[Recurrent fever in a patient treated with immunosuppressive therapy for Takayasu arteritis].
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We report a case of pulmonary nocardiosis in a 69-year-old man with rheumatoid arthritis who was receiving corticosteroid treatment. The patient received prednisolone for rheumatoid arthritis and antibiotics for his fever and pneumonia in another hospital, but the response to the therapy was poor. After admission to our hospital, he improved following treatment with imipenem/cilastatin for Nocardia asteroides. Pulmonary nocardiosis is difficult to diagnose and should be considered in the differential diagnosis, especially in an immunocompromised host.
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A 58-year-old woman was admitted to our hospital with complaints of general fatigue, thirst and lumbago. A diagnosis of Cushing's syndrome was made on the basis of elevated serum levels of cortisol and adrenocorticotropic hormone (ACTH). Although Cushing's disease was most suspected, no evident image of pituitary adenoma could be found on brain CT scan and MRI. Therefore, treatment with oral Trilostane was started. Three months after admission, left hemiplegia was noticed and cerebral abscess in the right frontal lobe was demonstrated by brain CT scan. In spite of surgical removal of the abscess by total resection, she had a relapse in the same site and also developed a new lesion in the left lateral lobe. Surgical drainage was performed and Nocardia asteroides was isolated from the drained pus. An intensive chemotherapy with aminobenzylpenicillin (ABPC) and latamoxef (LMOX) in combination resulted in marked decrease in size of the lesion in the brain and subsequent improvement of left hemiplegia was achieved. Since approximately one month before when a diagnosis of cerebral abscess was made, there had been demonstrated a coin lesion in the right middle field on chest X-ray films. This lesion in the right lung disappeared concomitantly with the improvement of the lesions in the brain. This fact strongly suggests that the lesion in both brain and lung were of the same nature. Nocardia is known to make a primary lesion in the lung after being inhaled and then through hematogenous dissemination to make distant lesions in various sites, especially in the brain.(ABSTRACT TRUNCATED AT 250 WORDS)
Low dose methotrexate is used increasingly often in the treatment of rheumatoid arthritis. Severe complications due to toxicity of the lung or bone marrow occur infrequently. This report describes a 71 year old woman with longstanding rheumatoid arthritis who developed pleuritis, a pulmonary infiltrate, and pancytopenia during treatment with low dose methotrexate. Fatal respiratory insufficiency followed, and cultures from the lung after death showed Nocardia asteroides.
A case of pulmonary nocardiosis with empyema in a 55-year-old man with macroglobulinemic lymphoma is presented. Treatment with imipenem followed by oral trimethoprim-sulfamethoxazole (TMP-SMX) resolved his symptoms and cleared the roentgenographic abnormalities. This case illustrates the clinical potential of imipenem against Nocardia.
Pyogranulomatous pneumonia was detected in two koalas (Phascolarctos cinereus). Nocardia asteroides was isolated from one koala with extensive pneumonia, pleurisy and splenitis. Staphylococcus epidermidis was isolated from a second koala with pneumonia restricted to the left cranial lobe. Both koalas were in poor condition and had underlying urogenital disease. It was concluded that each organism had acted as an opportunistic pathogen in its compromised host.
A 70-year-old man treated for 6 months with prednisolone for nephrotic syndrome, was referred to our pulmonary division because of a nodule in the right lower lung field. Nocardia asteroides was isolated from the culture of the percutaneous lung aspiration, and the case was diagnosed as pulmonary nocardiosis. The lesion disappeared after 2 months of therapy with sulfamethoxazole/trimethoprim (1,600 mg/320 mg once a day). Though it had been given prophylactically (800 mg/160 mg twice a week) for the prevention of pneumocystis carinii pneumonitis.
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A 37-year-old patient with systemic lupus erythematosus, who had been treated with oral corticosteroids for 10 years, developed primary cutaneous nocardiosis. Brown-violaceous, suppurative nodules and plaques arose on her right leg. Cultures of multiple biopsies on blood agar medium grew Nocardia. The patient received 500 mg of imipenem three times a day which resulted in complete regression of the lesions within two months. No relapse was observed 6 months later.