Episode 45
45: A Disrespectful Bug
Join Drs. Cesar Berto and Shweta Anjan as they take on this “disrespectful” bug causing trouble in a lung transplant recipient
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Transcript
Hi everyone.
Sara Dong:Welcome to Febrile, a cultured podcast about all things infectious disease.
Sara Dong:We use consult questions to dive into ID clinical reasoning, diagnostics, and anti-microbial management.
Sara Dong:I'm Sara Dong, your host and a Med-Peds ID fellow.
Sara Dong:Here on Febrile, we use patient cases and chat with ID discussants to learn more about high yield ID topics.
Sara Dong:Cesar co-host today is Dr.
Sara Dong:Cesar Berto.
Sara Dong:He is a chief resident at Jacobi Medical Center and Albert Einstein College of Medicine, but as now an incoming ID fellow at the combined Massachusetts General and Brigham and Women's Hospital ID fellowship program.
Sara Dong:Joining us as our discussant is Dr.
Sara Dong:Shweta Anjan.
Sara Dong:Dr.
Sara Dong:Anjan is a transplant ID physician at the Miami Transplant Institute.
Sara Dong:She is an Assistant Professor in Clinical Medicine and the associate Program Director of the Transplant ID Fellowship program at the University of Miami Miller School of Medicine.
Sara Dong:I'm so glad you guys are here.
Sara Dong:We always start with our one question as a cultured podcast.
Sara Dong:We'd love to hear about a little piece of culture that you enjoyed recently or brought you some happiness.
Cesar Berto:Sure.
Cesar Berto:Um, one of the things that I recently enjoyed was a musical Broadway "Come from Away.".
Cesar Berto:It's actually a Canadian musical about a real history of the 38 planes that, uh, suddenly during 9/11 had to, um, land in a very small town in Canada.
Cesar Berto:And it tells the events of how those passengers face this, um, it's actually on apple TV.
Cesar Berto:So it was really very nice, very well executed and, uh, uh, very sentimental.
Shweta Anjan:Hey.
Shweta Anjan:Hi, Sara and Cesar.
Shweta Anjan:um, I think I'd have to say little piece of culture have enjoyed recently, but have to be like a combination of K-pop.
Sara Dong:Oh, you're talking my language.
Shweta Anjan:The Peloton instructors, a lot of them play all the pop music during like all those Peloton sessions.
Shweta Anjan:It's actually made me Google all of them.
Shweta Anjan:So we're making progress here.
Sara Dong:Yeah.
Sara Dong:Well, you can share it.
Sara Dong:You can share any of those playlists with me.
Sara Dong:That sounds like something I would love.
Sara Dong:Um, well today's consult question is about recommendations for working up a cavitary lung lesion.
Sara Dong:Uh, so I will hand it over.
Cesar Berto:Okay.
Cesar Berto:So today we have the case of a 60 year old woman who is status-post lung transplantation, who has been admitted for two weeks of fever, asthenia, productive cough, and exertional dyspnea.
Cesar Berto:Uh, his past medical history is remarkable for, uh, bilateral lung transplantation 6 months ago due to severe emphysema.
Cesar Berto:She is CMV uh, donor positive recipient negative, and is currently on prophylaxis.
Cesar Berto:Her current medications includes triple immunosuppressive therapy -- tacrolimus, mycophenolate, and prednisone.
Cesar Berto:And in terms of prophylaxis, she is on valganciclovir and atovaquone.
Cesar Berto:Her social history, um, remarkable is that she lives in Las Vegas, Nevada.
Cesar Berto:She is currently retired.
Cesar Berto:She spends her weekends hiking.
Cesar Berto:She does not have any pets or no recent travels.
Cesar Berto:The physical exam of this patient um, shows, uh, tachycardic patient with decreased breath sounds in the right lower lobe.
Cesar Berto:Uh, and additionally, on the physical exam, we're able to find, uh, tender one by one centimeter ulcerated lesion of the left ankle without any purulent secretions.
Cesar Berto:Um, the CT scan of this patient shows a right lower lobe consolidation with a two centimeter lesion, um, with peripheral cavitation.
