infection, and brain imaging. Stereotaxic aspiration or surgical resection combined with adequate duration of treatment with antibiotics to which the bacteria are sensitive represent effective treatment strategies. CASE PRESENTATION: We report a rare case of brain abscess caused by Nocardia brasiliensis in a non-immunocompromised patient. He admitted to our hospital twice with a headache. Stereotaxic aspiration was performed at the patient's first appointment at the hospital, and a craniotomy was used to excise the lesion during subsequent abscess recurrence. CONCLUSION: Early diagnosis, reasonable surgical intervention, and adequate duration of treatment with effective antibiotics are critical for treating brain abscess.

Metacarpal tuberculosis with Nocardia infection: A case report.

INTRODUCTION: Isolated metacarpal tuberculosis is rare in orthopedic surgery. In the case of poor efficacy of traditional treatment methods, such as debridement surgery and anti-tuberculosis treatment, it is necessary to consider whether there is a special type of infection. We describe a case of metacarpal tuberculosis with Nocardia infection in a patient. PATIENT CONCERNS: A 65-year-old male patient who suffered from pain and dysfunction lasted for 6 years. DIAGNOSES: Confirmation of the diagnosis was finally achieved by isolation of M tuberculosis and Nocardia actinomycetes from bone specimens. INTERVENTIONS: The patient underwent debridement surgery, Masquelet technique was used during the operation, and oral antibiotics were combined after surgery. OUTCOMES: Bone graft surgery was performed 6 weeks after the first surgery. We followed up on bone healing at 1 and 3 months postoperatively. CONCLUSION: Tissue-specific necrosis usually occurs in particular types of infections such as tuberculosis, which limits the spread of antibiotics. Masquelet technique seems to bring new options to solve this problem. The performance of Nocardia infection is similar to that of tuberculosis infection, so it is difficult to identify clinically. Therefore, for cases where tuberculosis is suspected, and anti-tuberculosis treatment is ineffective, the possibility of Nocardia infection needs to be considered.

Nocardia Farcinica infection of a reversed shoulder prosthesis : case report and review.

We present a case of Nocardia farcinica after placement of reverse shoulder prosthesis in a 73-year-old woman. One month after surgery, the patient was admitted to the hospital with a spontaneous drainage of the wound and complaints of aggravating pain in the operated shoulder. There was no history of an immunosuppressive disease or therapy. After cultivation and empiric therapy with flucloxacillin, Nocardia farcinica was found and treated with a combination of intravenous amikacin and ceftriaxone. Eight days after drainage, a rinse and replacement of the polyethylene cup and glenosphere was executed. The treatment was proven to be successful whereas X-ray scans showed no complications nor any other consequences up until five years after therapy. To our knowledge, this is the first shoulder prosthetic Nocardia infection published in English literature. The aim of this report is to review/gather the knowledge about this particular infection and inform health care providers about this uncommon case.

Orbital and intracranial Nocardia farcinica infection caused by trauma to the orbit: a case report.

BACKGROUND: Localized `and disseminated Nocardia farcinica infection is frequently reported in immunocompromised patients. However, orbital nocardiosis is rare, and, to our knowledge, traumatic orbital nocardiosis that affects the brain has never been described. Here, we report a case of traumatic orbital and intracranial N. farcinica infection in an immunocompetent patient. CASE PRESENTATION: A 35-year-old man, who was immunocompetent, to the best of our knowledge and as per the absence of immunodeficiency symptoms, with orbital trauma caused by the penetration of a rotten bamboo branch developed lesions in the orbit and brain. Subsequently, he underwent debridement and received broad-spectrum antibiotic therapy, but orbital infection occurred, with drainage of pus through the sinus tract. The patient then underwent endoscope-assisted local debridement. Bacterial culture of the sinusal pus was positive for N. farcinica, and a combined intracranial infection had developed. The disease was treated effectively by trimethoprim-sulfamethoxazole and ceftriaxone sodium therapy. The patient remained infection free and without complications at the 14-month follow-up. CONCLUSIONS: Traumatic orbital and intracranial infection caused by N. farcinica is a rare infectious disease, and atypical presentations easily lead to misdiagnosis. When a patient presents with an atypical orbital infection that is unresponsive to empirical broad-spectrum antibiotics, along with suspicious neurologic symptoms, Nocardia infection should be considered. Identification by bacterial culture is the gold standard. Complete local debridement and appropriate antibiotic treatment are keys to the treatment of the disease.

