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Kidney Week

Abstract: PO2476

A Rare Presentation of Disseminated Nocardia in a Kidney Transplant Recipient

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Naik, Ruchi Harshadrai, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Shawar, Saed, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Schaefer, Heidi M., Vanderbilt University Medical Center, Nashville, Tennessee, United States
Introduction

Nocardiosis is a very rare infection caused by the Nocardia asteroids bacterium. It most commonly involves the lungs but can spread to other areas of the body and is more likely to infect immunosuppressed patients. We report a case of a kidney transplant patient who presented with a tender lump of his right shoulder.

Case Description

Patient is a 58 year s old African American male with a history ESRD secondary to hypertension and reduced kidney mass status post right radical nephrectomy for renal cell carcinoma in 2001. He underwent deceased donor kidney transplant in May 2017 after being on dialysis for 13 years. He received alemtuzumab and methylprednisolone prednisone for induction followed by maintenance immunosuppression with Tacrolimus, mycophenolate mofetil and prednisone. In January 2020, he presented to the orthopedic clinic with a 10-day history of pain and a soft tissue mass of the right scapula and was diagnosed with a parascapular muscle tear. One week later he presented to an outside hospital with fevers and CT of chest showing pulmonary nodule with satellite lesions in the RUL concerning for malignancy. He was transferred to our hospital where PET CT scan showed multiple intensely FDG avid masses in the lungs, brain, cecum and soft tissue inferior to the right scapula concerning for malignancy. Core tissue biopsy from the right scapular region was negative for bacterial or acid-fast bacilli stain but showed gram positive beaded rods identified as Nocardia. He was initially treated with intravenous sulfamethoxazole/trimethoprim and intravenous meropenem and then based on susceptibility transitioned to intravenous ceftriaxone and oral sulfamethoxazole/trimethoprim. A follow-up MRI two months from diagnosis showed marked improvement in all lesions and he was transitioned to oral doxycycline to complete at least 12 months of therapy.

Discussion

Nocardiosis can present in unusual fashion in transplant recipients and one should have a high suspicion in patients who present with fever and disseminated lesions on imaging with plan for biopsy and culture of tissue early. In most cases, Nocardia can be treated successfully with appropriate antibiotics.