Cesar Berto:So, how would you approach to this patient who's presented with lung and skin findings?
Shweta Anjan:Okay.
Shweta Anjan:That's a very interesting case, Cesar, thank you for that.
Shweta Anjan:Um, so to begin with, I know, like for the purposes of the session, um, this is the social history and everything you've provided, but I would definitely request for more history in terms of.
Shweta Anjan:Where was she born and raised.
Shweta Anjan:Has she lived in Nevada all her life, or did she find herself moving either like within the USA or internationally.
Shweta Anjan:that would put her at risk for different endemic fungi, which is just the first little bell that went off in my head when you said skin lesion and cavitary lung lesion, you know, Um, and then some more information about her underlying condition that led up to the transplant.
Shweta Anjan:Like she has emphysema, but why would, um, a female have emphysema?
Shweta Anjan:Is there a history of smoking, you know, any other medical history we need to think about?
Shweta Anjan:Auto-immune conditions, for example.
Shweta Anjan:Also, um, you didn't cover drug use or marijuana use, you know.
Shweta Anjan:Sure, like most transplant patients are very careful with regards to marijuana smoking, but it's still, um, something I would like to know.
Shweta Anjan:So coming up with a more broad differential diagnosis, and then we can narrow it down to specific features of our patients.
Shweta Anjan:The way I think through things is consider infections and noninfectious causes also.
Shweta Anjan:So you have like a table with one side that says infections.
Shweta Anjan:And the other side that has non-infectious causes.
Shweta Anjan:When you go through infectious causes, you look at the big four -- bacterial, viral, fungal, parasitic, and try to see which one would fit this picture.
Shweta Anjan:So we're looking at an immunocompromised host so, if you had to think of bacterial causes here, can, you can say like Staph aureus and MRSA can cause cavitary lesions.
Shweta Anjan:And if there's bacteremia and an hematogenous spread, you know, they could also be some skin lesions or cutaneous abscesses resulting from that.
Shweta Anjan:And then other, um, other bacteria like Rhodococcus, which is not very common.
Shweta Anjan:And she doesn't have a history of contact with animals, but it's still possible in transplant patients.
Shweta Anjan:And consider gram negative bacteria like Pseudomonas and Klebsiella, that can also cause more of a, um, echythma when it comes to a skin lesion.
Shweta Anjan:Um, and rarely cavitary lesion.
Shweta Anjan:The big thing to also consider is mycobacteria, non TB mycobacteria (NTM) especially, um, I'm assuming this patient would have had screening for TB pre-transplant.
Shweta Anjan:Hopefully there was a Quantiferon that was checked and negative, but it is still possible for her to either have donor derived TB or have, um, new TB infection.
Shweta Anjan:So keep, you know, tuberculosis, non TB mycobacteria also on top of the list.
Shweta Anjan:And in a different part of the country, I would say consider zoonoses like tularemia.
Shweta Anjan:You know, she obviously has had no contact with rabbits.
Shweta Anjan:So I wouldn't put that high on my list, but it's usually the board question where you have pulmonary symptoms and this ulcerative glandular lesion somewhere on the hand or leg.
Shweta Anjan:Um, and you have to consider rabbits and tularemia.
Shweta Anjan:All right.
Shweta Anjan:So that's bacterial.
Shweta Anjan:I think my favorite out of this will be working through the fungal etiology.
Shweta Anjan:So she is a lung transplant patient.
Shweta Anjan:Um, a question I would have is, was she on any antifungal prophylaxis?
Shweta Anjan:Because some centers choose to put their lung transplant patients on prophylaxis for six to 12 months.
Shweta Anjan:I know we do that here in Miami.
Shweta Anjan:They're on voriconazole prophylaxis for 12 months.
Shweta Anjan:That being said, just because they're on prophylaxis does not mean that they cannot have breakthrough infections or fungal infections in general because of sub-therapeutic antifungal levels.
Shweta Anjan:So when you think about fungal infections in these patients, I would consider aspergillosis as my number 1.
Shweta Anjan:And then other molds.
