|Year : 2014 | Volume
| Issue : 1 | Page : 53-55
Disseminated norcardial infection in a patient with myasthenia gravis on prolonged steroid therapy: A case report
Farouq M Dayyab1, Tiamiyu B Abdulwasi'u1, Edwin P Chinagozi2, Garba Iliyasu3, Habib G Abdulrazaq3, Ibrahim Nashabaru3, Muhammad Hamza3, Mahmoud Dalhat1, Sirajo Halliru1, Habib G Zaiyad1
1 Infectious Diseases Unit, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Microbiology, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Infectious and Tropical Diseases Unit, Bayero University Kano, Kano, Nigeria
|Date of Submission||24-Jul-2013|
|Date of Acceptance||29-Oct-2013|
|Date of Web Publication||24-Mar-2014|
Infectious and Tropical Diseases Unit, Bayero University Kano, Kano
This article presents the clinical manifestation of Norcardial infection in the setting of iatrogenic immunosuppression. The patient suffered from myasthenia gravis for which he received a prolonged course of high dose steroid. At the time of presentation he had lesions in the brain, lungs, and soft tissue consistent with Norcardial infection. He developed disseminated intravascular coagulopathy (DIC) and acute kidney injury (AKI) and died on the 12 th day in intensive care unit (ICU).
Keywords: Myasthenia gravis, Norcardia, steroid therapy
|How to cite this article:|
Dayyab FM, Abdulwasi'u TB, Chinagozi EP, Iliyasu G, Abdulrazaq HG, Nashabaru I, Hamza M, Dalhat M, Halliru S, Zaiyad HG. Disseminated norcardial infection in a patient with myasthenia gravis on prolonged steroid therapy: A case report. Sub-Saharan Afr J Med 2014;1:53-5
|How to cite this URL:|
Dayyab FM, Abdulwasi'u TB, Chinagozi EP, Iliyasu G, Abdulrazaq HG, Nashabaru I, Hamza M, Dalhat M, Halliru S, Zaiyad HG. Disseminated norcardial infection in a patient with myasthenia gravis on prolonged steroid therapy: A case report. Sub-Saharan Afr J Med [serial online] 2014 [cited 2020 Aug 11];1:53-5. Available from: http://www.ssajm.org/text.asp?2014/1/1/53/129322
| Introduction|| |
Nocardiosis is an uncommon gram positive bacterial infection characterized by the ability to cause localized or systemic suppurative disease in humans and animals. , It is caused by aerobic actinomycetes of the genus Nocardia. Although nocardiosis is regarded as an opportunistic infection, approximately one-third of infected patients are immunocompetent.  Nocardiosis has the ability to disseminate to virtually any organ, particularly the central nervous system. It also has the tendency to relapse or progress despite appropriate antimicrobial therapy. Protective immune response are primarily T cell mediated immunity (CMI), hence deficient CMI as in prolonged steroid use is a major risk factor.
| Case Report|| |
A 48-year-old primary school teacher known to have myasthenia gravis; who has been on treatment with pyridostigmine 180 mg daily in three divided doses and prednisolone 60 mg daily for 4 months, presented with 3 weeks history of localized soft tissue swellings in the left elbow and right infraclavicular area [Figure 1]A and B] and a 1 day history of pyrexia and loss of consciousness. No history of cough, no significant weight loss and no contact with a patient with chronic cough. No history of consumption of unpasteurized milk. He does not smoke cigarette and does not ingest alcoholic beverages. Physical examination revealed a Glasgow coma score of 8/15 with no focal neurologic deficit. Pulse rate was 136 beats/min, blood pressure 100/60 mmHg, respiratory rate 28 cycles/min, and temperature was 39.3°C. He had soft tissue swelling on the left elbow and right infraclavicular area aspiration of which yielded pus. Chest examination revealed crackles on both lower zones with oxygen saturation of 85% on room air. Total white cell count was 33,000 ΄ 10 9 with 88% neutrophils. He also had a platelet count of 68,000, hematocrit of 22.3%, total serum protein of 39 g/dl with 17 g/dl of albumin, alkaline phosphatase was 43 U/l, aspartate aminotransferase was 27 U/l, and alanine aminotransferase was 11 U/l. Human immunodeficiency virus (HIV) screening was negative. Initial serum electrolytes and urea revealed; urea of 8.9 mmol/l, creatinine of 58 mmol/l, sodium of 140 mmol/l, potassium of 4.6 mmol/l, and HCO 3 of 23 mmol/l. Pus aspirate microscopy showed gram positive branching rods with beaded appearance [Figure 2]A, subcultured sample yielded a weakly positive acid fast bacilli on modified Ziehl-Neelsen (ZN) stain suggestive of Norcadia spp [Figure 2]B. Chest X-ray showed multiple fluffy opacities in keeping with abscess [Figure 1]D. Brain computerized tomographic scan revealed multiple abscess with early capsule formation [Figure 1[C. He was admitted into the intensive care unit (ICU) and ventilated. He was treated with cotrimoxazole and levofloxacin based on the antibiotic sensitivity pattern, but died on the 12 th day of ICU admission from disseminated intravascular coagulopathy (DIC) and acute kidney injury (AKI).
