Neck pain, dysphagia and fevers in an immunocompromised patient: A case of Nocardia
AAPA ePoster library. Schreck D. 05/17/17; 180526; 175
Daniel Schreck
Daniel Schreck
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Abstract
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Introduction The differential diagnosis for patients with fever and neck pain is vast. An immunocompromised patient makes the diagnosis even more difficult with infection likely high on the differential. Nocardiosis is a rare gram-positive organism that can affect almost every system in the body and should be considered in immunocompromised patients with fevers. Case Presentation Mr. T is a 65-year-old male with end-stage renal disease secondary to diabetes mellitus s/p renal transplant approximately one year ago and coccidiomycosis on fluconazole, who presented to the emergency room with fevers and a one month history of head and neck pain. Two weeks prior he had been hospitalized with E. coli bacteremia in the setting of transplant pyelonephritis. During that hospitalization, he reported a headache and neck pain. A CT scan of his head and neck were unremarkable, and he was treated with tramadol and cyclobenzaprine, which provided minimal relief. In the ER, Mr. T. reported fevers and continued head and neck pain. Additionally, he had developed dysphagia. His review of systems was otherwise unremarkable, and his vital signs were stable. Mr. T's physical exam was only significant for right-sided cervical paraspinous muscle tenderness. Laboratory studies revealed a mild chronic anemia, leukocytosis, and a mildly elevated ESR. An infectious work up included a urinalysis, chest x-ray, and lumbar puncture, which were unremarkable. Blood cultures were obtained. A CT of the head was without acute intracranial abnormalities. A MRI of his cervical spine showed extensive prevertebral and paraspinous inflammatory changes consistent with cellulitis/myositis. Mr. T was empirically started on piperacillin and tazobactam sodium, as there was a question if his MRI findings were related to his recent E. coli bacteremia. At 60 hours, his blood cultures grew gram positive cocci, resembling Nocardia, and his piperacillin and tazobactam sodium was changed to meropenem and trimethoprim-sulfamethoxazole. Mr. T underwent further imaging to rule out disseminated Nocardia. MRI of his brain was negative for lesions, and MRI of his face and neck revealed persistent prevertebral and paravertebral soft tissue swelling with new findings of multiple areas of abscess formation. CT of the chest showed clustered nodularity in the right upper lobe with a new nodule in the left upper lobe. Due to progression of his disease, linezolid was added. Final blood cultures grew N...
Introduction The differential diagnosis for patients with fever and neck pain is vast. An immunocompromised patient makes the diagnosis even more difficult with infection likely high on the differential. Nocardiosis is a rare gram-positive organism that can affect almost every system in the body and should be considered in immunocompromised patients with fevers. Case Presentation Mr. T is a 65-year-old male with end-stage renal disease secondary to diabetes mellitus s/p renal transplant approximately one year ago and coccidiomycosis on fluconazole, who presented to the emergency room with fevers and a one month history of head and neck pain. Two weeks prior he had been hospitalized with E. coli bacteremia in the setting of transplant pyelonephritis. During that hospitalization, he reported a headache and neck pain. A CT scan of his head and neck were unremarkable, and he was treated with tramadol and cyclobenzaprine, which provided minimal relief. In the ER, Mr. T. reported fevers and continued head and neck pain. Additionally, he had developed dysphagia. His review of systems was otherwise unremarkable, and his vital signs were stable. Mr. T's physical exam was only significant for right-sided cervical paraspinous muscle tenderness. Laboratory studies revealed a mild chronic anemia, leukocytosis, and a mildly elevated ESR. An infectious work up included a urinalysis, chest x-ray, and lumbar puncture, which were unremarkable. Blood cultures were obtained. A CT of the head was without acute intracranial abnormalities. A MRI of his cervical spine showed extensive prevertebral and paraspinous inflammatory changes consistent with cellulitis/myositis. Mr. T was empirically started on piperacillin and tazobactam sodium, as there was a question if his MRI findings were related to his recent E. coli bacteremia. At 60 hours, his blood cultures grew gram positive cocci, resembling Nocardia, and his piperacillin and tazobactam sodium was changed to meropenem and trimethoprim-sulfamethoxazole. Mr. T underwent further imaging to rule out disseminated Nocardia. MRI of his brain was negative for lesions, and MRI of his face and neck revealed persistent prevertebral and paravertebral soft tissue swelling with new findings of multiple areas of abscess formation. CT of the chest showed clustered nodularity in the right upper lobe with a new nodule in the left upper lobe. Due to progression of his disease, linezolid was added. Final blood cultures grew N...
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