Shweta Anjan:Mucor would be rare and she should be a lot more sicker if she had that and it was disseminated.
Shweta Anjan:Um, Fusarium also causes a skin rash, another board question.
Shweta Anjan:One of the few that actually grows in blood culture, um, and the other endemic fungi, for example, Cryptococcus can definitely cause pulmonary cryptococcosis with the cavitary lesion and skin rashes.
Shweta Anjan:And, um, specific to where she is in the Southwest, I would say even Coccidioidomycosis.
Shweta Anjan:She's, she is in Nevada, which puts her at risk.
Shweta Anjan:She's out hiking.
Shweta Anjan:Um, she's definitely had exposure to, um, air and soil, I would say.
Shweta Anjan:So.
Shweta Anjan:And, uh, coming to endemic fungi.
Shweta Anjan:So you think about Histoplasma and blastomycosis also that has similar presentations with pulmonary and skin involvement.
Shweta Anjan:The map for the geographic burden of Histoplasma has been changing.
Shweta Anjan:So initially, while we classically learned that it's mostly like the Midwest and Ohio and Mississippi valley, now it is also seen in the South.
Shweta Anjan:So it's also there in the Southeast and Florida and Texas.
Shweta Anjan:And it seems to be moving more to the West, that new geographic distribution map for Histoplasma.
Shweta Anjan:So that's it.
Shweta Anjan:But the fungal.
Shweta Anjan:Um, viral etiologies, it's uncommon for any of the viruses to cause a cavitary lesion and skin lesions, and sometimes they rarely, maybe a herpes virus can do that, but that's unlikely.
Shweta Anjan:Parasites.
Shweta Anjan:So one of the parasites I respect is Strongyloides, just because of what it's capable of doing.
Shweta Anjan:So it can cause pulmonary lesions like a consolidation and can cause a skin rash.
Shweta Anjan:But the skin rash, it's not generally, usually not a nodule.
Shweta Anjan:It's more of a diffuse rash, or it looks like purpura really.
Shweta Anjan:And other pulmonary parasites like schistosomiasis, you know, the lung flukes.
Shweta Anjan:You can see um, pulmonary hydatid cysts, unlikely in this lady.
Shweta Anjan:I think that's it with the parasites.
Shweta Anjan:Um, and then coming to the noninfectious causes with her being a recent lung transplant and being out in the sun, I would say there's a high chance of skin cancer or melanoma, which could present with a lung lesion and a skin lesion.
Shweta Anjan:Also think about primary, um, pulmonary adenocarcinoma with lung mets [metastases] and the malignancy section.
Shweta Anjan:Possibility of auto immune diseases like sarcoid or granulomatosis with polyangiitis.
Shweta Anjan:Though auto-immune conditions would be subdued because she's already on immunosuppressants.
Shweta Anjan:So I'd be surprised if it was auto immune because she's already on tacrolimus and prednisone, but should, um, you know, dial down the symptoms from that.
Shweta Anjan:So to narrow it down to our patient.
Shweta Anjan:So you're presented lung transplant patient who is six months from transplant.
Shweta Anjan:She lives in Nevada, which is this dry climate with occasional winds.
Shweta Anjan:She likes hiking and spending time outdoors.
Shweta Anjan:So I would say our patient is at risk for bacterial or a fungal infection she could have inhaled.
Shweta Anjan:So my top three in her would be a non TB mycobacteria, so it could be M abscessus or M.avium or M.kansasii.
Shweta Anjan:Um, a fungal infection like Aspergillus, Cocci, or Cryptococcus and, um, Nocardia.
Shweta Anjan:Malignancy is still a possibility, and of course we will know more as we start to work this patient up.
Shweta Anjan:Now approach to like the early steps of approach to getting to a diagnosis, start with blood cultures.
Shweta Anjan:That will definitely help us.
Shweta Anjan:Um, and noninvasive fungal markers.
Shweta Anjan:You can learn a lot from the serum Aspergillus galactomannan and Cryptococcal antigen, Coccidioides antibody.
Shweta Anjan:And, um, the best part about having skin lesions in transplant patients is that you can get them biopsied.
