Pithy Case (…or a regular
consult)
Camille Nelson Kotton MD, FIDSA
Clinical Director, Transplant & Immunocompromised Host Infectious Diseases Group,
Infectious Diseases Division, Massachusetts General Hospital
Associate Professor, Harvard Medical School
Chair, Infectious Disease Community of Practice,
American Society of Transplantation
Immediate Past President, Infectious Disease Section,
The Transplantation Society
Clinical Vignette
 36yo male, Type I diabetes, 3 months after
kidney/pancreas transplant (on prednisone 5 mg/day,
mycophenolate mofetil (Cellcept) 1000mg twice a day,
tacrolimus 4 mg twice a day)
 Transferred with three days of worsening L sided
abdominal and flank pain
 Chest CT findings concerning for necrotizing
pneumonia/cavitating lesion.
 On valganciclovir and TMP/SMX prophylaxis
 Exam: ill appearing, febrile, dull breath sounds at left
base, crackles both lungs, surgical incisions are fine
Two days later
What is the diagnosis?
A. Aspergillus
B. Mucormycosis
C. Necrotizing Gram negative
D. Mycobacterial (M. kansasii, etc)
E. Nocardia
Diagnostics
 Fungal markers all negative (blood)
 1,3 beta D glucan
 Galactomannan Ag
 Cryptococcal Ag
 Thoracentisis  exudate, chest tube placed
 Bronchoscopy, biopsy
Culture Data
Specimen Type: LEFT
EFFUSION/PLEURAL FLUID
(and BAL)
Gram Stain – SPUN SLIDE:
abundant polys, moderate red
blood cells, few mononuclear
cells, no organisms seen
Fluid Culture -
MIC DILUTION METHOD
Amikacin
Amoxicillin/Clavulanate
Susceptible **
Ceftriaxone
Intermediate
Ciprofloxacin
Resistant
Clarithromycin
Susceptible
Doxycycline
Resistant
Imipenem
Susceptible
Linezolid
NOCARDIA NOVA COMPLEX,
subspecies veterana
Susceptible
Susceptible
Minocycline
Intermediate
Moxifloxacin
Resistant
Tobramycin
Resistant
Trimethoprim/Sulfa
Susceptible
Treatment
 Brain CT negative for metastatic infection
 Imipenem + azithromycin until radiographic
improvement**
 Markedly improved in first few days (?chest tube
placement)
 Doing well at 6 months, double treatment stopped
 Will need long term secondary prophylaxis with
TMP/SMX
“There are increasing reports of breakthrough infections by TMP-SMX-susceptible
Nocardia isolates in patients taking TMP-SMX prophylaxis, creating some doubt
about the utility of this agent for prevention of nocardiosis (14). Minero and
colleagues found that 21.6% in their series were on TMP-SMX prophylaxis at the
diagnosis of nocardiosis, of which 62.5% were still susceptible to the drug (14).
Similarly, in their series of 19 Nocardia cases, Santos and colleagues noted that
most had received TMP-SMX prophylaxis for Pneumocystis jiroveci (25). In many of
these reports, dosing of
TMP-SMX prophylaxis is not provided. Because the dosing of TMP-SMX employed
at some centers for prophylaxis of Pneumocystis jiroveci in organ transplant
recipients is two to three times per week, insufficient blood levels due to intermittent
dosing could explain breakthrough infections, although nocardiosis has also been
reported despite daily TMP-SMX prophylaxis (54).”
Clinical Vignette
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