title: Disseminated nocardiosis masking an atypical zygomycosis presentation in a kidney transplant recipient.
abstract: Immunosuppressive agents increase the vulnerability of solid organ transplant patients to opportunistic infections. An atypical clinical presentation of a bacterial and fungal co-infection makes diagnosis and treatment even more challenging in this population. A 54-year-old hypertensive woman underwent a cadaveric kidney transplant after years on hemodialysis. Her treatment included mycophenolate, tacrolimus, and prednisone. By post-transplant week 8, she had pneumonia followed by progressive visual changes and seizures. Diagnostic work-up, consisting of magnetic resonance imaging of the brain and chest x-ray, showed several cerebral ring-enhancing lesions, and a pulmonary cavitary lesion. Disseminated nocardiosis was suspected and therapy was started. Skin biopsy was taken from a nodular lesion and culture confirmed Nocardia species infection. During hospitalization, neurological deficit persisted with worsening of brain lesions. She underwent excision of a brain abscess and the final pathologic report showed mucormycosis, revealing the patient's co-infection by 2 different pathogens. After therapy with liposomal amphotericin B and posaconazole, she has remained stable for more than 1 year. Disseminated nocardiosis masked and delayed the diagnosis and treatment of a more aggressive and worrisome organism. Mucormycosis, as a non-fatal isolated brain abscess without rhinal involvement, is an atypical presentation, and only a few cases have been reported.
authors.affiliation: Department of Internal Medicine, Infectious Diseases Program, San Juan, Puerto Rico, USA. eileencs@gmail.com
authors.forename: E
authors.initials: E
authors.lastname: Colón-Santos
authors.forename: M
authors.initials: M
authors.lastname: González-Ramos
authors.forename: J
authors.initials: J
authors.lastname: Bertrán-Pasarell
authors.forename: G
authors.initials: G
authors.lastname: Rodríguez-Vega
authors.forename: M
authors.initials: M
authors.lastname: Almira-Suarez
authors.forename: R
authors.initials: R
authors.lastname: Vélez-Rosario
mesh_terms: D000666:Amphotericin B / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D001922:Brain Abscess / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology; D060085:Coinfection / Q000175:diagnosis* / Q000382:microbiology; D005260:Female; D006801:Humans; D016030:Kidney Transplantation / Q000009:adverse effects*; D008875:Middle Aged; D009615:Nocardia / Q000302:isolation & purification; D009617:Nocardia Infections / Q000150:complications* / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000188:drug therapy; D009894:Opportunistic Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D018410:Pneumonia, Bacterial / Q000150:complications / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000188:drug therapy; D011859:Radiography; D014230:Triazoles / Q000627:therapeutic use; D020096:Zygomycosis / Q000150:complications* / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000382:microbiology
chemical_list: D000935:Antifungal Agents; D014230:Triazoles; C068538:liposomal amphotericin B; C101425:posaconazole; D000666:Amphotericin B