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J Thorac Cardiovasc Surg 1995;109:181-183
© 1995 Mosby, Inc.
BRIEF COMMUNICATIONS |
Berlin, Germany
From the German Heart Institute Berlin, Department of Thoracic and Cardiovascular Surgery, Berlin, Germany.
Nocardia is known to cause severe infection, especially in immunocompromized patients with malignant disease, viral immunodeficiency syndrome, or in those patients receiving immunosuppressive therapy.
1 To our knowledge, a total of 47 cases of nocardiosis in cardiac transplant recipients have been published, 2 but this is the first case of primary cutaneous infection caused by Nocardia farcinica in a transplant recipient, without dissemination of the infection and without pulmonary or cerebral affection.
In May 1992, a 57-year-old male patient underwent orthotopic cardiac transplantation because of end-stage ischemic heart disease. Revascularization operations had already been performed in 1977 and 1988. The treatment regimen consisted of triple drug immunosuppression with initial induction therapy with rabbit antithymocyte globulin 100 mg for 3 days. The intraoperative and perioperative course was uneventful, and the rehabilitation program was performed as usual. No rejection episodes had to be controlled.
Seven weeks after transplantation, the patient began having a backache. Computed tomography (CT) of the spine showed typical signs of severe osteoporosis and osteoporotic fractures of the eighth and eleventh thoracic vertebrae. Treatment was started with conservative drug therapy and a corset. One month later at home, low back pain increased again and an emergency physician started analgesic treatment by intramuscular injection of nonsteroidal antiphlogistics. Radiologic reinvestigation showed beginning osteoporotic fracture of the tenth thoracic vertebra. Three weeks later, swelling, tenderness, and increasing pain developed in the left groin and thigh, and the man was admitted to his local hospital because of high fever, chills, malaise, and a swollen left thigh. A CT scan revealed a circumscript hypodense intramuscular mass medial above the left knee, reaching the left groin (Fig. 1). Physical examination on admission was unremarkableexcept for the left thigh, which showed erythema with tenderness and severe pain from the hip to the knee. No abnormality could be detected neurologically or on the chest roentgenogram. Sonographic controlled puncture of the liquid mass revealed pus. A migrating abscess caused by an intramuscular injection was assumed. Antibiotic therapy was started immediately with ampicillin/sulbactam 4.5 gm/day and gentamicin 240 mg/day. Subsequently, the patient was transferred to our hospital.
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Superficial division of the abscess was performed immediately. The fever disappeared, but swelling, erythema, and tenderness did not resolve. Eight days later, the patient had a convulsion with subsequent apnea. He was resuscitated successfully and imipenem treatment was stopped for 2 days, because imipenem was thought to be the cause of the convulsion, possibly as a result of the diminished excretion by the kidney (creatinine level increased to 1.97 mg/dl). After reduction of antibiotic therapy to imipenem 1.5 gm/day and amikacin 300 mg/day, swelling, tenderness, and pain in the left thigh increased again, and the fever recurred. Another CT scan of the left thigh showed multiple abscesses mainly involving the flexor muscles. Additionally, serum creatinine levels rose to 3.4 mg/dl and the patient had hypoacusis and diplopia, which are typical signs of intoxication with amikacin. Antibiotic therapy was stopped for 2 days and continued thereafter with lowered dosages of imipenem 1 gm/day and amikacin 100 mg/day. Three days later, a second operation was performed. Excessive abscess dissection, wound debridement, and installation of a lavage-suction drainage were done. Intraoperatively, disseminated abscesses partially infiltrating the flexor muscles were detected.
The patient's condition improved dramatically during the next 3 weeks. Double drug antibiotic treatment was continued for a further month, and the patient was discharged on November 19, 1992, shortly after the antibiotic treatment had been changed to oral doxycycline monotherapy (100 mg/day). This was continued for another 3 months. A follow-up CT scan at time of discharge still revealed disseminated fluid accumulation in the left thigh. CT studies performed once a month after discharge showed slow regression of these structures. Three months later no abnormality could be revealed by CT scan. No recurrence of the infection has yet been seen.
Primary cutaneous disease is rare but may occur as a result of iatrogenic or traumatic inoculation because of the organism's wide resistance, especially to disinfectants, such as alcohol. Because no signs of pulmonary or cerebral manifestation of Nocardia infection could be detected, an iatrogenic cause due to intramuscular application of analgesics is the most probable source of this Nocardia infection. Silent infection of the saphenoctomy wound where the bypass operation was performed some years earlier, with late reactivation of Nocardia because of aggressive immunosuppression, can be discussed but does not seem likely.
Because a high lethality for nocardiosis (40% to 80%)has been described, 3 prompt and effective surgical and drug therapy is essential.
Footnotes
J THORAC CARDIOVASC SURG 1995;109;181-3 
References
This article has been cited by other articles:
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  F. D. Knollmann, M. Hummel, R. Hetzer, and R. Felix CT of Heart Transplant Recipients: Spectrum of Disease RadioGraphics, November 1, 2000; 20(6): 1637 - 1648. [Abstract] [Full Text] [PDF]
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