Lymphocutaneous Nocardiosis in a Lymphopenic Breast Cancer Patient under Treatment with Docetaxel

Abstract

A 65-year-old woman with metastatic breast cancer received 10 courses of chemotherapy with docetaxel 100 mg/m 2 and achieved considerable symptomatic relief despite minimal disease regression. Before her last course, a pustule appeared over her right ankle, which was aspirated for smear and culture. Profound lymphopenia (lymphocytes 100/ µ l) with normal granulocyte counts were also noticed in her peripheral blood. Despite 4 days of empirical treatment with amoxicillin and clavulanate, the lesion ulcerated ( Fig. 1a) and her entire leg was inflamed. The initial sample, cultured in routine bacteriologic media, recovered a gram-positive, fine branching rod (Fig. 1b) susceptible to levofloxacin only, which was initiated at a dose of 500 mg twice a day. Finally, Nocardia otitidiscaviarum was identified as the offending agent. Twenty-eight days after levofloxacin initiation, considerable improvement was observed (Fig. 1c), and the patient was discharged on 2-months additional antibiotic treatment.Nocardiosis resulted in stopping an otherwise beneficial chemotherapy and delayed the application of an alternative one. Docetaxel-induced lymphopenia probably resulted in a transient cell-mediated immune defect that predisposed to this rare infection. Lymphopenia subsided 2 months after docetaxel cessation and did not reoccur with subsequently applied non-docetaxel-containing chemotherapy regimens. Figure 1. (a) Nocardial cutaneous lesion at its maximal ulceration. (b) N. otitidiscaviarum visualized as a gram-positive, fine branching rod. (c) The lesion after 4 weeks of levofloxacin treatment.

Clinical Characteristics ofNocardiaInfection in Patients with Rheumatic Diseases

“…Seven out of the 10 patients had pulmonary diseases including pulmonary lesions induced by underlying rheumatic diseases, a history of pulmonary tuberculosis, and pulmonary aspergillosis (Table 2). In contrast to the previous reports suggesting the association between Nocardia infection and lymphocytopenia [13, 14], white blood cell (WBC) counts and lymphocyte counts in peripheral blood in our patients were within normal limits (Table 2). In addition, no patients had severe hypogammaglobulinemia or hypoalbuminemia.…”

“…On the other hand, lymphocytopenia and CMV infection, which have been suggested to be associated with Nocardia infection in patients with organ transplantation or neoplastic diseases [6, 13, 14], were not identified in our patients with rheumatic diseases who developed Nocardia infection (Table 2) possibly due to the relatively low incidence of lymphocytopenia and CMV infection in these conditions [18, 19]. Taken together, these results suggest that the risk factors for development of Nocardia infection can be different in patients with rheumatic diseases compared to those with organ transplantation or neoplastic diseases presumably because of the differences in the preexisting immunological abnormalities and/or the therapy for underlying diseases.…”

Clinical Analysis of Pulmonary Nocardiosis in Patients With Autoimmune Disease

“…The possible relationship between Nocardia infection and lymphocytopenia had been observed in previous studies. 2 , 4 – 5 , 31 – 32 In AIDS patients, it was reported that the incidence of nocardiosis was ∼140-fold higher than that in the general population, and those whose peripheral CD4 + T-cell counts were < 0.1 × 10 9 /l were at the highest risk. 2 , 4 – 5 Because more than half of our cases had lower CD4 + T-cell counts, it appeared that lymphocytopenia, particularly low peripheral CD4 + T-cell counts, may be a risk factor in patients with autoimmune disease complicated by pulmonary nocardiosis.…”