Year : 2002 | Volume
: 13 | Issue : 4 | Page : 498--500
Systemic Nocardiosis with Multiple Brain Abscesses in a Renal Transplant Recipient: Successfully Treated with Antibiotics Alone
Khaled Charfeddine, M Kharrat, S Yaich, R Abdelmalek, H Hakim, H Bahloul, F Jarraya, A Hammami, J Hachicha
Department of Nephrology, University-Hospital, Sfax-Jadida, Tunisia
Professor of Nephrology, Sfax University, P.O. Box 288,3027, Sfax-Jadida
|How to cite this article:|
Charfeddine K, Kharrat M, Yaich S, Abdelmalek R, Hakim H, Bahloul H, Jarraya F, Hammami A, Hachicha J. Systemic Nocardiosis with Multiple Brain Abscesses in a Renal Transplant Recipient: Successfully Treated with Antibiotics Alone.Saudi J Kidney Dis Transpl 2002;13:498-500
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Charfeddine K, Kharrat M, Yaich S, Abdelmalek R, Hakim H, Bahloul H, Jarraya F, Hammami A, Hachicha J. Systemic Nocardiosis with Multiple Brain Abscesses in a Renal Transplant Recipient: Successfully Treated with Antibiotics Alone. Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2021 Dec 9 ];13:498-500
Available from: https://www.sjkdt.org/text.asp?2002/13/4/498/33105
Nocardiosis is a rare but important cause of morbidity and mortality among renal transplant recipients. ,,3] Nocardia is most frequently acquired by the respiratory route and usually produces localized or disseminated infection, late after transplantation.  The successful management of nocardial brain abscess remains problematic. , We herewith report on a renal transplant recipient who suffered from pulmonary involvement, septic arthritis and subcutaneous nocardial infection with life-threatening central nervous system involvement, who was successfully treated by imipenem in combination with ofloxacin.
A 22-year-old woman underwent a livingrelated donor kidney transplant in December 1994. Baseline immunosuppression was prednisolone, cyclosporine and azathioprine.
In April 1995, the patient was admitted to the hospital with a one-week's history of productive cough with purulent sputum and high fever.
One month prior to this, she had been hospitalized for fever, cough and pleuretic pain. She responded satisfactorily to treatment with ceftriaxon-pefloxacin.
The clinical examination revealed right elbow arthritis and a painful subcutaneous fluctuating nodule over the left arm. Two days later, she presented with seizures. On chest X-ray, a non-cavitating infiltrate was seen in the left lower lobe. Brain tomography scan showed multiple intracerebral abscesses with mass-effect [Figure 1].
Aspiration of the subcutaneous nodule and surgical drainage of the septic arthritis yielded green pus and gram positive branching rods, which was later, identified as Nocardia farcinica. We initially started treatment with trimethoprim-sulfamethoxazole (TMP-SMX) combined with imipenem. Antimicrobial sensitivity of Nocardia revealed that the strain was resistant to TMP-SMX, which was then changed to ofloxacin. The subcutaneous nodule and radiographic abnormalities resolved gradually and this drug regimen was continued for six months [Figure 2]. She has had no recurrence of nocardiosis after 1 year of follow-up.
Nocardiosis is caused by an aerobic, gram positive filamentous bacteria of the order of Actinomycetales and the genus Nocardia.  In order of frequency, the most common pathogenic Nocardia species are N. asteroides, N. brasiliensis and N. otitidiscaviarum. , Other species of Nocardia such as N. farcinica have rarely been isolated from clinical specimens.
Isolation of nocardia is often done from routine specimens (sputum, purulent material, blood). , Cultures of nocardia grow in five days to three weeks typically on blood agar but sub-cultures may grow in 48 hours. If physicians do not inform the microbiologist about suspected nocardiosis and to extend the routine incubation period, cultures will be discarded in three days. , Thus, the microbiological laboratory must be informed about suspected nocardiosis to extend the routine incubation period. , Our patient had an infection caused by N. farcinica identified on the culture of pus yielded from a subcutaneous abscess.
Human infections with Nocardia species are infrequently recognized. ,,,,, Most nocardial infections occur in immunocompromised patients.  In immunocompetent patients, nocardiosis is rare and is commonly pulmonary or cutaneous without other foci, but in the immunocompromised, the infection can spread hematogenously and give a disseminated disease that is defined by the presence of two or more foci of nocardiosis. ,
The majority of cases reported indicate that the onset of nocardiosis occurs from seven to 104 weeks following therapy for rejection.  In our case, the infection occurred 16 weeks after the initiation of immunosuppressive therapy.
