Pulmonary Nocardiosis in a Multiple Myeloma Patient Treated with Proteasome Inhibitors

Abstract

Patient: Male, 71Final Diagnosis: Pulmonary nocardiosisSymptoms: Cough • dyspnea • feverMedication: CarfillzomibClinical Procedure: BronchoscopySpecialty: Infectious DiseasesObjective:Rare co-existance of disease or pathologyBackground:The use of proteasome inhibitors like Bortezomib to treat multiple myeloma has been associated with increased rates of opportunistic infections, including Nocardia, especially when lymphopenia is present. The prevalence or association of such infections with newer agents like Carfilzomib is not known.Case Report:A 71-year-old man with multiple myeloma presented with a 6-week history of respiratory symptoms and cyclic fevers. He was undergoing chemotherapy with Carfilzomib. Work-up revealed severe lymphopenia and a CT chest showed multiple lung nodules and a mass-like consolidation. He underwent a bronchoscopy, and respiratory cultures grew Nocardia species. He responded well to intravenous antibiotics with resolution of symptoms and CT findings.Conclusions:With the introduction of newer agents like Carfilzomib for the treatment of multiple myeloma, clinicians must maintain a high degree of suspicion for opportunistic infections to achieve early diagnosis and treatment.

Nocardia farcinica Brain Abscess in a Multiple Myeloma Patient Treated with Proteasome Inhibitor: A Case Report and Review of the Literature

“…In previous reports [18][19][20], four patients with multiple myeloma who received bortezomib and dexamethasone developed central nervous system symptoms (Table 2). Proteasome inhibitors, such as bortezomib and carfilzomib, can reduce the effects of T cells, B cells, NK cells, and dendritic cells on the host immune system [21]. Compared with high-dose dexamethasone [7], bortezomib is associated with an increased incidence of shingles reactivation.…”

Nocardiosis Associated with Novel Agents at Relapsed Multiple Myeloma: Case Series

“…Herpes simplex and Varicella zoster virus activations are highly possible with bortezomib, but opportunistic actinomyces infections such as nocardia are unusual, but ,they can be seen especially in the setting of lympopenia [8,9]. Carfilzomib is also a novel and irreversible proteasome inhibitor with a sustained and spesific action; and although the prevelance of pulmonary nocardiosis associated with carfilzomib is not known yet, it is reported, therefore it must be considered [10]. In our cases, all of the patients were above 65 years old, had a nonspesific cough complaint ,they were all relapsed cases and have imid-based therapies, proteasome inhibitors(bortezomib), dexamethasone usage and stem cell transplantation histories in common.…”