Diagnosis at first sight
Lung nodules and retinal lesions in an immunocompromised patient
Nódulos pulmonares y lesiones retinianas en una paciente inmunocomprometida
Oscar Morado-Aramburo, Brenda G. Delgado-Ávila, Sergio A. Calderón-Campas, Laura M. Badel-Ramos
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Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico
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Delgado-Ávila, Sergio A. Calderón-Campas, Laura M. Badel-Ramos" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Oscar" "apellidos" => "Morado-Aramburo" ] 1 => array:2 [ "nombre" => "Brenda G." "apellidos" => "Delgado-Ávila" ] 2 => array:2 [ "nombre" => "Sergio A." "apellidos" => "Calderón-Campas" ] 3 => array:4 [ "nombre" => "Laura M." "apellidos" => "Badel-Ramos" "email" => array:1 [ 0 => "lauris_b3@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nódulos pulmonares y lesiones retinianas en una paciente inmunocomprometida" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 929 "Ancho" => 2500 "Tamanyo" => 84464 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Funduscopic findings. (A) Dilated fundus examination revealed a white, rounded, small retinal lesion with well-defined borders in the superior temporal quadrant of the right eye (black arrow). (B) Left eye with vitreous haze and multiple vitreous condensations in the form of bands, extending from the optic nerve (black arrows); and a similar retinal lesion as the contralateral eye, in the superior temporal quadrant.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case description</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 29-year-old woman with systemic lupus erythematosus, on treatment with prednisone (30<span class="elsevierStyleHsp" style=""></span>mg/day PO for 2 months), hydroxychloroquine (200<span class="elsevierStyleHsp" style=""></span>mg/day PO for 2 months), and mycophenolate mofetil (2.5<span class="elsevierStyleHsp" style=""></span>g/day PO for 2 months), presented to the emergency room with odynophagia, myalgias, arthralgias, and persistent fever for the last 5 days without any abnormal physical finding. After an initial assessment, the chest radiograph revealed lobar pneumonia and received outpatient management with levofloxacin (750<span class="elsevierStyleHsp" style=""></span>mg/day PO for 4 days). Later, after the lack of improvement and the appearance of productive cough, and dyspnea, the patient was admitted to the hospital. On examination, presented high fever (39.2<span class="elsevierStyleHsp" style=""></span>°C), tachycardia, and SaO<span class="elsevierStyleInf">2</span> of 92%, without any abnormal neurologic nor cardiopulmonary findings. Laboratory testing revealed increased WBC (16,500/mm<span class="elsevierStyleSup">3</span>) and neutrophil count (15,741/mm<span class="elsevierStyleSup">3</span>), but lymphopenia (148/mm<span class="elsevierStyleSup">3</span>), also showed an increased CRP (25<span class="elsevierStyleHsp" style=""></span>mg/dL), alkaline phosphatase (204<span class="elsevierStyleHsp" style=""></span>U/L), and GGT (78<span class="elsevierStyleHsp" style=""></span>U/L), but a normal renal function, additionally blood cultures were drawn. Based on the progression of symptoms, persistent fever, and former tests, a thorax-abdomen CT scan (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) was done and revealed multifocal pneumonia, hepatic lesions suggestive of abscesses (segments VI and VII), and a perinephric abscess in the right kidney. Hence she was started on broad-spectrum antibiotics with meropenem (1gr q8h IV) and vancomycin (1gr q12h IV).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Evolution</span><p id="par0010" class="elsevierStylePara elsevierViewall">Over the next days, the patient presented the progression of respiratory symptoms, including dyspnea, and tachypnea, as well as higher oxygen requirements. Therefore a bronchoalveolar lavage was performed without microbiological isolation. As part of its diagnostic approach, an echocardiogram showed a low probability of endocarditis. A brain MRI, revealed multiple brain abscesses, the largest with an 18<span class="elsevierStyleHsp" style=""></span>mm diameter. And in the absence of clinical and radiological signs of intracranial hypertension, a lumbar puncture was performed, which resulted in a normal CSF without any culture isolation.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On the seventh day of admission, Gram-positive branching rods were observed in blood cultures and filamentous rods in the Kinyoun stain (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), and finally identified as <span class="elsevierStyleItalic">Nocardia farcinica.