Reactions Weekly | 2021
Antibacterials
Abstract
Nocardia nova septic pulmonary emboli, endocarditis, diffuse maculopapular drug rash and lack of efficacy: case report A 34-year-old woman developed Nocardia nova septic pulmonary emboli and endocarditis following antibiotic therapy with doxycycline and ceftriaxone for chronic Lyme disease and a diffuse maculopapular drug rash during empirical antibiotic therapy with cotrimoxazole. Additionally, she experienced lack of efficacy during antibiotic therapy with azithromycin [not all routes and time to reaction onsets stated; dosages not stated]. The woman presented with daily low-grade fevers, dry cough, loss of appetite for 1 month, and a weight loss. Thus, she received antibiotic therapy with azithromycin as an outpatient. She received a total of two separate 5 days courses of azithromycin. However, there was no improvement in her symptoms. Thus, lack of efficacy was considered for antibiotic therapy of azithromycin. She was then admitted. Ten years ago, she was diagnosed with Lyme disease and she was treated with doxycycline. She continued to have polyarthralgia and fatigue. On detail anamnesis, she reported that she was diagnosed with chronic Lyme disease 5 years before the current presentation. She had an indwelling peripherally inserted central catheter (PICC) for the previous 22 months. She had received IV antibiotic therapy with ceftriaxone for 10 months, which was followed by IV doxycycline for 6 months. She was also prescribed intermittent courses of disulfiram and doxycycline for the treatment of chronic Lyme disease. Her medical history was significant for Ehlers-Danlos syndrome, postural orthostatic tachycardia syndrome, psychogenic nonepileptic seizures and gastrointestinal malabsorption. For gastrointestinal malabsorption, she underwent enteral feeding through a nasogastric tube. She reported that unspecified sulfa drugs had cause hives in childhood. On the day of the presentation, temperature was found to be 38.1°C with an HR of 103 beats/minute. A PICC line was in place in the right arm. A chest CT scan demonstrated multiple scattered pulmonary nodules concerning emboli. Branching, Gram-positive bacilli grew in 4/4 blood cultures. The organism was stained with a modified acid-fast bacilli stain and was identified as Nocardia nova. The multiple, bilateral small nodular opacities noted on the CT scan of the chest were consistent with septic pulmonary emboli. A transthoracic echocardiogram was normal. However, a transesophageal echocardiogram showed a 3mm x 1mm mobile vegetation on the mitral valve. Thus, a diagnoses of PICC associated Nocardia nova septic pulmonary emboli and endocarditis secondary to IV doxycycline and IV ceftriaxone was made. Consequently, the woman’s PICC line was removed, and she was started on imipenem. On the second day of admission, her fever resolved, and her symptoms improved significantly. Due to the history of a severe allergy to cotrimoxazole [trimethoprimsulfamethoxazole], she was desensitised to cotrimoxazole. She was then discharged on empirical antibiotic therapy with cotrimoxazole and amikacin. Following 10 days of cotrimoxazole initiation, she developed a diffuse maculopapular drug rash secondary to cotrimoxazole. Consequently, her cotrimoxazole was discontinued and imipenem was re-started along with the continuation of amikacin. Subsequently, her rash resolved. After 4 weeks of empiric antibiotic treatment, the organism was identified as Nocardia nova, which was sensitive to cotrimoxazole, amikacin, ceftriaxone, imipenem, and linezolid; however, resistant to tetracyclines, fluoroquinolones, and amoxicillin/clavulanicacid [amoxicillin/clavulanate]. Thus, imipenem and amikacin were terminated, and she was started on ceftriaxone.