Abstract: SA-PO951

Nocardiosis in a Renal Transplant Patient: A Case Report and Review of Literature

Session Information

Category: Nephrology Education

  • 1302 Fellows and Residents Case Reports

Authors

  • Gupta, Mohit, Cleveland Clinic Akron General, Akron, Ohio, United States
  • Shahid, Irtsam, Cleveland Clinic Akron General, Akron, Ohio, United States
  • Raina, Rupesh, Cleveland Clinic Akron General, Akron, Ohio, United States
Background

Nocardiosis is a rare and systemic disease that occurs in up to 5% of renal transplant recipients. Amongst patients with Nocardiosis, Central Nervous System involvement is seen in approximately 50% of cases. We report a patient with remote history of renal transplantation who was found to have multiple brain abscesses consistent with Nocardia infection.

Methods

A 66 year-old male with prior history of living donor renal transplant approximately 4 years ago presented for evaluation of progressive dizziness, nausea and vomiting. MRI revealed the presence of a peripherally enhancing lesion in the medial right cerebellum in addition to 2 smaller lesions in the right frontal lobe. CT Scan of the Chest done also revealed the presence of several small pulmonary nodules in both lungs. With the use of Mycophenolate Mofetil and Tacrolimus, there was a concern for brain abscess versus malignancy. The patient was started on IV Trimethoprim – Sulfomethaxozole in addition to Vancomycin and Ceftazidime with plan for aspiration and culture. Immunosuppression was modified due to concern for worsening kidney function thought to be due to calcineurin toxicity. However, false elevation in Creatinine secondary to Trimethoprim was also considered. Aspirate of the culture revealed the presence of branching gram positive organisms consistent with Nocardia. Vancomycin was switched to Linezolid and Ceftazidime to Imipenem with a plan to continue IV antibiotics for 6 weeks.

Conclusion


Nocardiosis is an opportunistic infection that occurs in up to 5 % of renal transplant recipients. It is seen commonly in the intense immunosuppression period after renal transplantation (which is 1-6 months) or after high dose therapy is used to treat rejection. The primary site of involvement is the pulmonary system, but spread to the CNS can also occur. Risk factors for development of Nocardia include multiple rejection episodes, worsening kidney function as well as high dose immunosuppression. Empiric antimicrobial therapy is often recommended as it is very slow growing. Trimethoprim-Sulfomethaxozole is first line therapy for management of Nocardia brain abscess due to good penetration of sulfonamides. The mortality rate in immunosuppressed patients has been reported to be up to 50%. Hence, a high degree of clinical suspicion is necessary when such CNS findings are observed in renal transplant recipients.