Unveiling the Complexity of Nocardia Septic Arthritis in an Immunocompromised Patient: A Case Report.

HCA healthcare journal of medicine Pub Date : 2024-08-01 eCollection Date: 2024-01-01 DOI:10.36518/2689-0216.1694
Steven A Kessler, Meghan R Mansour, Ali Khreisat, Mamon Tahhan
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Abstract

Background: Nocardiosis is the systemic manifestation of Nocardia infection, often found in immunocompromised individuals. Nocardia are transmitted via inhalation or skin wounds, disseminating hematogenously to organs and rarely, joints. We present a patient with immunosuppression who developed gout of the knee with superimposed Nocardial septic arthritis and a possible subsequent systemic infection.

Case presentation: A 74-year-old man presented with left lower extremity swelling and pain. He was taking immunosuppressive medication for antineutrophilic cytoplasmic antibody-positive vasculitis. A week prior, an arthrocentesis test was positive for gout. He received prednisone without improvement. A repeat arthrocentesis was positive for Nocardia farcinica septic arthritis. Chest imaging showed subpleural nodules. After failed antibiotics, a susceptibilities test yielded results that favored linezolid. The patient exhibited acute anemia from hematomas intramuscularly above the infection, which resolved with transfusions. Immunosuppression was stopped, and the patient recovered appropriately after the correct antibiotics were administered.

Conclusion: This case involves septic arthritis with possible pulmonary nodule involvement, showcasing the complexity of infections in immunocompromised individuals. Clinicians should maintain adequate suspicion for an infectious cause of arthritis in patients with immunosuppression. In our case, the hematomas are a curious finding, without known etiology. The question of when and how to reintroduce immunosuppressive agents while preventing the recurrence of nocardiosis remains a complex consideration.

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揭示免疫力低下患者诺卡菌化脓性关节炎的复杂性:病例报告。
背景:诺卡氏杆菌病是诺卡氏杆菌感染的全身表现,通常出现在免疫力低下的人群中。诺卡氏菌通过吸入或皮肤伤口传播,经血行播散到器官,很少传播到关节。我们为您介绍一位患有免疫抑制的患者,他的膝关节痛风伴有叠加的诺卡菌化脓性关节炎,随后可能出现全身感染:一名 74 岁的男子因左下肢肿胀和疼痛前来就诊。他正在服用免疫抑制剂治疗抗中性粒细胞胞浆抗体阳性的血管炎。一周前,关节穿刺检查结果呈痛风阳性。他接受了泼尼松治疗,但没有好转。再次进行关节穿刺检查,结果显示远志诺卡氏菌败血症性关节炎阳性。胸部成像显示胸膜下有结节。抗生素治疗失败后,药敏试验结果显示利奈唑胺有效。患者因感染部位上方肌肉内血肿而出现急性贫血,输血后症状缓解。在使用正确的抗生素后,患者恢复良好:本病例涉及脓毒性关节炎,并可能累及肺结节,显示了免疫功能低下患者感染的复杂性。临床医生应充分怀疑免疫抑制患者关节炎的感染原因。在我们的病例中,血肿是一个奇怪的发现,病因不明。在预防诺卡菌病复发的同时,何时以及如何重新使用免疫抑制剂仍是一个复杂的问题。
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