A43-18 Weak Immunity Resulting in Disseminated Nocardia Cyriacigeorgica in an Idiopathic Pulmonary Fibrosis Patient: A Case Report

Abstract Introduction Nocardia species most often cause indolent pulmonary infections in immunocompromised patients before disseminating, often to the CNS or the skin.1 Review of data showed increased incidence of nocardia infection, possibly due to increased use of immune-compromising medications and improved methods for identifying this bacteria.2 Infections have previously caused high mortality rates, but improvement in both early identification and treatment options have led to improved patient outcomes. Case Presentation Patient is a 77 M with interstitial lung disease and idiopathic pulmonary fibrosis “IPF”, presented with left chest wall and left lower extremity skin lesions of four weeks in duration. Labs significant for leukocytosis 21.5K, otherwise clinically stable. He denied exposures or history of skin infections. Currently prescribed Rituximab and prednisone. Skin lesion biopsy grew beaded gram-positive cocci that were partially acid-fast, concerning for Nocardia. Treatment with Bactrim and Imipenem initiated. CT chest, A/P scans with no concerning findings for disease dissemination. Brain MRI displayed multiple ring-enhancing lesions in the right frontal and left parietal occipital region. Patient underwent craniotomy, with biopsy grew Nocardia cyriacigeogica after which Linezolid added to Rx regimen. A repeated MRI brain post craniotomy showed interval decrease in right frontal lobe abscess w/o change to the other masses. He was discharged on ceftriaxone for 1 year in addition to lifelong suppressive therapy with trimethoprim-sulfamethoxazole. Discussion Nocardia are aerobic, gram-positive rods that form branched filaments resembling hyphae found in molds, which is why they were originally classified as fungi before being discovered to be bacteria.3 Described as weakly acid-fast, which is a distinguishing feature, along with aerial hyphae that can be helpful in identification and are often found in soil and decaying plant material, causing opportunistic infections, primarily of the respiratory system in immunocompromised patients.1 Nocardia species appears to correlate with the mortality rate, which can be as high as 50% in patients with disseminated disease, especially with brain involvement.2,5Nocardia cyriageorgica is a new species identified in 2001 with the same properties as the other species, with the lungs being the primary site of infection as well.4 Most cases involve immunocompromised patients, which includes those on prolonged courses of steroids and monoclonal antibodies such as Rituximab, as was the case with this patient.3,4 The use of immune suppressing medications along with the history of IPF provided the perfect environment for this opportunistic bacteria. This abstract is funded by: None