Disseminated Nocardia otitidiscaviarum Presenting as Lung-Brain-Skin Syndrome in a Renal Transplant Recipient: A Case Report

Abstract

We present a case of disseminated Nocardia otitidiscaviarum infection in a 72-year-old male with a history of renal transplantation on chronic immunosuppressive therapy with prednisone, cyclosporine, and mycophenolate mofetil. He presented with pneumonia and was initially treated with ceftriaxone and azithromycin. Bronchoalveolar lavage (BAL) and cultures from a biopsied thigh lesion both grew N. otitidiscaviarum. His hospital course was complicated by visual hallucinations, and brain magnetic resonance imaging (MRI) revealed multiple intracranial abscesses. He initially received meropenem, trimethoprim-sulfamethoxazole (TMP-SMX), and linezolid. His antimicrobial regimen was subsequently modified during the treatment course. Linezolid was discontinued after hematologic abnormalities developed, TMP-SMX was temporarily held because of worsening renal function and later reintroduced, and meropenem was also discontinued. He was discharged on TMP-SMX and minocycline and completed an initial six-week antimicrobial treatment course from the time of diagnosis. He was subsequently maintained on minocycline and moxifloxacin; moxifloxacin was later discontinued because of QT-interval prolongation, while minocycline was continued for slightly longer than one year, with clinical and radiologic resolution.