The lung is the most frequent primary site of systemic nocardiosis (60-80% of cases) while cerebral and other foci may occur in 20-40% of cases. ,, Pulmonary location was the first focus in our case followed by involvement of the brain, elbow and subcutaneous tissue.
The successful management of nocardial brain abscesses remains problematic. They require image-directed stereotactic aspiration for diagnosis; however, craniotomy and total excision are necessary in most cases, because nocardial abscesses are usually multiloculated.  Patients with minimal neurological deficits, small abscesses or with single lesion may be treated initially with antibiotics alone given for a very prolonged duration. ,,
In our case, surgery could not be performed because of lack of adequate facilities. Antimicrobial management of nocardiosis is usually with TMP-SMX and imipenem, amikacin or cyclones. ,, We started with TMP-SMX and imipenem but the bacteriologic study of the strain demonstrated resistance to TMP-SMX. We used a combination of ofloxacin and imipenem for six months although the literature recommends treatment for one year. ,
Strains of N. farcinica had already been described to be resistant for most antimicrobial agents and for this reason, a combination of amikacin with imipenem or amoxicillin plus clavulanic acid seems to be the treatment of choice for such infections. 
The response to the antibiotic treatment was good with complete radiological resolution of brain abscesses and recovery of a normal activity with no disease recurrence in one-year follow-up despite the fact that the duration of treatment was only six months.
Among the organisms causing brain abscesses in renal transplant recipients, Nocardia species should be given particular consideration because of their sub-acute onset, the clinical polymorphism and therapeutic difficulties.
N. farcinica is usually resistant to most antimicrobial agents particularly TMP-SMX, which is generally regarded as therapy of choice for nocardiosis.
Generally, the multiloculated brain abscesses require surgery in combination with antibiotics therapy. We demonstrated here successful treatment of multiple brain abscesses with antibiotics alone.
|1||Gutierrez H, Salgado O, Garcia R, Henriquez C, Herrera J, Rodriguez Iturbe B. Nocardiosis in renal transplant patients. Transplant Proc 1994;26:341-2.|
|2||Arduino RC, Johnson PC, Miranda AG. Nocardiosis in renal transplant recipients undergoing immunosuppression with cyclosporine. Clin Infect Dis 1993;16:505-12.|
|3||Ruiz LM, Montejo M, Benito JR, et al. Simultaneous pulmonary infection by Nocardia asteroides and Pneumocystis carinii in a renal transplant patient. Nephrol Dial Transplant 1996;11:711-4.|
|4||Pourmand G, Jazaeri SA, Mehrsai A, Kalhori S, Afshar K. Nocardiosis: report of four cases in renal transplant recipients. Transplant Proc 1995;27:2731-3.|
|5||Mamelak AN, Obana WG, Flaherty JF, Rosenblum ML. Nocardial brain abscess: treatment strategies and factors influencing outcome. Neurosurgery 1994;354:622-31.|
|6||Smego RA Jr, Moeller MB, Gallis HA. Trimethoprim-Sulfamethoxazole therapy for Nocardia infections. Arch Intern Med 1983; 143:711-8.|
|7||McNeil MM, Brown JM, Magruder CH, et al. Disseminated Nocardia transvalensis infection: an unusual opportunistic pathogen in severely immunocompromised patients. J Infect Dis 1992;165:175-8.|
|8||Velasco N, Farrington K, Greenwood R, Rahman AF. Atypical presentation of systematic nocardiosis and successful treatment with meropenem. Nephrol Dial Transplant 1996;11:709-10.|
|9||Tolkoff-Rubin NE, Rubin RH. Chronologies des infections et infections virales chez les transplantes d'organes: une vue d'ensemble. in "Transplantation d'organes et greffe de tissus" 1994:443-458.|
|10||Chapman SW, Wilson JP. Nocardiosis in transplant recipients. Semin Respir Infect 1990;5(1):74-9.|
|11||Curry WA. Human Nocardiosis. A clinical review with selected case reports. Arch Intern Med 1980;140:818-26.|
|12||Miksits K, Stoltenburg G, Neumayer HH, et al. Disseminated infection of the central nervous system caused by Nocardia farcinica. Nephrol Dial Transplant 1991;6:209-14.|