VATS-visualisatie van een ernstige pulmonale infectie met Nocardia nova resistent tegen trimethoprim-sulfamethoxazol

Abstract

Severe pulmonary Nocardia nova infection in a kidney transplant patient This article describes the disease course of a severe Nocardia nova infection in a patient with an underlying immunodeficiency due to a kidney transplantation, with the visualisation of Nocardia colonies in the pleural cavity through video-assisted thoracoscopic surgery. The patient was hospitalised in the emergency department with acute respiratory symptoms and respiratory failure. A CT scan of the chest revealed a massive unilateral pleural effusion with complete compressive atelectasis of the left lung. Video-assisted thoracoscopic surgery revealed bloody pleural effusion and white, nodular, pleural structures. Cultures of the biopsies grew N. nova. The empiric antibiotic treatment was switched to a combination therapy with trimethoprim-sulfamethoxazole, meropenem and a single dose of amikacin. Sensitivity testing revealed a strain of N. nova resistant to trimethoprim-sulfamethoxazole. The antibiotics were thereupon switched to linezolid and meropenem. Unfortunately, the patient died due to a refractory septic shock with multi-organ failure. Infections due to the Nocardia genus are rare and usually occur in patients with underlying immunodeficiencies. Pulmonary disease is the most frequent presentation and pleural effusion is common. Disseminated disease with central nervous system and skin involvement is also frequent. A correct microbiological diagnosis, species identification and sensitivity testing are of utmost importance because of the high intra- and interspecies differences. The strain isolated in this case had an unexpected resistance to trimethoprim-sulfamethoxazole, which is considered to be the cornerstone treatment of a Nocardia infection.