UNUSUAL PRESENTATION OF PULMONARY NOCARDIOSIS WITH A NOVEL SPECIES

SESSION TITLE: Chest Infections 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Nocardiae are uncommon anaerobic gram-positive bacterial infection caused by actinomycetes in the genus Nocardia. Is an opportunistic infection, but can affect immunocompetent patients. These bacteria are found in soil and water and infect humans due to inhalation causing pulmonary nocardiosis. Pulmonary nocardiosis possess a mortality rate of 50%. This organism may translocate to any organ. The relapse of the infection is very frequent despite the adequate treatment. Delayed diagnosis is associated with poor prognosis secondary to disseminated disease. CASE PRESENTATION: A 29-year-old male with recently diagnosed with classical Hodgkin’s lymphoma, who was admitted to start chemotherapy. Approximately 48 hours after admission patient started to complaint of shortness of breath and productive cough. Also found with tachycardia, fever and peripheral oxygen saturation of 88% at room air. Physical exam relevant for decreased breath sound bilateral bases, diffuse pulmonary ronchi, bilateral lower extremity edema and abdominal distensions non-tender and depressible to palpation. Chest Xray performed and was found with right lung consolidation. Chest CT showed right middle lobe consolidation and bilateral multiple nodular densities. Patient was started on empiric IV antibiotic therapy for hospital-acquired pneumonia with vancomycin and meropenem. Patient didn’t improve with current management, blood culture was negative and sputum gram stain positive for gram positive modified acid fast bacilli with some branching suspected of Nocardia sp. Patient was started on amikacin and doxycycline since patient was allergic to sulfa drugs. Chest CT was repeated and was found with worsening of pulmonary finding and development of cavitary lesions on the left upper lobe and left infrahilar region with persistent right middle lobe consolidation. In less than 24 hours patient developed left side hydropneumothorax which required left chest tube placement and endotracheal intubation in view of clinical instability. The chest tube drainage had characteristics of serous empyema. Repeated sputum culture, blood culture, peripheral and from central line, came back positive for Nocardia sp. Novel. DISCUSSION: This case relevant in view of aggressive disease and complications despite appropriate management of Nocardia with development of hydropneumothorax in the setting of immunosuppression. Nocardiosis incidence in United States, is 500–1000 cases per year. Review of literature revealed two other case reports where the patient presented with empyema and one pneumothorax. This case distinguished from other cases due to the Novel Nocardia species not responsive to recommended antibiotic therapy. CONCLUSIONS: This disease should be considered in all patients not only in the immunocompromised but also in the immunocompetent without pre-existing lung disease who failed initial therapy for pneumonic process. Reference #1: Kandi V (August 15, 2015) Human Nocardia Infections: A Review of Pulmonary Nocardiosis. Cureus 7(8): e304. DOI 10.7759/cureus.304 DISCLOSURES: No relevant relationships by Christian Castillo Latorre, source=Web Response Speaker/Speaker's Bureau relationship with merck Please note: $1001 - $5000 Added 03/04/2018 by MIGUEL COLON, source=Web Response, value=Honoraria No relevant relationships by Marlene Farinacci Vilaro, source=Web Response No relevant relationships by Juan Garcia-Puebla, source=Web Response No relevant relationships by Luis Gerena Montano, source=Web Response