Reactions Weekly | 2021
Hydroxychloroquine/mycophenolate-mofetil/prednisolone
Abstract
Disseminated nocardiosis secondary to Nocardia otitidiscaviarum infection: case report A 29-year-old woman developed disseminated nocardiosis secondary to Nocardia otitidiscaviarum infection following immunosuppressive therapy with hydroxychloroquine, mycophenolate-mofetil and prednisolone [routes and duration of treatment to reaction onset not stated]. The woman, who had systemic lupus erythematosus (SLE) complicated by multi-organ involvement including cerebritis, lupus nephritis, autoimmune haemolytic anaemia, non-specific interstitial pneumonia and cardiomyopathy. She started receiving immunosuppressive therapy with mycophenolate mofetil 1000mg twice daily, hydroxychloroquine 200mg once daily and prednisolone 40mg daily which was planned to be tapered over 8 weeks. Due to the involvement of multiple organs and slow response towards the treatment, she required hospital admission for 2 weeks. Two weeks following discharge, she developed dry cough, generalised body pain, fever, progressive shortness of breath, skin rash, nausea and vomiting. On subsequent investigation, she was malnourished in addition to alopecia. Physical examination revealed HR 147 beats/minutes, body temperature 39.4°C, BP 137/88mm Hg and RR 24 cycles/minute. She was found to have multiple skin pustules over the upper limbs, lower limbs, abdomen and back. Chest auscultation showed reduced air entry at the right lung base. An abdominal examination showed right upper quadrant tenderness. Further investigations revealed leucocytosis, neutrophilia, normocytic normochromic anaemia, in addition to elevated CRP and procalcitonin levels. Haematological workup revealed elevated haptoglobin, LDH and reticulocytes of 1.5%. The chest X-ray demonstrated pleural effusion and consolidation with cavitation in the right lower zone. The fluid from skin pustules, sputum as well as blood samples were sent for microbiological studies. All cultures from broncho-alveolar lavage, skin pustules and sputum revealed branching, fine, delicate filaments with fragmentation, beaded gram-positive bacilli on gram staining. The modified Ziehl–Neelsen staining showed partially acid-fast bacilli. Matrix assisted laser desorption/ionisation time of flight showed presence of N. otitidiscaviarum. A chest CT-scan showed necrotising pneumonia with lung abscess and pneumothorax in the left lung. Few septic emboli were visible in the left lung. The brain MRI revealed numerous supra and infratentorial brain micro-abscesses with the left para-median cerebellar hemisphere and the largest involving the cerebellar vermis. Those abscesses showed internal enhancing septations, central diffusion restriction and peripheral enhancement. She was diagnosed with disseminated nocardiosis secondary to N. otitidiscaviarum infection and it was associated with immunosuppressive therapy. The woman was then treated with cotrimoxazole, amikacin and meropenem. Her condition rapidly worsened after 3 days, with a decrease in her level of consciousness with a Glasgow coma scale (GCS) of 6/15. She was kept on mechanical ventilation and intubated. A repeat imaging demonstrated intracranial haemorrhage and right frontal vascular malformation of 6mm of diameter with a feeding vessel from the distal portion of the anterior cerebral artery and draining into a cortical vein, which was indicative of intracranial aneurysm. She underwent decompressive craniectomy and insertion of an external ventricular drain was performed. She received unspecified antibiotics for 8 weeks and was then switched to moxifloxacin, in addition to cotrimoxazole. A brain CT-scan at 6 months after treatment revealed complete resolution of the brain abscesses and a repeat chest X-ray revealed clearance of the initial changes. Despite all supportive measurements and appropriate antibiotics, she had low GCS levels and remained tracheostomised, ventilator-dependent and fed through a nasogastric tube.