Disseminated systemic Nocardia farcinica infection complicating alefacept and infliximab therapy in a patient with severe psoriasis.
Nocardiosis is a cause of significant morbidity and mortality in the immunocompromised host, and is an infrequent complication of tumor necrosis factor alpha (TNF-alpha) blockers in chronic inflammatory diseases. Nocardiosis occurs at a rate of 3.55 and 0.88 per 100 000 patients treated with infliximab or etanercept, respectively. Disseminated nocardiosis remains an uncommon complication of these agents. Here, we present a fatal case of disseminated systemic nocardiosis in a patient with psoriasis following sequential therapy with alefacept and then infliximab therapy. The patient developed disseminated disease involving the brain, lymph nodes, and adrenal glands. The diagnosis was made by blood culture and aspiration of the adrenal gland abscess, which revealed Gram-positive bacilli and later grew Nocardia farcinica. The organism was identified by DNA sequencing, and was susceptible to moxifloxacin, gatifloxacin, ciprofloxacin, amoxicillin-clavulanic acid, linezolid, sulfamethoxazole, and amikacin. It was resistant to clarithromycin, ceftriaxone, and tobramycin and was intermediately susceptible to imipenem.
Al-Tawfiq
Jaffar A
JA
Internal Medicine Services Division, PO Box 76, Room A-428-2, Building 61, Dhahran Health Center, Saudi Aramco Medical Services Organization, Saudi Aramco, Dhahran 31311, Saudi Arabia. jaffar.tawfiq@aramco.com
Al-Khatti
Adil A
AA
D000368:Aged; D000077944:Alefacept; D000911:Antibodies, Monoclonal / Q000009:adverse effects / Q000627:therapeutic use; D003879:Dermatologic Agents / Q000009:adverse effects / Q000627:therapeutic use; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D016867:Immunocompromised Host; D000069285:Infliximab; D009615:Nocardia / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D009617:Nocardia Infections / Q000175:diagnosis* / Q000382:microbiology / Q000473:pathology; D011565:Psoriasis / Q000150:complications* / Q000188:drug therapy / Q000503:physiopathology; D011993:Recombinant Fusion Proteins / Q000009:adverse effects / Q000627:therapeutic use; D012720:Severity of Illness Index; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
D000911:Antibodies, Monoclonal; D003879:Dermatologic Agents; D011993:Recombinant Fusion Proteins; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D000077944:Alefacept