Nocardial clival osteomyelitis secondary to sphenoid sinusitis: an atypical skull base infection.

Clival osteomyelitis is a life-threatening complication of untreated malignant otitis externa or paranasal sinus infection. Although various pathogens have been implicated, to our knowledge, primary nocardial clival osteomyelitis has never been reported. We describe a 74-year-old woman who presented with headaches, abducens and hypoglossal nerve palsies, facial numbness, photophobia, and neck stiffness. Imaging revealed a heterogeneous mass within the sphenoid sinus with clival extension. The lesion was extirpated via a binostril endoscopic endonasal transsphenoidal approach. Histopathological and microbiological examination revealed a nocardial source. Clival osteomyelitis associated with sphenoid sinusitis should be included in the differential diagnosis of progressive skull base lesions in the setting of an underlying infection. Early recognition and intervention with antibiotics and surgical debridement is essential in the management of this rare entity.

Nocardial brain abscess mimicking lung cancer metastasis in immunocompetent patient with pulmonary nocardiasis: a case report.

Nocardia is a ubiquitous microorganism which can be the cause of local and disseminated infection in humans. Immunocompetent and immunocompromised patients both can be affected and Nocardia cyriacigeorgica was reported as a pathogen isolated in patients worldwide. In most cases, nocardiosis is present as pulmonary infection because inhalation is the primary way of bacterial exposure. Nocardial brain abscess occurs usually secondary to a septic focus elsewhere in the body. Considering the facts that the elderly population is growing, such as the number of immunocompromised patients together with high mortality rate in patients with nocardial infection of the central nervous system, we have to raise awareness of the possibility for this rare but potentially fatal condition. We present a case where nocardial abscesses of lung and brain were initially suspected as lung cancer with brain metastases. The patient was treated with a combination of surgical resection and antimicrobial therapy with good outcome.

Chronic Nocardia cyriacigeorgica Periprosthetic Knee Infection Successfully Treated with a Two-Stage Revision: A Case Report.

CASE: We report the successful treatment of a Nocardia cyriacigeorgica periprosthetic joint infection (PJI) that occurred at the site of a total knee arthroplasty. To our knowledge, this organism has not previously been reported in the literature as a cause of PJI. Given the need for a prolonged duration of treatment for this organism (a minimum of 6 to 12 months), modifications to the standard 2-stage revision were made in consultation with infectious-disease specialists. CONCLUSION: PJI is a devastating complication that leads to substantial patient morbidity and utilization of health-care resources. As the number of PJIs continues to rise, new and increasingly challenging infections are being encountered more frequently. In the case described here, the second stage of the revision was delayed for 6 months and antibiotics were continued for 7 months after the second operation, for a total of 13 months of antibiotic treatment. The present report provides a possible treatment plan for patients infected with durable bacteria similar to N. cyriacigeorgica.

Therapeutic Femtosecond Laser-Assisted Lamellar Keratectomy for Multidrug-Resistant Nocardia Keratitis.