Shweta Anjan:So it's like the one thing I tell every fellow and every medical student, I can catch hold of.
Shweta Anjan:If there's a rash, you biopsy that.
Shweta Anjan:It'll give us so many answers and fast answers that, um, even cultures cannot get back to you that quickly.
Shweta Anjan:So I would say push for invasive testing, call dermatology, biopsy the rash, send it for culture and for pathology.
Shweta Anjan:Let both the micro lab and pathology know what you're looking for, what you're considering in your patients.
Shweta Anjan:Um, especially so Pathology can work on special stains for AFB and uh fungal staining.
Shweta Anjan:And then after the skin, I would say, um, go after the pulmonary nodule.
Shweta Anjan:Consider invasive testing for the pulmonary nodule and the cavitary lesion.
Shweta Anjan:Request for bronchoscopy and BAL.
Cesar Berto:Thank you Dr.
Cesar Berto:Anjan, that was a very, very complete differential.
Cesar Berto:And so to complete some of the history information.
Cesar Berto:The patient is a former smoker, and the reason for transplantation was that.
Cesar Berto:In terms of her pre-transplant screening, basically everything was negative including a Quantiferon except for the CMV that is a high risk.
Cesar Berto:And, uh, she is on prophylaxis.
Cesar Berto:In terms of the workup that was done in the hospital.
Cesar Berto:So of course blood cultures were collected.
Cesar Berto:Fungal markers were sent.
Cesar Berto:She was started empirically on vancomycin and cefepime.
Cesar Berto:And then as you said, a skin biopsy was pursued.
Cesar Berto:We got the result of the skin biopsy and it shows a Gram positive branching and beaded rods surrounded by extensive inflammation.
Cesar Berto:Cultures of the biopsy were also sent and they were in progress.
Cesar Berto:While waiting on these cultures, what do you think should be the best antibiotic regimen and how do these change your differential?
Shweta Anjan:Okay.
Shweta Anjan:So the gram-positive branching and beaded rods definitely helped.
Shweta Anjan:So if you had stopped at gram-positive rods, I would say, Hmm.
Shweta Anjan:Is this Rhodococcus, you know, Streptomyces, NTM.
Shweta Anjan:Um, but when you say gram-positive branching and beaded, kind of forced to think Nocardia.
Shweta Anjan:So I guess, Pathology did a great job at that.
Shweta Anjan:And like, you know, helped us out there saying, okay, all right.
Shweta Anjan:So if we narrow it down from all of the broad differential diagnosis to, there is a 99% chance, this is Nocardia.
Shweta Anjan:The 1% we still have to wait for the culture.
Shweta Anjan:In transplant patients, I have come to learn that you should expect curveballs and plan ahead for them.
Shweta Anjan:So I would say, okay, I'm comfortable knowing that this is Nocardia, so we can plan our treatment around.
Shweta Anjan:So in solid organ transplant and immunocompromised patients, honestly, Nocardia is not that common.
Shweta Anjan:The incidence is less than 4%.
Shweta Anjan:Um, our patient lives in the United States, Southwest, where the incidence of Nocardia is higher.
Shweta Anjan:So, which is why this makes it more likely in her.
Shweta Anjan:And there are other risk factors that you need to consider.
Shweta Anjan:She's a lung transplant patient, and heart and lung transplant patients are at higher risk of compared to liver and kidney for Nocardia infections.
Shweta Anjan:She is six months post transplant.
Shweta Anjan:So she kind of fits the timeline where the highest chances of having, um, Nocardia infections are one to two years post-transplant.
Shweta Anjan:Um, though, the bacteria doesn't read the guidelines and the timeline.
Shweta Anjan:So it's still possible that you can see it a little earlier, you can see it after two years, you can see to the later point in life, especially if they have recently been treated for rejection and they had, you know, augmentation in their immunosuppression.
Shweta Anjan:So certain immunosuppressants also increase the risk factors for Nocardia, I would say.
Shweta Anjan:There have been various case control studies done.
