Nocardiosis as an unexpected complication of end-stage, untreated HIV disease

Abstract number: 1734_208

Manfredi R.

Introduction: AIDS presenters are increasing worldwide, due to HIV infection lasting undiagnosed-neglected for many years.

Case report: A 43-year-old drug-alcohol abuser was recently diagnosed with HBV-alcohol-related liver cirrhosis, and an advanced, untreated HIV infection with a CD4+ count of 14 cells/mL, and an initial AIDS-dementia complex. Hospitalised owing to >15% weight loss, fever, cough with blood emission, and multiple pulmonary infiltrates, when undergoing a HRCT a consolidated 4–5 diameter lesion involving the apical-dorsal left upper lung lobe was accompanied by multiple subpleuric lesion, with excavations at right lower lobe. Either tubercular, bacterial, other opportunistic infections, or a malignancy, were suspected. While waiting for microscopy, cytology, and culture examinations of respiratory secretions-BAL, based on blood cultures which yelded a multi-sensitive S. epidermidis strain, a broad-spectrum therapy including cefazolin, and later cefriaxone and fluconazole was attempted. After the microscopic-culture isolation of Nocardia asteroides (testing susceptible in vitro to co-amoxiclav, chloraphenicol, cotrimoxazole and gentamycin), treatment was adjusted to include cotrimoxazole, and a triple HAART was conducted for 12 days, until an overwhelming anaemia-leukopenia needed RBC transfusion and G-CSF administration, followed by a modified antimicrobial therapy (imipenen-amikacin), in the suspect of cotrimoxazole intolerance. A slowly progressive clinical ameliorement occurred, as confirmed by repeated X-ray-HRCT controls, associated with a partial immune recovery obtained thanks to HAART.

Discussion: In patients with recently diagnosed HIV disease and a deep immunodeficiency, the differential diagnosis of multiple pulmonary infiltrates with tendency to excavation includes tuberculosis-atypical mycobacteriosis, but also bacterial infection and malignancies. In our case, the diagnostic difficulties were complicated by the emerging of cotrimoxazole intolerance which prompted to a severe anaemia-leukopenia, so that a second-line therapy for nocardiosis was performed favourably. Notwithstanding Nocardia spp. infects immunosuppressed hosts, however nocardiosis remains very infrequent in advanced HIV disease, when only sparse pulmonary, cerebral and skin localisations were anecdotally reported. Our case underlines that opportunism may go beyond the most usual disorders, and its treatment may be conducted effectively with second-choice agents.

Session Details

Date: 31/03/2007
Time: 00:00-00:00
Session name: European Society of Clinical Microbiology and Infectious Diseases
Location: ICC, Munich, Germany
Presentation type:
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