A 52-year-old man comes to the emergency department with fevers, cough, and headache. The headache has worsened over the last week with localization to the right side and is associated with nausea. Yesterday he noted left-hand weakness and difficulty grasping objects. He has no history of travel outside of the northeastern United States or exposure to domestic animals or sick contacts. The patient underwent liver transplantation for primary biliary cirrhosis 8 months ago and had an uneventful postoperative course. His medications include prednisone and tacrolimus. His preoperative tuberculin skin testing was negative and he has had no postoperative infections. He is physically active and had walked 2-3 miles a day until 1 week ago.
His temperature is 38.2 C (100.8 F), blood pressure is 124/84 mm Hg, pulse is 96/min, and respirations are 18/min. Crackles are present over the right upper lung field. There are no heart murmurs. The abdomen is soft without organomegaly. There are no skin rashes. Neurological examination is notable for left-hand weakness and decreased sensation of the left hand and forearm.
Chest x-ray reveals patchy alveolar opacities in the right upper lobe and a 3-cm abscess in the right middle lobe. Head CT scan shows an abscess in the right cerebral hemisphere. A transesophageal echocardiogram reveals no vegetations.
Which of the following conditions is most consistent with this patient's clinical presentation?

Question

A 52-year-old man comes to the emergency department with fevers, cough, and headache.  The headache has worsened over the last week with localization to the right side and is associated with nausea.  Yesterday he noted left-hand weakness and difficulty grasping objects.  He has no history of travel outside of the northeastern United States or exposure to domestic animals or sick contacts.  The patient underwent liver transplantation for primary biliary cirrhosis 8 months ago and had an uneventful postoperative course.  His medications include prednisone and tacrolimus.  His preoperative tuberculin skin testing was negative and he has had no postoperative infections.  He is physically active and had walked 2-3 miles a day until 1 week ago.
His temperature is 38.2 C (100.8 F), blood pressure is 124/84 mm Hg, pulse is 96/min, and respirations are 18/min.  Crackles are present over the right upper lung field.  There are no heart murmurs.  The abdomen is soft without organomegaly.  There are no skin rashes.  Neurological examination is notable for left-hand weakness and decreased sensation of the left hand and forearm.
Chest x-ray reveals patchy alveolar opacities in the right upper lobe and a 3-cm abscess in the right middle lobe.  Head CT scan shows an abscess in the right cerebral hemisphere.  A transesophageal echocardiogram reveals no vegetations.
Which of the following conditions is most consistent with this patient's clinical presentation?

Quizplus · Accepted Answer

11ec193a_9642_cb20_853d_7fb45f97d017_MD0002_00 This patient with lung and CNS disease after organ transplantation has likely nocardiosis. Nocardia is found in the soil and can enter the body through inhalation or direct contact with soil. Because it is not part of normal human flora, isolation of the organism from any bodily fluids (eg, sputum) is considered an infection. Patients usually present with lung (primary site) infection. Nocardia has special tropism to neural tissue, and usually manifests as brain abscess. Immunocompromised patients presenting with pulmonary nocardiosis should therefore undergo brain imaging to rule out abscess. Diagnosis of nocardiosis is made clinically with symptoms and partially acid-fast, branching rods isolated in specimens. Aerobic cultures for Nocardia can take 5-20 days for growth. PCR testing for Nocardia is more rapid and accurate but is not widely available. Nonsevere cutaneous nocardiosis can be treated with oral antibiotics (eg, TMP-SMX); systemic disease requires IV antibiotics. Patients usually require antibiotics for prolonged periods due to the relapsing nature of the infection. Immunocompromised patients may require lifelong suppressive therapy with TMP-SMX or doxycycline. (Choice A) In contrast to Nocardia, Actinomyces is an anaerobic Gram-positive rod that is part of normal oral flora and contains sulfur granules. Actinomyces most commonly affects the face (usually after dental work/infections or oromaxillary trauma) and abdominal organs. CNS and pulmonary actinomycosis are less common. (Choice B) Atypical mycobacterial infections usually present with chronic pulmonary symptoms or soft-tissue infections but rarely become disseminated or involve the CNS. (Choice D) This patient's absence of known predisposing factors and vegetations on TEE makes endocarditis less likely. (Choice E) Toxoplasma gondii most commonly affects the CNS (95%) and rarely affects the lungs. Most infections occur due to reactivation of latent infection. CT usually shows multiple ring-enhancing brain lesions with surrounding edema, most commonly in the basal ganglia. Educational objective: Nocardia is commonly seen in immunocompromised patients and typically involves the lung, brain, and skin. Diagnosis is made clinically and confirmed with culture isolating acid-fast, filamentous Gram-positive rods. Treatment involves TMP-SMX, imipenem, amikacin, or third-generation cephalosporins. __________ References: Nocardiosis: updated clinical review and experience at a tertiary center. (http://www.ncbi.nlm.nih.gov/pubmed/20306281) Nocardiosis: updates and clinical overview. (http://www.ncbi.nlm.nih.gov/pubmed/22469352)

A 52-Year-Old Man Comes to the Emergency Department with Fevers