Abstract Introduction Nocardiosis is a rare condition caused by the bacteria Nocardia spp. and typically occurs in patients with compromised cell-mediated immunity. Disseminated nocardiosis involves two or more noncontiguous organs and is the most severe form of the infection. Here we present a patient without known immunocompromise who had a minor injury that caused lethal nocardiosis. Case A 64-year-old male with a history of chewing tobacco use, chronic back pain on long-term opioids, and gout sustained a puncture wound to the left hand from a falling air conditioner component. He noticed swelling at the wound site which started draining serosanguineous fluid within several days. Two weeks later he presented to the emergency room with severe pain and swelling of his left upper limb and left calf. Pulse was 124 bpm with other vitals within normal range. He had an elevated ESR (77 mm/hr) and CRP (32.75 mg/dL) but negative initial infectious workup. Despite being started on empiric broad-spectrum antibiotics he rapidly developed hypoxia with imaging of the chest demonstrating innumerable shaggy pulmonary nodules. Imaging of the left-sided extremities revealed septated rim-enhancing collections in his distal triceps and soleus muscles. Material from biopsies of those collections and bronchoscopy grew Nocardia brasiliensis. Brain imaging showed multiple rim-enhancing lesions. After diagnosis, the patient was started on intravenous trimethoprim-sulfamethoxazole in addition to ongoing treatment with linezolid. The patient became increasingly hypoxic and developed encephalopathy over the next week despite additional treatment with amikacin and surgical debridement of identified abscesses. Immunodeficiency workup showed hypogammaglobulinemia (429 mg/dL), low CD4+ T-cell count (112 cells/mm3), and elevated anti-GM-CSF concentration (3297 ng/mL; normal 338). Tests for HIV and chronic granulomatous disease were negative. After two weeks of hospitalization, despite uptitraton of antibiotics, the patient developed progressive hypoxemic respiratory failure requiring intubation and shortly after was transitioned to comfort care. Discussion Disseminated nocardiosis is thought to require compromised cell-mediated immunity, but reports have described its occurrence in healthy individuals. GM-CSF is important for the immune response to nocardia infection. Autoantibodies against GM-CSF are reported to have a role in the etiology of pulmonary alveolar proteinosis, a rare lung disease highly associated with pulmonary nocardia infection and not identified in this patient. The high levels of autoantibodies for GM-CSF in this patient may have been the predisposing factor resulting in his disseminated nocardiosis, suggesting such hidden immunocompromised states could exist in other supposedly healthy patients that incur this condition. This abstract is funded by: None
Zent et al. (Fri,) studied this question.