Shweta Anjan:A large one here in the USA and another one from Europe that in solid organ transplant patients that identified that the risk factors include high doses of corticosteroids, um, a high serum concentration of calcineurin inhibitors and prior CMV infection, like in the past six months.
Shweta Anjan:In addition, older age, prolonged ICU stay at also considered to be risk factors for nocardia infection.
Shweta Anjan:So this is specific to solid organ transplant, but remember like other stem cell transplants, leukemics, lymphoma, patients receiving monoclonal antibodies like rituximab and infliximab.
Shweta Anjan:They are also at risk for Nocardia.
Shweta Anjan:Especially I think with infliximab, they have, there have been reports where there, um, Nocardia infections in like patients being treated for rheumatoid arthritis.
Shweta Anjan:So consider other immunosuppressants while you're at it.
Shweta Anjan:Typical clinical manifestations of Nocardia.
Shweta Anjan:Um, I would say the primary site of infection is the lung, you know, you inhale it.
Shweta Anjan:So that's why it's going straight to your lungs.
Shweta Anjan:Um, and in some cases there is cutaneous involvement, either alone, so the isolated cutaneous involvement.
Shweta Anjan:If there is trauma, um, and you know, people who are into gardening and landscaping, where you just have a single nodule and hopefully it stays contained there, or it could be from hematogenous spread from the primary site to the skin.
Shweta Anjan:So you could have that, uh, pulmonary infection.
Shweta Anjan:And then of course, CNS infection.
Shweta Anjan:Um, Nocardia seems to have affinity for the brain and, due to the tropism, there are a predominant number of cases in solid organ transplant that have disseminated nocardia infections.
Shweta Anjan:When it comes to diagnosis, I would say we absolutely need it on culture.
Shweta Anjan:Growth on culture is a must to help in diagnosis.
Shweta Anjan:In cases where it is not growing on culture, um, consider molecular testing like PCR testing, or like a 16 s RNA um, testing, where you can send it to a reference lab.
Shweta Anjan:I actually honestly saw a similar case where the patient was initially diagnosed with organizing pneumonia, because it didn't grow on culture for weeks.
Shweta Anjan:And the treatment.
Shweta Anjan:The treatment is completely different because they get steroids for organizing pneumonia versus nocardia treatments.
Shweta Anjan:So it's something to think about.
Shweta Anjan:While you're waiting for the culture, is first of all, get adequate samples, send the skin biopsy for cultures, send the BAL culture, whatever specimen you can find that's a source of infection.
Shweta Anjan:You send it for culture.
Shweta Anjan:Let the microlab know, communicate with the micro lab because they're your best friends.
Shweta Anjan:Tell him you're considering nocardia so they can do a modified acid fast stain.
Shweta Anjan:They can incubate it for longer.
Shweta Anjan:Cause sometimes it might grow soon or sometime it might choose to grow 3-4 weeks later so they can hold your specimens and incubate them for longer.
Shweta Anjan:Also there's a role where they can consider certain selective media to help nocardia grow faster.
Shweta Anjan:So communicate with them about your potential diagnosis and that will help you.
Shweta Anjan:And then we're coming to imaging.
Shweta Anjan:Imaging for nocardia is important.
Shweta Anjan:What you described, uh, in our patient's CT scan, where you said she had a right lower lobe consolidation with a two centimeter nodular lesion and peripheral cavity.
Shweta Anjan:So.
Shweta Anjan:Almost typical for, um, nocardia and other infections also unfortunately, but an irregular nodule, large mass, like a third of them have cavitation, can easily be considered to be malignancy.
Shweta Anjan:Um, that's what you typically see on a CT chest.
Shweta Anjan:Remember, not just with nocardia infections, I would also say with fungal infections and non TB mycobacteria, remember to stage your infection.
Shweta Anjan:So, you know the severity.
Shweta Anjan:So staging of disease involves imaging of the chest, sinuses and brain to understand the extent of involvement.
Shweta Anjan:So in this case, you know, just to see if the patient has no CNS symptoms, no headaches, vision problems, we can start with a CT brain and, and then ask for an MRI brain.