PURPOSE: To describe the novel use of femtosecond laser technology for therapeutic resection of infectious foci in a case of multidrug-resistant Nocardia asteroides keratitis. METHODS: A 30-year-old man presented with a corneal infiltrate. Cultures were taken, and fortified vancomycin and tobramycin were initiated. After 3 negative cultures and minimal improvement on various broad-spectrum antibiotics, all topical medications were stopped and a final fourth corneal culture grew N. asteroides. Treatment with topical amikacin was initiated, but the infection continued to worsen. With drug sensitivities still pending, the patient's clinical status continued to deteriorate rapidly, despite treatment with amikacin, gatifloxacin, and polymyxin B/trimethoprim. The femtosecond laser was then used to perform targeted lamellar keratectomy. RESULTS: Femtosecond laser-assisted lamellar keratectomy successfully removed the infected tissue and allowed for increased penetration of topical antibiotics. Drug sensitivities finally returned, revealing multidrug resistance and sensitivity only to trimethoprim/sulfamethoxazole and tobramycin, some of which the patient had previously tried and failed. The infection fully resolved after readministering polymyxin B/trimethoprim and tobramycin, leaving minimal residual scarring. CONCLUSIONS: Multidrug-resistant N. asteroides keratitis can be difficult to manage even with appropriate antibiotic therapy based on drug sensitivity testing. Femtosecond laser-assisted resections may facilitate treatment in these cases by safely and precisely debulking infected tissue and enhancing penetration of topical medications.

Surgery of a nocardia lung abscess presenting as a tension pyopneumothorax.

While some cases of nocardial pneumonia develop secondary empyema, tension pyopneumothorax is a very rare and lethal complication. A 74-year-old man who exhibited thrombocytopenia during steroid therapy for autoimmune hepatitis, presented to our department with a nocardial tension pyopneumothorax. He underwent a left lower lobectomy after chest drainage, and was discharged without any complication other than reoperation to remove a postoperative hematoma.

Myelosuppression-sparing treatment of central nervous system nocardiosis in a multiple myeloma patient utilizing a tedizolid-based regimen: a case report.

Central nervous system (CNS) nocardiosis is a recognised opportunistic infection in immunocompromised patients. Treatment involves prolonged institution of antibiotics, making oral agents a convenient and desired option. Unfortunately, devising an effective, well-tolerated antimicrobial for the duration required to treat CNS nocardiosis is challenging owing to treatment intolerance and toxicities. This report highlights myelosuppression-sparing treatment with an oral tedizolid-based regimen following a complicated course with standard agents. A 68-year-old female from Florida (USA) with low-risk lambda light chain multiple myeloma complicated by persistently low CD4 counts, absolute neutrophil counts and IgG levels presented 18 months after diagnosis with fever, pneumonia, new-onset atrial fibrillation, right-sided hemiparesis, encephalopathy and slurred speech. Magnetic resonance imaging (MRI) showed numerous ring-enhancing lesions, and blood cultures were positive for Nocardia farcinica. The patient failed initial therapy with trimethoprim/sulfamethoxazole (SXT), linezolid and imipenem plus surgical debridement of the frontal lobe abscess. Intraoperative cultures were positive for N. farcinica. The treatment course was also complicated by steadily declining white blood cell and platelet counts despite receiving filgrastim. She was therefore placed on SXT and tedizolid for 6 months. Subsequent brain MRI showed complete resolution of the lesions and thus chemotherapy for multiple myeloma was re-initiated. In conclusion, tedizolid-based regimens may be an option for patients with myelosuppression requiring prolonged antibiotic therapy for CNS nocardiosis.

Bronchoscopic Drainage of Lung Abscesses Using a Pigtail Catheter.

BACKGROUND: Lung abscesses are commonly treated with antibiotics. However, some patients fail to respond and may require percutaneous catheter drainage or surgical intervention. Bronchoscopic drainage (BD) of lung abscesses emerged as a therapeutic alternative in selected patients. OBJECTIVE: To describe our experience with 15 patients who underwent BD at our center during 2006-2016. METHODS: Patients underwent flexible bronchoscopy. Under fluoroscopic guidance, a pigtail catheter was introduced into the abscess cavity, its correct position being confirmed by the injection of contrast medium. The catheter remained in place for a few days and was flushed repeatedly with antibiotics. RESULTS: Fifteen patients (9 males; median age 59 years) underwent 16 BD procedures. A pigtail catheter was successfully inserted and pus was drained from the abscess cavity in 13 procedures (81%) conducted in 12 patients, leading to rapid clinical improvement in 10 of them; resolution of fever occurred a median of 2 days (range <1-4) following pigtail insertion, and patients were discharged after 8 days (range 4-21). The pigtail catheter was extracted after a median of 4 days (range 2-6). CONCLUSION: BD of lung abscesses was achieved in 13 out of 16 procedures, leading to rapid improvement in the majority of patients. This work adds to the existing literature in establishing this procedure as an acceptable therapeutic alternative in selected patients who fail to respond to antibiotics, especially those with an airway obstruction or a fairly central lung abscess.