</span> The treatment was adjusted accordingly to the antimicrobial susceptibility test (supplemental material), to trimethoprim-sulfamethoxazole (TMP/SMX, 15<span class="elsevierStyleHsp" style=""></span>mg/kg/day IV), amikacin (15<span class="elsevierStyleHsp" style=""></span>mg/kg/day IV), and linezolid (600<span class="elsevierStyleHsp" style=""></span>mg q12<span class="elsevierStyleHsp" style=""></span>h IV). Besides the perinephric abscess was drained with the isolation of the same microorganism. Suddenly, presented diminished visual acuity with clinical data of endophthalmitis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) and vitrectomy with an application of intravitreal amikacin was performed. On the right thigh, initially an area of cellulitis, an MRI showed pyomyositis with abscesses at the vastus intermedius muscle and quadriceps myositis. Therefore surgical lavage was performed. In the follow-up eight weeks of intravenous treatment, she had a satisfactory clinical response, with improvement in visual acuity and a decrease in lung lesions and the others abscesses on the CT scan; although brain abscesses reduced in a less proportion on MRI. Based on the susceptibility pattern, the patient completed over a year of treatment with ciprofloxacin and TMP/SMX with a radiological resolution of the previous findings.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comments</span><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Nocardia</span> species are actinomycetes with a wide environmental distribution, as a saprophytic component.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> The most common species include <span class="elsevierStyleItalic">N. asteroides, brasiliensis, farcinica, nova, otitidiscaviarum, transvalensis.</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Cause opportunistic infections in immunocompromised, including those with corticosteroid use, hematologic malignancies, transplant recipients, systemic lupus erythematosus, and with non-drug induced immunosuppression (chronic granulomatous disease, chronic alcoholism, diabetes, HIV).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Immunocompetent are affected, as primary cutaneous infections, by <span class="elsevierStyleItalic">N. brasiliensis</span> in 80% of cases.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> A hallmark of nocardiosis is the diversity of the clinical presentation, from localized to disseminated disease.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The most common manifestation is pulmonary, frequently occurring in those who have underlying chronic lung disease, and up to 50% involve extrapulmonary disease. 20% of disseminated disease present without pulmonary involvement, but is associated with CNS pathology, with ≥1 brain abscesses that tend to be indolent. Bacteremia is unusual, results from either pulmonary or extrapulmonary origins.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Ocular pathology is an uncommonly reported clinical entity. Nocardial endophthalmitis is associated with high mortality, unlike this case, most progress to blindness despite treatment.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Diagnosis requires the identification of <span class="elsevierStyleItalic">Nocardia</span> spp on specimens. Culture requires a minimum of 48–72<span class="elsevierStyleHsp" style=""></span>h, the colonial morphology is variable, from chalky white to orange colonies, a “cotton candy” (aerial hyphae) appearance on the surface, that differentiate it from related genera (<span class="elsevierStyleItalic">Mycobacterium</span>, <span class="elsevierStyleItalic">Rhodococcus</span>). Staining with modified acid-fast (Kinyoun stain) and Gram stains, being the latter the most sensitive method to recognize it, will provide a rapid presumptive diagnosis. The speciation by molecular methods is more precise and rapid than other tests.</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Nocardia</span> spp are variably resistant to antibiotics. Therefore, antimicrobial susceptibility testing for all specimens is essential; and the preferred method is broth microdilution.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> TMP/SMX remains the drug of choice for <span class="elsevierStyleItalic">Nocardia</span> spp. However <span class="elsevierStyleItalic">N. farcinica</span> had a high resistance rate to the prior antibiotic and to most beta-lactam.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> The severe and disseminated disease have a high mortality rate with monotherapy, therefore is recommended initial combination therapy.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> According to the clinical presentation and evolution, surgical treatment may be necessary; with CNS involvement most patients are likely to require drainage.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6,7</span></a> The role of vitrectomy is uncertain, and intravitreal antibiotic recommended is amikacin.