Shweta Anjan:Um, or you could just get the MRI first.
Cesar Berto:Perfect.
Cesar Berto:So actually a more careful review of systems of these patient reveals some intermittent headache.
Cesar Berto:Patient underwent a brain MRI and it show a well-defined very small ring enhancing lesion in a temporal lobe with minimal surrounding edema.
Cesar Berto:So knowing this, how could these affect your management and what changes could you recommend?
Shweta Anjan:Okay.
Shweta Anjan:So what we know now is that there is lung, skin, and CNS enrollment.
Shweta Anjan:So this patient definitely has a disseminated process, likely disseminated nocardia, because there's involvement more than more than two sites.
Shweta Anjan:This can be life-threatening with the high mortality rate, mortality as high as 20%.
Shweta Anjan:So we would need to act fast.
Shweta Anjan:One, establish from a neurosurgery standpoint, how safe is the edema and the lesion.
Shweta Anjan:with a typical ring enhancing lesion would mean, um, could also be toxoplasma but get neurosurgery involved.
Shweta Anjan:Is there any role for an intervention?
Shweta Anjan:Is there something to evacuate or drain?
Shweta Anjan:And is there anything to be done for the surrounding edema and inflammation?
Shweta Anjan:So starting there, I believe this patient is on vancomyvin and cefepime empirically?
Cesar Berto:Vancomycin and cefepime empirically.
Cesar Berto:Yes.
Cesar Berto:Correct.
Shweta Anjan:Alright.
Shweta Anjan:So we're thinking most likely this patient has Nocardia, but until I know more, I might also want to cover for NTM.
Shweta Anjan:But the good thing is that the treatment for nocardia sort of covers some, some NTM also.
Shweta Anjan:So the first line of treatment from nocardia, like the backbone has to be a sulfonamide, like Bactrim (trimethoprim-sulfamethaxazole) so you start off include Bactrim in your regimen.
Shweta Anjan:And then in addition, the other first line options are the drugs you can add would be, you know, imipenem, Amikacin, linezolid, depending on the severity of disease.
Shweta Anjan:So, if it is just cutaneous, you can get away with monotherapy with Bactrim.
Shweta Anjan:If it was limited to the lung with imaging confirming that there's no brain or sinus involvement, you can also get away with monotherapy with Bactrim.
Shweta Anjan:In our patient, we actually know she has disseminated disease.
Shweta Anjan:So I would say combination therapy, um, depending on what she can tolerate, I would say bactrim, imipenem and if the symptoms progress or don't improve within a week, also add amikacin IV and monitor her.
Shweta Anjan:Now, this is the best case scenario, but what do you do in terms of Bactrim allergies or, you know, patients who are intolerant to Bactrim?
Shweta Anjan:Um, if they have a serious allergy to Bactrim consider desensitization, but even after that, if patients are intolerant to it, then you would have to consider treatments, such as linezolid.
Shweta Anjan:So you can try imipenem and linezolid, which has proven to be effective multiple times.
Shweta Anjan:In fact, linezolid is a great, great drug with the bioavailability being a hundred percent, ease of administration, there are both IV and PO options, you know, transitioning would be easy.
Shweta Anjan:It achieves good CNS and lung tissue concentration.
Shweta Anjan:So it will be perfect.
Shweta Anjan:The only problem is the duration of treatment and toxicities, you'd have to factor in because when you're thinking about treating nocardia, you're thinking about prolonged treatment and with linezolid, you would have bone marrow suppression, thrombocytopenia, peripheral neuropathy, you know, serotonin syndrome to consider.
Shweta Anjan:It it's a good option, but a short-term option.
Shweta Anjan:You would still need something else to complete the duration of treatment.
Shweta Anjan:So empirically, um, I would choose bactrim, imipenem, but without amikacin, depending on how the patient progresses.
Shweta Anjan:Imipenem would also cover some NTM.
Shweta Anjan:Um, and if there's a strong feeling that this is probably NTM, you could also add a macrolide, uh, while you wait for the final culture.
Shweta Anjan:So while we're managing this patient empirically.
