Disseminated nocardiosis masking an atypical zygomycosis presentation in a kidney transplant recipient

Abstract

Immunosuppressive agents increase the vulnerability of solid organ transplant patients to opportunistic infections. An atypical clinical presentation of a bacterial and fungal co-infection makes diagnosis and treatment even more challenging in this population. A 54-year-old hypertensive woman underwent a cadaveric kidney transplant after years on hemodialysis. Her treatment included mycophenolate, tacrolimus, and prednisone. By post-transplant week 8, she had pneumonia followed by progressive visual changes and seizures. Diagnostic work-up, consisting of magnetic resonance imaging of the brain and chest x-ray, showed several cerebral ring-enhancing lesions, and a pulmonary cavitary lesion. Disseminated nocardiosis was suspected and therapy was started. Skin biopsy was taken from a nodular lesion and culture confirmed Nocardia species infection. During hospitalization, neurological deficit persisted with worsening of brain lesions. She underwent excision of a brain abscess and the final pathologic report showed mucormycosis, revealing the patient's co-infection by 2 different pathogens. After therapy with liposomal amphotericin B and posaconazole, she has remained stable for more than 1 year. Disseminated nocardiosis masked and delayed the diagnosis and treatment of a more aggressive and worrisome organism. Mucormycosis, as a non-fatal isolated brain abscess without rhinal involvement, is an atypical presentation, and only a few cases have been reported.

Primary cutaneous nocardiosis: a diagnosis of consideration in a renal transplant recipient

“…In present case, the infections masqueraded as cutaneous tuberculosis preceding characteristic erythematous papules which eventually coalesced into plaques. Nevertheless, the clinical form masquerading: atypical zygomycosis, superficial celluitis or localized abscesses, lymphoadenities or lymphocutaneous infection, and even generalized limbs swelling; has also been reported in renal transplant recipient with presumed cutaneous nocardiosis [ 11 – 13 ]. The culture revealed no other bacterial and fungal growth in routine culture procedures (incubated for 24-48 h); however, the patient was treated empirically with anti-tubercular therapy for months, based on clinical presentations.…”

Dual disseminated infection with Nocardia farcinica and Mucor in a patient with systemic lupus erythematosus: a case report

“…A handful of cases of mucormycosis in SLE were reported in the English literature and most of them were disseminated infections with fatal outcome even if adequate therapy with amphotericin B was initiated [ 4 ]. Only a few cases of combined disseminated mucormycosis and nocardiosis in immunosuppressed patients have been reported [ 13 ].…”

Pulmonary Mucormycosis Over 130 Years: A Case Report and Literature Review

“…In his review, 55 patients underwent antifungal therapy, in which most received amphotericin B and only seven received an Azole. The overall survival rate was 44% and was higher in patients who underwent combined medical and surgical therapy.In this study, we describe a patient with diabetic ketosis who presented subacutely with semi-invasive pulmonary mucormycosis infection and review 22 other cases of pulmonary mucormycosis treated with posaconazole reported in the literature since 2001 [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. …”