Disseminated Nocardiosis Associated with Treatment with Infliximab in a Patient with Ulcerative Colitis

Abstract

Patient: Female, 57Final Diagnosis: Disseminated nocardiosisSymptoms: Chills • cough • fever • shortness of breathMedication: InfliximabClinical Procedure: —Specialty: Infectious DiseasesObjective:Rare diseaseBackground:Opportunistic infections may occur when patients with inflammatory bowel disease (IBD) are treated with tumor necrosis factor (TNF)-alpha inhibitors. With the increasing use of new immunosuppressant drugs, the incidence of opportunistic or atypical infections is also increasing, including with Nocardia spp. A high level of awareness of atypical infections is warranted in immunosuppressed patients.Case Report:A 57-year-old female African American, with a past medical history of ulcerative colitis (UC) and arthritis, was treated with infliximab and prednisone. She presented to the emergency department with acute onset of chest pain, shortness of breath, and a two-week history of a productive cough. Examination showed hypoxia, tachypnea, decreased and coarse bilateral breath sounds, and fluctuant, tender, erythematous masses on her trunk and groin. Laboratory investigations showed a leukocytosis with a left shift. She was initially treated for presumed community-acquired pneumonia (CAP). However, blood cultures grew Nocardia farcinica and treatment with trimethoprim-sulfamethoxazole (TMP-SMX) was begun, which was complicated by severe symptomatic hyponatremia. Following recovery from infection and resolution of the hyponatremia, the patient was discharged to a senior care facility, but with continued treatment with TMP-SMX.Conclusions:To our knowledge, this is the first case of disseminated nocardiosis associated with infliximab treatment in a patient with ulcerative colitis. As with other forms of immunosuppressive therapy, patients who are treated with infliximab should be followed closely due to the increased risk of atypical infections. When initiating antibiotic therapy, careful monitoring of possible side effects should be done.

Primary cutaneous nocardiosis caused by Nocardia nova with possible Apremilast contribution

“…This inhibition results in the reduced expression of pro-inflammatory mediators including TNF-alpha and an increased expression of anti-inflammatory mediators [ 34 ]. Given that TNF-alpha is an important proinflammatory mediator involved in the clearance and immune response against infection from Nocardia spp., it is possible that this patient’s use of Apremilast may contributed to the development of cutaneous nocardiosis infection [ 35 , 36 ]. However, Nocardia has been reported rarely among patients on anti-TNF agents [ 37 , 38 ].…”

“…Further, phase III and IV clinical trials of Otezla have failed to demonstrate increased risk of cutaneous infections, and a very small number of systemic infections have been reported [ [40] , [41] , [42] ]. On the other hand, there is a well-established association showing association of nocardiosis with immunosuppressants intake, in particular topical and oral corticosteroids [ 18 , 36 , 43 , 44 ]. Our patient received intralesional triamcinolone acetate injections right before his trip to Aruba that possibly contributed to his disease in the way of local immunosuppression that theoretically could provide the direct inoculation of Nocardia spp.…”