Shweta Anjan:You do need to emphasize on the cultures because a species identification and anti-microbial susceptibilities are absolutely necessary.
Shweta Anjan:The species of nocardia vary by geographical region.
Shweta Anjan:So the species that's predominant in Europe is not predominant in the U S and even within the U S every state has a predominant species.
Shweta Anjan:So you would have to know that.
Shweta Anjan:And every species differs in terms of pathogenicity and antibiotic susceptibility.
Shweta Anjan:We have empiric treatment, but there are certain species of nocardia.
Shweta Anjan:I would say the dangerous ones are, um, N.farsinica, which almost always causes disseminated disease.
Shweta Anjan:It can be resistant to Bactrim, imipenem, third-generation cephalosporins.
Shweta Anjan:And there's also N.pseudobraziliensis that's also can be resistant to Bactrim and N.abscessus sometimes, um Nocardia abscessus has variable sensitivity to.
Shweta Anjan:Um, imipenem and Bactrim.
Shweta Anjan:So like knowing these things, it's very important that we get down to the details.
Shweta Anjan:Like what is the species, what the antibiotic susceptibility, and then we can narrow our treatment from there.
Cesar Berto:Great.
Cesar Berto:So the culture was obtained by the team and it was finally identified by the micro lab as Nocardia abscessus, which was sensitive to imipenem and sensitive to bactrim.
Cesar Berto:So the patient was transitioned to imipenem and bactrim as per ID recommendations.
Cesar Berto:Um, so in this particular case, how long would you, would you treat this patient?
Shweta Anjan:Okay, that's great.
Shweta Anjan:That's great that we had Nocardia abscessus and it's sensitive to imipenem, bactrim.
Shweta Anjan:So we're winning!
Shweta Anjan:So talking about a disseminated disease.
Shweta Anjan:So I would say a minimum of six months, six to 12 months is what the guideline says, but I would say at least six, more likely 12, push towards 12.
Shweta Anjan:Even the 12 months would depend on clinical progression.
Shweta Anjan:So this patient will likely become your best friend.
Shweta Anjan:So you need to know everything about them at this point.
Shweta Anjan:Um, because this patient's going to be followed by you in clinic for the next 12 months.
Shweta Anjan:So for ease of communication, make sure you have emails and phone numbers, um, and a way to get ahold of labs.
Shweta Anjan:She's going to need clinical monitoring.
Shweta Anjan:I would say at least 1, 3, 6 months after diagnosis.
Shweta Anjan:Um, for both for drug toxicity, and also repeat imaging, you know, repeat the MRI of the brain, the CT chest.
Shweta Anjan:See where you're at with radiological resolution.
Shweta Anjan:After completion of treatment, she may or may not need secondary prophylaxis.
Shweta Anjan:Um, but you would still need to follow up with imaging at least at six months and 12 months post stopping treatment.
Cesar Berto:Great.
Cesar Berto:So in the case of this patient, uh, he remains on therapy and was able to tolerate it.
Cesar Berto:One of the things that we wanted you to expand a little bit more, it's the impact of uh, PJP prophylaxis, um, usually on bactrim and in this case, the patient was on Atovaquone, in terms of the prevention also of, of Nocardia infections,
Shweta Anjan:Alright, and that's a good question.
Shweta Anjan:So your patient here was on atovaquone.
Shweta Anjan:Bactrim does have a role, so Bactrim use for PJP prophylaxis.
Shweta Anjan:The dosing's either a single strength daily or double strength three times a week.
Shweta Anjan:It does have a role in primary prevention of Nocardia.
Shweta Anjan:However breakthrough infections have been reported.
Shweta Anjan:And this has been an ongoing debate about, you know, is it because of the dosing, that the dosing for PJP prophylaxis is insufficient to ensure complete primary prevention of Nocardia?
Shweta Anjan:Um, and there are studies that show patients who have these breakthrough infections on Bactrim for PJP prophylaxis, the isolates can still be susceptible to Bactrim.
Shweta Anjan:And then there are a few instances where they're resistant to Bactrim, so that would explain the breakthrough infection.