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4,8</span></a> The duration of therapy depends on the site of infection and the immunological status of the patient. With CNS involvement the course must be established on clinical and imaging response (≥1 year).<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6,9</span></a> Delay in diagnosis is often associated with poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patient consent</span><p id="par0035" class="elsevierStylePara elsevierViewall">A written informed consent was obtained from the patient's family.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">The present research has not received any specific scholarship from public, commercial or non-profit agencies.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflict of interests</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors do not have conflicts of interest to disclose.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Evolution" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Comments" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Patient consent" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0055" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2060 "Ancho" => 2508 "Tamanyo" => 406074 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Radiologic findings. (A) Chest CT scan. Bilateral ground-glass opacifications, with nodules and consolidations in the right lung (white arrowheads). (B) Abdomen CT scan. Liver with well-defined, hypodense round lesions suggestive of abscesses (black arrowheads). (C) Brain MRI, T1 weighted sequence. Multiple brain abscesses, a small pontine lesion (white arrowheads), and (D) an intra-axial lesion in the left hemisphere, with a well-defined ring-enhancing wall and surrounding edema, that measure 18<span class="elsevierStyleHsp" style=""></span>mm in diameter (white arrowheads).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3107 "Ancho" => 1500 "Tamanyo" => 730378 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Culture and Kinyoun stain of Nocardia farcinica. (A) Sabouraud Dextrose Agar. The colonial morphology is variable, here displayed pigment-producing orange colonies. (B) Kinyoun Stain, X100. Branching filamentous rods that are partially acid fast.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 929 "Ancho" => 2500 "Tamanyo" => 84464 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Funduscopic findings. (A) Dilated fundus examination revealed a white, rounded, small retinal lesion with well-defined borders in the superior temporal quadrant of the right eye (black arrow). (B) Left eye with vitreous haze and multiple vitreous condensations in the form of bands, extending from the optic nerve (black arrows); and a similar retinal lesion as the contralateral eye, in the superior temporal quadrant.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.xlsx" "ficheroTamanyo" => 10281 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and laboratory features of the nocardia spp based on current molecular taxonomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B.A. Brown-Elliott" 1 => "J.M. Brown" 2 => "P.S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 9 | 8 | 17 |
| 2024 September | 44 | 8 | 52 |
| 2024 August | 32 | 10 | 42 |
| 2024 July | 34 | 12 | 46 |
| 2024 June | 31 | 11 | 42 |
| 2024 May | 43 | 15 | 58 |
| 2024 April | 20 | 31 | 51 |
| 2024 March | 45 | 16 | 61 |
| 2024 February | 33 | 10 | 43 |
| 2024 January | 41 | 7 | 48 |
| 2023 December | 42 | 15 | 57 |
| 2023 November | 57 | 53 | 110 |
| 2023 October | 61 | 37 | 98 |
| 2023 September | 60 | 8 | 68 |
| 2023 August | 31 | 5 | 36 |
| 2023 July | 63 | 78 | 141 |
| 2023 June | 65 | 58 | 123 |
| 2023 May | 86 | 11 | 97 |
| 2023 April | 67 | 3 | 70 |
| 2023 March | 29 | 5 | 34 |
| 2023 February | 55 | 8 | 63 |
| 2023 January | 38 | 5 | 43 |
| 2022 December | 43 | 28 | 71 |
| 2022 November | 69 | 26 | 95 |
| 2022 October | 51 | 14 | 65 |
| 2022 September | 54 | 45 | 99 |
| 2022 August | 68 | 11 | 79 |
| 2022 July | 38 | 19 | 57 |
| 2022 June | 39 | 9 | 48 |
| 2022 May | 39 | 11 | 50 |
| 2022 April | 44 | 19 | 63 |
| 2022 March | 54 | 14 | 68 |
| 2022 February | 44 | 7 | 51 |
| 2022 January | 84 | 15 | 99 |
| 2021 December | 71 | 9 | 80 |
| 2021 November | 72 | 11 | 83 |
| 2021 October | 66 | 10 | 76 |
| 2021 September | 43 | 11 | 54 |
| 2021 August | 55 | 11 | 66 |
| 2021 July | 48 | 4 | 52 |
| 2021 June | 35 | 6 | 41 |
| 2021 May | 50 | 8 | 58 |
| 2021 April | 112 | 22 | 134 |
| 2021 March | 86 | 11 | 97 |
| 2021 February | 43 | 11 | 54 |
| 2021 January | 41 | 19 | 60 |
| 2020 December | 34 | 4 | 38 |
| 2020 November | 36 | 8 | 44 |
| 2020 October | 23 | 8 | 31 |
| 2020 September | 37 | 11 | 48 |
| 2020 August | 3 | 0 | 3 |
| 2020 June | 1 | 0 | 1 |
| 2020 May | 16 | 0 | 16 |
| 2020 April | 11 | 4 | 15 |
| 2020 March | 97 | 29 | 126 |
| 2019 September | 0 | 2 | 2 |
| 2019 August | 0 | 2 | 2 |
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