Nocardia farcinica pericarditis after kidney transplantation despite prophylaxis

Abstract

A deceased-donor kidney transplant recipient developed purulent pericarditis caused by Nocardia despite trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis for Pneumocystis jirovecii. She was treated empirically with ceftriaxone and amikacin and subsequently underwent sternotomy with drainage of an intrapericardial abscess. Culture and susceptibility data demonstrated Nocardia farcinica, which was susceptible to SMX and amikacin, although resistant to ceftriaxone. Nocardia asteroides, the more common human pathogen, is generally susceptible to third-generation cephalosporins and TMP-SMX. N. farcinica is rare in the United States, more virulent and resistant than N. asteroides, and is more likely to cause disseminated disease. Successful therapy of disseminated Nocardia infections is dependent upon choice of appropriate empiric antibiotics in addition to surgical drainage of purulent fluid collections. TMP-SMX prophylaxis may not be sufficient to prevent infections due to Nocardia species in all immunosuppressed transplant recipients. Here, a rare complication of this unusual pathogen is discussed.

Nocardia in Solid Organ Transplant Recipients

“…Organisms appear in tissue sections as gram-positive branching and beading rods surrounded by a pyogenic inflammatory reaction (2,38). No (14,31,(44)(45)(46). (76,77) and been effective in human cases (14,78 (1,2,11,15,36,44,(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)59,(61)(62)(63)(65)(66)(67)(68)(69)(70)(71)(72)(73)(74)(75) …”

“…Susceptibility studies suggest meropenem is less active against the more common N. asteroides complex organisms than imipenem; however, it is more active against N. brasiliensis and N. otitidiscaviarum (74). With its less frequent dosing, good penetration of the blood brain barrier and reported lower incidence of seizures, meropenem is an additional option for therapy (74,81 (4,46,47,55,85).…”

“…In fact, nocardiosis appears to be a rare infection in children (105)(106)(107) (20,108). However, there are increasing reports of breakthrough infections by TMP-SMX-susceptible Nocardia isolates in patients taking TMP-SMX prophylaxis (11,13,14,19,34,46,69,(108)(109)(110), creating some doubt about the utility of this agent for prevention of nocardiosis (34) (13,14,109), though nocardiosis has also been reported despite daily TMP-SMX prophylaxis (46). Data are limited on which to base recommendations for secondary prophylaxis.…”

Purulent Pericarditis and Cardiac Tamponade Caused by <i>Nocardia farcinica</i> in a Nephrotic Syndrome Patient

“…Since 1967, only 19 cases of such disease have been reported worldwide and, of these, only two were caused by the N. farcinica species (7,8). We herein report the third documented case of N. farcinica pericarditis, and its progression into cardiac tamponade.…”

Imaging Pericardial Nocardiosis by Cardiac Magnetic Resonance

“…1 Most Nocardia pericarditis in the literature has resulted in pericardial tamponade 2,3 or constrictive pericarditis. 4 In the present case, the masses were well encapsulated according to cardiac magnetic resonance assessment, and transthoracic echocardiography showed no signs of constriction or tamponade.…”