Fatal Pulmonary Nocardiosis in a Steroid‐Dependent Patient: The Role of Hypercortisolemia and Reduced Infection Clearance

Case Presentation:

A 62‐year‐old man was admitted for fever, dyspnea, cough, and hemoptysis for the past 4 months. His past medical history was notable for chronic lymphocytic leukemia and COPD (controlled with oral steroids). He was a longtime smoker. Travel and other social history were unremarkable. The history of the present illness starred 4 months earlier, when he began experiencing respiratory symptoms. After multiple courses of antibiotics and increasing doses of oral steroids with no improvement of his symptoms, a chest CT was done 1 week prior, which revealed multiple pulmonary nodules. A PET scan demonstrated a 4.5 × 3.7 cm right upper lobe lung mass with internal cavitation and increased FDG uptake. He then underwent bronchoscopy, with cultures and biopsies taken, and was subsequently admitted to the hospital. In The hospital, the patient remained febrile. Physical exam demonstrated bilateral wheezing and scattered rhonchi. Interim labs were notable for uncontrolled glucose and a WBC count of 37.5 × 10³ cells/mm³ (57% lymphocytes). Chest radiograph showed right midlung opacification. Blood cultures were drawn, arid the patient was started on broad‐spectrum antibiotics and intravenous corticosteroids. Transbronchial biopsy of the lung mass showed extensive necrotic tissue with clusters of filamentous, gram‐positive bacteria. Gomori methamine silver staining of lung tissue revealed filamentous bacteria that subsequent cultures grew Nocardia asteroides. He was started on intravenous TMP‐SMX. Head CT was negative for CNS nocardiosis. Over the next several weeks, he became afebrile, but his cough persisted. After 24 days of hospitalization, he was discharged on high doses of oral TMP‐SMX and prednisone. He returned 10 days later with worsening dyspnea, cough, fever, and lethargy. Vitals on readmission were notable for temperature of 101.3°F, respirations 28 breaths/minute, pulse of 150/minute, and oxygen saturation 83%. Physical exam revealed diffuse bilateral rhonchi, decreased breath sounds, and accessory muscle use. Chest x‐ray revealed new bilateral pulmonary consolidations. He was intubated for airway protection and was started on broad‐spectrum antimicrobials. Despite aggressive intervenlions, the patient died. Autopsy was declined.

Discussion:

Nocardiosis is an infrequent but severe infection; particularly lethal in immunosuppressed patients. Our patient was on steroids as an outpatient for COPD and received parenteral corticosteroids while in the hospital. Steroids and the ensuing hypercortisolemia can predispose a patient to infection by impairment of the immune response. Glucocorticoids have been shown to impair neutrophil adherence and decrease degranulation, thereby reducing effective infection clearance.

Conclusions:

In patients receiving pharmacological treatment with glucocorticoids, every effort should be made to use the lowest effective dose for the shortest period of time in order to limit the immunosuppression and predisposition to opportunistic infections.

Author Disclosure:

A. Kushawaha, Staten Island University Hospital, resident; H. Rizvi, Staten Island University Hospital, resident; N. Mobarakai, Staten Island University Hospital, attending physician.