Primary cutaneous Nocardia farcinica infection after heart transplantation: a case report

Pulmonary infiltrate and painful nodular leg lesions in a patient with membranous glomerulonephritis

Nocardia otitidis-cavarium is rarely isolated as an infectious pathogen in the western world. We report on a 71-year-old Caucasian man with membranous glomerulonephritis who presented with several seemingly unrelated clinical symptoms that, after laborious diagnostics, turned out to be caused by disseminated infection with N. otitidis-cavarium. This case highlights the variable clinical presentations that can occur in nocardial infections and underscores the need to search for rare pathogens in patients taking immunosuppressive medication.

Nocardia asteroides abscess after heart transplantation

We describe a patient who developed a primary, thigh adductor-muscle abscess caused by Nocardia asteroides 3 years after orthotopic cardiac transplantation. Nocardia was diagnosed by microbiologic culture and responded fully to a prolonged course of cotrimoxazole. The patient remains free of local or systemic disease at 2 years follow-up.

CT of heart transplant recipients: spectrum of disease

The emergence of heart transplantation as the ultimate treatment for end-stage heart failure has been accompanied by new diagnostic challenges. Computed tomography (CT) has emerged as an important diagnostic tool in the evaluation of heart transplant recipients because many infectious, ischemic-hemorrhagic, and neoplastic complications are amenable to early detection with this modality. In the early postoperative period, CT is mostly indicated in the evaluation of infectious complications or cerebral symptoms. Later, CT is mostly performed for staging of infectious or neoplastic disease. Infectious complications include mediastinitis, soft-tissue inflammation, abscess formation, cerebral infarction, and aspergillosis. Complications related to ischemia or hemorrhage include allograft rejection and coronary allograft vasculopathy, the latter being the leading long-term cause of death in heart transplant recipients. CT is also indicated in malignant disease (eg, lymphoma, visceral carcinoma, skin tumors), which is the second most important long-term cause of death. Moreover, CT is helpful in identifying disease caused by immunosuppressive therapy (eg, leukoencephalopathy, osteoporosis, thoracic lipomatosis). CT has proved superior to both ultrasound and magnetic resonance imaging in the evaluation of heart transplant recipients. It has become the diagnostic modality of choice for many transplant-related complications and may help improve postoperative treatment of affected patients.

Infections in solid-organ transplant recipients

Solid-organ transplantation is a therapeutic option for many human diseases. Infections are a major complication of solid-organ transplantation. All candidates should undergo a thorough infectious-disease screening prior to transplantation. There are three time frames, influenced by surgical factors, the level of immunosuppression, and environmental exposures, during which infections of specific types most frequently occur posttransplantation. Most infections during the first month are related to surgical complications. Opportunistic infections typically occur from the second to the sixth month. During the late posttransplant period (beyond 6 months), transplantation recipients suffer from the same infections seen in the general community. Opportunistic bacterial infections seen in transplant recipients include those caused by Legionella spp., Nocardia spp., Salmonella spp., and Listeria monocytogenes. Cytomegalovirus is the most common cause of viral infections. Herpes simplex virus, varicella-zoster virus, Epstein-Barr virus and others are also significant pathogens. Fungal infections, caused by both yeasts and mycelial fungi, are associated with the highest mortality rates. Mycobacterial, pneumocystis, and parasitic diseases may also occur.