key: cord-0858753-evead31g
authors: Arif, Muhammad; Talon, Andrew; Sarma, Hursh; Munoz, Jonathan; Charley, Ericka
title: NOCARDIA AFTER COVID-19 INFECTION
date: 2021-10-31
journal: Chest
DOI: 10.1016/j.chest.2021.07.424
sha: acd1f77d0661f34abdac9b46d12350f3651b4d5f
doc_id: 858753
cord_uid: evead31g

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Nocardia is an opportunistic aerobic actinomycete that most frequently affects the lungs, brain, and skin in 0.04% to 3.5%2 patients after solid organ transplant. Natural and synthetic glucocorticoids are at the forefront of anti-inflammatory and immunosuppressive therapies in transplant patients who often succumb to Nocardia infections. Out of the eight species, N. farcinica is potentially more lethal because of its tendency to disseminate and its resistance to antibiotics1. We present a unique patient who developed N. farcinica at the end of a 10-day course of dexamethasone for COVID-19. CASE PRESENTATION: A 61-year-old female with past medical history of non- insulin dependent type II diabetes (hgbA1c 6.3), hypertension, CHF on GDMT, and COVID-19 pneumonia presented with chest pain on the 10th and last day of per oral 4mg dexamethasone course. On admission patient's vitals were stable and labs were notable for leukocytosis, elevated glucose, BNP, and D-dimer prompting a CTA which showed subsegmental PE and a thrombus in SVC extending to the IVC. She was also found to have a right upper lobe 3.3 x 3.2 cm subpleural mass and a left upper lobe 1.9 x 1.5 cm nodule (figure 2). Percutaneous CT-guided coaxial core needle biopsy of right lung mass was done with pathology results notable for branching filamentous organisms consistent with Nocardia further refined by cultures growing Nocardia farcinica. The MRI brain did not show any abscess. She was started on IV Bactrim and meropenem. Eventually, the patient was discharged home on Bactrim and linezolid due to N. farcinica's high resistance rates to Bactrim alone. DISCUSSION: Nocardiosis usually occurs in immunosuppressed states, such as lymphomas, HIV, diabetics, transplant recipients or patients on long term immunosuppressants. Glucocorticoids are widely used as an effective treatment to control inflammatory and autoimmune diseases with more recent prevalent use for covid-19 infections to control immune-mediated damage of lung tissue. We are presenting the first case of N. farcinica infection in a COVID-19 patient after a brief steroid course. The case also highlights N. farcinica infection mimicking a lung mass and demonstrates that pulmonary Nocardia infections can easily be misdiagnosed, highlighting the importance of keeping a broad differential. CONCLUSIONS: steroid use in the management of COVID-19 infection can result in opportunistic infections, including N. farcinica. REFERENCE #1: Margalit I, Goldberg E, Ben Ari Y, Ben-Zvi H, Shostak Y, Krause I, Muhsen K. Clinical correlates of nocardiosis. Sci Rep. 2020 Aug 31;10(1):14272. doi: 10.1038/s41598-020-71214-4. PMID: 32868850;PMCID: PMC7459281 REFERENCE #2: Coussement J, Lebeaux D, van Delden C, Guillot H, Freund R, Marbus S, Melica G, Van Wijngaerden E, Douvry B, Van Laecke S, Vuotto F, Tricot L, Fernández-Ruiz M, Dantal J, Hirzel C, Jais JP, Rodriguez-Nava V, Lortholary O, Jacobs F;European Study Group for Nocardia in Solid Organ Transplantation. Nocardia Infection in Solid Organ Transplant Recipients: A Multicenter European Case-control Study. Clin Infect Dis. 2016 Aug 1;63(3):338-45. doi: 10.1093/cid/ciw241. Epub 2016 Apr 18. PMID: 27090987. DISCLOSURES: No relevant relationships by Muhammad Arif, source=Web Response No relevant relationships by Ericka Charley, source=Web Response No relevant relationships by Jonathan Munoz, source=Web Response No relevant relationships by Hursh Sarma, source=Web Response No relevant relationships by Andrew Talon, source=Web Response

Nocardia is an opportunistic aerobic actinomycete that most frequently affects the lungs, brain, and skin in 0.04% to 3.5%2 patients after solid organ transplant. Natural and synthetic glucocorticoids are at the forefront of antiinflammatory and immunosuppressive therapies in transplant patients who often succumb to Nocardia infections. Out of the eight species, N. farcinica is potentially more lethal because of its tendency to disseminate and its resistance to antibiotics1. We present a unique patient who developed N. farcinica at the end of a 10-day course of dexamethasone for COVID-19.

A 61-year-old female with past medical history of non-insulin dependent type II diabetes (hgbA1c 6.3), hypertension, CHF on GDMT, and COVID-19 pneumonia presented with chest pain on the 10th and last day of per oral 4mg dexamethasone course. On admission patient's vitals were stable and labs were notable for leukocytosis, elevated glucose, BNP, and D-dimer prompting a CTA which showed subsegmental PE and a thrombus in SVC extending to the IVC. She was also found to have a right upper lobe 3.3 x 3.2 cm subpleural mass and a left upper lobe 1.9 x 1.5 cm nodule (figure 2). Percutaneous CT-guided coaxial core needle biopsy of right lung mass was done with pathology results notable for branching filamentous organisms consistent with Nocardia further refined by cultures growing Nocardia farcinica. The MRI brain did not show any abscess. She was started on IV Bactrim and meropenem. Eventually, the patient was discharged home on Bactrim and linezolid due to N. farcinica's high resistance rates to Bactrim alone.

DISCUSSION: Nocardiosis usually occurs in immunosuppressed states, such as lymphomas, HIV, diabetics, transplant recipients or patients on long term immunosuppressants. Glucocorticoids are widely used as an effective treatment to control inflammatory and autoimmune diseases with more recent prevalent use for covid-19 infections to control immune-mediated damage of lung tissue. We are presenting the first case of N. farcinica infection in a COVID-19 patient after a brief steroid course. The case also highlights N. farcinica infection mimicking a lung mass and demonstrates that pulmonary Nocardia infections can easily be misdiagnosed, highlighting the importance of keeping a broad differential.

CONCLUSIONS: steroid use in the management of COVID-19 infection can result in opportunistic infections, including N. farcinica.

Clinical correlates of nocardiosis. Sci Rep

European Study Group for Nocardia in Solid Organ Transplantation. Nocardia Infection in Solid Organ Transplant Recipients: A Multicenter European Case-control Study