UPMC Dermatopathology "Case of the Month" Presentations
UPP - Department of Dermatology, Dermatopathology Unit
Lori Spencer, MD, PhD, Rana Rofagha, MD, Sourav Ray, MD, Jonhan Ho, MD, and Drazen Jukic, MD, PhD
JANUARY 2007 CASE OF THE MONTH
CLINICAL FINDINGS
We were consulted for skin lesions on a 70 year old Caucasian male with history of dilated cardiomyopathy status post orthotopic heart transplant four months earlier. His post-transplant course had been complicated by a Pseudomonal UTI and CMV antigenemia. His immunosuppressive medications at the time of our assessment included CellCept, tacrolimus, and prednisone. The reason for his admission had been diarrhea with weakness and dehydration.
The patient was an elderly, pleasant male, appearing chronically ill but otherwise in no acute distress. Vital signs were stable and temperature was 99.8 degrees. On exam, several 2-3mm pustules were noted on the left lower extremity (Fig 1). There were two erythematous papules with hemorrhagic crusts on the right upper arm (Fig 2). A larger pustule was present on the left medial thigh just superior to the knee. This lesion was chosen for biopsy, both for H&E and for tissue culture (Fig 3). His right knee had an appreciable effusion but range of motion was full.
As per recommendations by ID, patient was initially started on triple therapy with Bactrim, Linezolid, and imipenem for three weeks. Final sensitivities showed that the isolate was sensitive to both Bactrim and Linezolid but was resistant to imipenem (which was discontinued). The pt was discharged to home with plans to continue Bactrim for one year. Repeat CT and MRI studies showed appropriate response to the antibiotic. He was subsequently re-admitted with acute-on-chronic renal failure (thought to be due to the Bactrim) and allograft rejection, manifested as decrease in left ventricular function. He is followed by the transplant service, and his cardiac function parameters continue to improve.
The right knee effusion was tapped by Rheumatology, and synovial fluid also grew Nocardia brasiliensis. Disseminated infection was suspected, given the patient’s immunocompromised status, and further studies were undertaken. Daily chest films showed an ill-defined left lower lobe infiltrate. Chest CT confirmed subsegmental mass-like consolidation in the left lower lobe and several bilateral pulmonary nodules, felt be to consistent with fungal infection. MRI showed multiple, small, bilateral cerebellar and cerebral foci of abnormal ring enhancement, largely at gray-white junctions, findings which were compatible with disseminated nocardiosis.
On H&E stain, follicle-based abscess formation was observed. The infiltrate was predominantly neutrophilic. There were numerous filamentous Gram positive and GMS positive microorganisms, consistent with the culture, which grew Nocardia brasiliensiss.
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