Abscesses in immunosuppressed host

A 27 year old woman from rural Ahmednagar district presented with multiple soft tissue abscesses, fever and weight loss of 5 kg since 1 month. The patient had been diagnosed with systemic lupus erythematosus 2 years earlier and was on prednisolone 20 mg/day, methotrexate and azathioprine. She weighed 35 kg and examination showed multiple soft tissue abscesses over scalp, submandibular region, legs, shoulder and back. The hemoglobin was 5.9 g/dl, ESR 115, serum albumin 2.3 mg/dl, serum globulin 3.6 g/dl and serum creatinine 0.6 mg/dl. Ultrasound abdomen revealed multiple liver abscesses with partial thrombus in the portal vein.

The submandibular collection was aspirated. Gram and modified acid-fast stains revealed branching filamentous gram positive bacteria resembling Nocardia. Nocardia species was isolated on bacterial cultures; however species were not identified. GeneXpert MTB-RIF, fungal cultures and subsequently mycobacterial cultures were negative on the specimen.

Disseminated nocardiosis was diagnosed. The patient was started on a regimen of Imipenem-Cilastatin 500 mg q6h, oral cotrimoxazole 960 mg q8h and amikacin 500 mg IV OD. Immunosuppressive medications were discontinued. The soft tissue abscesses were aspirated via a wide-bore needle several times during the hospital stay. A CT brain revealed multiple brain abscesses.

IV antibiotics were continued for 4 weeks. Over the next several weeks, symptoms resolved, appetite and weight improved. The patient was subsequently continued on oral cotrimoxazole for 1 year. She remained asymptomatic at followup.