Shweta Anjan:Um, but I would say yes, when possible, and if the patient tolerates it, um, Bactrim for PJP prophylaxis is still preferred, um, and will definitely offer some protection against nocardia.
Shweta Anjan:Again, the data on, both dosing and duration of Bactrim for primary prevention and secondary prophylaxis for nocardia is, um, limited, I would say.
Shweta Anjan:We don't really have, you know, any head to head trials or prospective studies in this area.
Shweta Anjan:Most of our information is from retrospective studies and case reports.
Shweta Anjan:In fact, there are, I think there's a study from Mayo clinic from a few years ago where they looked at recurrence rates in patients while they were on secondary prophylaxis and there was still a 5% recurrence rate on their secondary prophylaxis of Bactrim, single strength daily.
Shweta Anjan:And they identified the risk factor for those recurrences, mostly lung transplant, patients, chronic lung problems.
Shweta Anjan:Um, and if for some reason they received less than six months of treatment.
Shweta Anjan:So even on the single strength daily, you know, they can still have recurrence, I think that might be why our AST guideline recommends Bactrim double strength daily for secondary prophylaxis in these patients.
Shweta Anjan:But there is no data to back that up.
Sara Dong:Yeah.
Sara Dong:Cause I feel like this question, it always comes up when there's a case of nocardia and I think emphasizing that you can still have it regardless of the isolate is susceptible or if they're on daily prophylaxis is such an important point because I think sometimes, when teams call us, they sort of say like, oh, well there's no way it could be X, Y, and Z, because they're on prophylaxis.
Sara Dong:And it's the same with fungal disease, that we use that as a piece of information, but can't really take something off the table.
Shweta Anjan:No, absolutely.
Shweta Anjan:That's always a problem.
Shweta Anjan:I would say a take home message for nocardia is that it does not respect fascial planes.
Shweta Anjan:Okay.
Shweta Anjan:Like, it's a very disrespectful bug.
Shweta Anjan:It can spread right to your lungs, you know, it can go, go to spread to the chest wall from its primary site of infection.
Shweta Anjan:So no respect for fascial planes.
Shweta Anjan:There is hematogenous spread.
Shweta Anjan:Like who does that?
Sara Dong:Uh, I think that's most of the case we have, I wanted to make sure there weren't other pearls or things that we should keep in mind with Nocardia.
Sara Dong:I feel like we talk about it a lot and we see it occasionally, but, uh, at least for me, I feel like the cases are actually somewhat spread out.
Shweta Anjan:No, that's true.
Shweta Anjan:Like, um, like as I said before, like our incidence in solid organ transplant is low.
Shweta Anjan:But there's a good chance that you might see an increase, especially now that there's an increase in the number of transplants overall, increasing the number of lung transplant.
Shweta Anjan:So there are a lot more immunocompromised people in our community.
Shweta Anjan:Um, and also global warming.
Shweta Anjan:Like it or not, it's going to become a big infectious disease problem with the rise of temperatures and providing this like favorable environment for all these bacteria, fungi and parasites to grow and multiply.
Shweta Anjan:Um, you're going to see a lot of these infections.
Sara Dong:Well, thank you guys so much for coming on the show and talking about Nocardia, but also thinking this is a really nice case to think about brain and skin and then brain and lung, and a lot of the combos that we see on ID consult.
Sara Dong:And of course, cavitary lung lesions, which are one of my favorite ID differentials, so!
Shweta Anjan:Yes, thank you for having us, Sara.
Cesar Berto:Thank you!
Sara Dong:Thanks again to Shweta and Cesar for joining Febrile today.
Sara Dong:Our usual disclaimer, that all presented patients on this podcast are inspired by patient experiences.
Sara Dong:The cases are constructed or significantly altered, and de-identified for learning purposes.
Sara Dong:Please, don't forget to check out the website, febrilepodcast.com, where you will find our Consult Notes, which are written complements of the show with links to references, our library of ID infographics, and a link to our merch store.
Sara Dong:So please reach out if you have any suggestions for future shows or if you just want to be more involved with Febrile.
Sara Dong:Thanks for listening.
