It never rains but pours: disseminated nocardiosis in a renal transplant patient from Nigeria - a case report.

backgroundNocardiosis is a rare opportunistic infection with high mortality and a tendency to relapse. The causative Nocardia spp. are filamentous Gram-positive aerobic bacteria. The lungs and brain are commonly affected and bacteraemia is rare, occurring in < 8% of cases. Solid organ transplant recipients receiving steroid immunosuppression are particularly at risk. The mainstay of treatment is prolonged antibiotic combination therapy, typically including trimethoprim-sulfamethoxazole. CASE PRESENTATION: We present the case of a renal transplant recipient from Nigeria with disseminated Nocardia cyriacigeorgica infection with lung and brain abscesses and, unusually, bacteraemia. Most recommended antibiotic regimens were precluded by severe deterioration of graft function and anaemia whilst being unable to receive blood products due to religious beliefs. He was initially treated with intravenous ceftriaxone 2g twice a day and meropenem 1g twice a day before commencing continuation therapy with oral minocycline 100mg twice a day. Despite resolution of the acute cavitating complications of Nocardia infection with antibiotic therapy and controlled reduction of immunosuppression, graft function continued to deteriorate. Serum BK viral load was found to be very high at 6.40 × 107 copies/mL, prompting a graft biopsy which showed BK virus nephropathy with severe inflammation. The patient later recalled he had received pulsed methylprednisolone prior to travel for presumptive rejection.

conclusionsTo the best of our knowledge, this is the first time concomitant BK virus nephropathy and Nocardia cyriacigeorgica bacteraemia have been described in the literature. The presence of bloodstream infection amenable to culture significantly aided in the diagnosis of nocardiosis and therefore in the prompt initiation of treatment. In our patient’s case, intravenous meropenem and ceftriaxone then oral minocycline were effective in the treatment of disseminated Nocardia cyriacigeorgica with lung and cerebral abscesses. The rarity of bloodstream nocardiosis alongside florid BK virus nephropathy demonstrated clear overimmunosuppression and the importance of a ‘for cause’ graft biopsy before immunosuppression escalation. Whilst rare, the significant associated mortality makes nocardiosis an important differential to consider in transplant recipients with unexplained fever. Furthermore, as access to transplantation increases globally, access to quality post-transplant care must too. CLINICAL TRIAL NUMBER: Not applicable.