Nocardia abscessus-related intracranial aneurysm of the internal carotid artery with associated brain abscess: A case report and review of the literature.

Nocardia infections primarily begin in the lungs and spread hematogenously to other sites in the body. Thus, a Nocardia brain abscess is not a completely uncommon occurrence. However, a Nocardia brain abscess complicated by a middle cerebral artery and infectious intracranial aneurysm is a very rare clinical entity. We present a case of an infectious intracranial aneurysm with an associated Nocardia brain abscess that required surgical intervention and resection. The patient was an immunocompetent 60-year-old male who presented with a chief complaint of headache and was found to have an infected intracranial aneurysm and cerebral abscess. He underwent drainage of the abscess with subsequent resection of the infected aneurysm. Cultures from both the blood vessel and brain tissue grew Nocardia abscessus. He was successfully treated with 6 weeks of ceftriaxone and high-dose trimethoprim-sulfamethoxazole. Infectious intracranial aneurysms of the brain caused by Nocardia are rare occurrences, and only a single previous case has been described in the literature. The outcomes of this condition can be catastrophic if it is not treated with a combination of surgery and intravenous antibiotics. The guidelines for the management of this infection are not well defined at this time.

Successful treatment of multifoci nocardial brain abscesses: a case report and literature review.

Brain nocardiosis is a serious opportunistic infection with high mortality. It exists more common in the immunocompromised hosts than the immunocompetent patients. Trimethoprim-sulfamethoxazole (TMP-SMZ) has been mostly considered as the choice of the medical treatment. Linezolid is also newly found to be effective to avoid the invasive surgery. The authors reported a case of patient with multifoci nocardial brain abscesses who failed with the combination of linezolid and TMP-SMZ alone but recovered with the surgery intervention and sequential antibiotics for 2 years. The patient lived a high quality life without recurrence and complications during the 30 months follow-up.Through the literature review, we recommend earlier stereotactic aspiration for diagnosis, combination with surgery intervention and prolonged anti-infection therapy would improve the prognosis.

Nocardia prosthetic knee infection successfully treated by one-stage exchange: case report and review.

A 64-year-old man with a history of sarcoidosis on corticosteroids and azathioprine was admitted to our hospital with complaints of worsening left knee pain and swelling for the past 3 weeks. His past medical history is also significant for severe osteoarthritis requiring a cemented total left knee arthroplasty 1 year ago. Diagnostic investigation during his hospital admission eventually led to the diagnosis of Nocardia nova knee prosthetic joint infection in the setting of a disseminated nocardiosis. He was successful treated by one-stage complete hardware exchange in conjunction with an adapted antibiotic therapy regimen (meropenem and doxycycline followed by ceftriaxone and doxycycline). Two years later, his recovery was deemed excellent.

Nocardia brasiliensis vertebral osteomyelitis and epidural abscess.

Nocardia species exist in the environment as a saprophyte; it is found worldwide in soil and decaying plant matter. They often infect patients with underlying immune compromise, pulmonary disease or history of trauma or surgery. The diagnosis of nocardiosis can be easily missed as it mimics many other granulomatous and neoplastic disease. We report a 69-year-old man who presented with chronic back pain and paraparesis. He was found to have Nocardial brasiliensis vertebral osteomyelitis and epidural abscess. Laminectomy and epidural wash out was performed but with no neurological recovery. This is the second reported case of N brasiliensis vertebral osteomyelitis in the literature.