Pulmonary co-infection withNocardiaandAspergillusin a patient with adult-onset Still's disease receiving steroids and tacrolimus

Abstract

Patients on immunosuppression are at risk of unusual infections. We present a man diagnosed to have adult-onset Still's disease who, on high-dose oral steroid and tacrolimus, developed a cavitating pneumonia due to co-infection withAspergillus flavusandNocardia.Timely diagnosis and institution of appropriate therapy resulted in a favourable clinical outcome. Such co-infection in a patient receiving tacrolimus is rare in the published literature. This case serves to emphasise the need to be vigilant for unusual infections in patients who are immunosuppressed, either due to drugs or underlying disease condition.

Nocardia cyriacigeorgica and Aspergillus Co-infection in a Patient with Giant-cell Arteritis

“…Immunocompromised patients, particularly those with impaired cell-mediated immunity due to neoplasms, human immunodeficiency virus infection or immunosuppressive therapy, are more susceptible to opportunistic infections [1,2] . Nocardiosis is an uncommon infection caused by Gram-positive aerobic bacteria belonging to the genus Nocardia [3,4] .…”

“…The invasive form is the most severe and can be fatal, thus requiring timely diagnosis and treatment [18,19]. Nocardiosis and aspergillosis are typically opportunistic infections but are rarely associated with each other, with few cases described even in the presence of immunosuppression [1,2,9] .…”

Pulmonary nocardiosis and scrub typhus in an immunocompromised host

“…Commonly, coinfections occur among patients with an underlying background of immunocompromised condition such as solid organ transplantation, stem cell transplant, long-term corticosteroid therapy, and acquired immunodeficiency syndrome due to HIV. [ 6 8 ] Pulmonary nocardiosis as such is seen commonly in patients with an underlying chronic lung disease, thereby increasing the list of its differential diagnosis such as Mycobacterial infections, fungal infections (pulmonary aspergillosis and pulmonary zygomycosis), lung malignancy, and actinomycosis. [ 1 ] Coinfections have been commonly reported with tuberculosis and aspergillosis.…”

“…[ 5 ] Pulmonary manifestations in patients with scrub typhus include varying grades of bronchitis and interstitial pneumonitis progressing to acute respiratory distress syndrome. [ 6 ]…”

Epidemiology Opportunistic Mycoses

“…В Индии у пациента с ювенильным ревматоидным артритом в форме болезни Стилла, который получал высокие дозы пероральных кортикостероидов, развившаяся пневмония была обусловлена сочетанной инфекцией A. flavus + Nocardia spp. Этот процесс, очевидно, развился на фоне имевшейся у пациента иммуносупрессии [32]. Необычный случай микст-инфекции -L. pneumophila, серогруппа 8 и А. fumigatus -был выявлен у пациента 60 лет, госпитализированного в реанимацию в связи с острой дыхательной недостаточностью, во франции.…”