|Figure 1: (a) and (b) show soft swelling involving the right infraclavicular region and elbow (c) shows CT scan of the brain shows multiple abscesses and (d) shows multiple lesions in the left lung fields|
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|Figure 2: (a) shows Gram positive branching rods with beaded appearance while (b) shows weakly positive acid and alcohol fast bacilli on modified Zeihl-Neelsen stain|
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| Discussion|| |
Nocardia spp is a ubiquitous gram positive branching rod present in the soil, dust, and stagnant water. It can cause acute, subacute, and chronic infections that are acquired mainly by inhalation,  and has tendency of exacerbations and remissions.  Norcardia spp has predilection for hosts who are deficient in cell-mediated immunity, have structural lung disease, especially chronic obstructive pulmonary disease (COPD), posttransplant patients, or have history of trauma 3 . In a large case series, about 94% of risk factors established in patients with nocardiosis are mostly the use of corticosteroid and immunosuppressant therapy. 
Our patient had a clinical presentation very suggestive of disseminated nocardiosis. The need for an invasive diagnostic procedure could be challenging or may not be feasible especially for those with brain lesion in the absence of extraneural focus. In our case, abscess aspirated from the skin provided the diagnosis of Norcadia. We are not aware of any known guideline specific for the treatment of Norcadia. Most treatment recommendations are based on animal models, basic research, case reports, and expert's opinions.  Disseminated Norcadia is usually treated with either imipenem or ceftriazone plus trimethoprim-sulfamethoxazole (TMP-SMX) and amikacin for at least 1 year for nervous system involvement and according to clinical and radiological improvements.  Similar regimen was used in our case except for levofloxacin which was used in lieu of amikacin based on the aspirate sensitivity pattern and because of nephrotoxicity in view of the preexisting AKI and lack of facility to monitor serum level. Mortality of pulmonary norcadiosis is as high as 38.7%.  In disseminated disease, the mortality rate may reach 64%, and up to 100% in cases with CNS involvement. 
In conclusion, nocardia presentation is protean and a high index of suspicion is required especially in predisposed individuals. Furthermore, CNS involvement should always be ruled out emergently in all cases of nocardiosis, because of its attendant high mortality. To the best of our knowledge, no relationship between Norcardia infection and myasthenia gravis was reported in the literature.
| Acknowledgement|| |
The entire staff of Intensive care unit, Record department, and Department of Medicine, Aminu Kano Teaching Hospital.
| References|| |
|1.||Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ Jr. Clinical and laboratory features of the Nocardia spp. Based on current molecular taxonomy. Clin Mircobiol Rev 2006;19:259. |
|2.||Beaman BL, Beaman L. Nocardia species: Host-parasite relationships. Clin Microbiol Rev 1994; 7:213. |
|3.||Martnez Tomas R, Menedez Villanueva R, Reyes Calzada S, Santos Durantez M, Vallés Tarazona JM, Modesto Alapont M, et al. Pulmonary norcadiosis: Risk factors and outcomes. Respirology 2007;12:394-400. |
|4.||El-Herte RI, Kanj SS, Araj GF, Chami H, Gharzuddine W. First Report of Nocardia asiatica Presenting as an Anterior Mediastinal Mass in a Patient with Myasthenia Gravis: A Case Report and Review of the Literature. Case Rep Infect Dis 2012;2012:325767. |
|5.||Ambrosioni J, Lew D, Garbino J. "Norcadiosis: Updated clinical review and experience at a tertiary center". Infection 2010;38:89-97. |
[Figure 1], [Figure 2]