Disseminated nocardiosis in a bone marrow transplant recipient with chronic GVHD

Abstract

Summary:We describe a case of disseminated nocardiosis in a 53-year-old male allogeneic marrow recipient with chronic GVHD, 15 years post BMT. Six months prior to admission he was treated for recurrent chronic GVHD with corticosteroids with a good response. He deteriorated subsequently while still on steroids requiring admission for fever, anorexia, weight loss, productive cough and progressive dyspnoea. On admission he had multiple nodular lesions on chest roentgenogram and subsequently grew Nocardia farcinica in blood culture. N. farcinica is rare post BMT, has a high mortality, is resistant to various antibiotics and needs prolonged antimicrobial therapy. We report the successful management of our patient with single agent trimethoprimsulphamethoxazole.

Pulmonary Nocardiosis Developed in a Hematopoietic Stem Cell Transplant Recipient with Bronchiolitis Obliterans

“…Most of the reported cases were treated with 640/3,200 mg daily dose of TMP/ STX (5,11,12), although this medication often caused myelosuppression and renal dysfunction especially in patients receiving calcineurin-inhibitors after allogeneic HSCT. In recent years, carbapenem has been shown to possess antiNocardia activities both in vivo (20,21) and in vitro (22).…”

“…The underlying conditions in patients with nocardiosis include corticosteroid medication, antineoplastic chemotherapy, solid-organ transplantation, AIDS, and chronic obstructive pulmonary disease (COPD) (6)(7)(8)(9). HSCT has recently been described as a risk factor for nocardiosis, especially when the systemic immunosuppressive therapy (IST) is prolonged to control GVHD (5,(10)(11)(12)(13).…”

“…Nocardia species are gram-positive aerobic actinomycetes ordinarily found in soil, which infect immunocompromised humans predominantly through the respiratory tract disseminating in circulation potentially to the brain and the skin (2)(3)(4)(5). The underlying conditions in patients with nocardiosis include corticosteroid medication, antineoplastic chemotherapy, solid-organ transplantation, AIDS, and chronic obstructive pulmonary disease (COPD) (6)(7)(8)(9).…”

Central Nervous System Infections in Cancer Patients and Hematopoietic Stem Cell Transplant Recipients

“…Nocardiosis is also seen as a late complication of bone marrow and HSCT, [78,79,[86][87][88][89][90][91][92][93][94][95][96][97][98][99][100][101] with reported incidences of 0.2 and 1.7 % in recipients of autologous and allogeneic transplants, respectively [89,94]. Many cases have occurred following the development and steroid treatment of GVHD [79,[89][90][91][92][93][94][95][96][97][100][101][102].…”

Pulmonary nocardiosis

“…Several recent case reports and small case series have described nocardiosis in recipients of organ transplants, both of bone marrow [12,13] and solid organs (lung [14], heart [15], and kidney [16][17][18][19]). Risk factors for the development of nocardiosis in transplant recipients include multiple early rejection episodes, intensive immunosuppressive therapy, and impaired allograft function [20].…”