Pulmonary nocardiosis in heart transplant recipients: treatment and outcome

BACKGROUND

Nocardial infections typically affect patients receiving immunosuppressants, occurring early after surgery in 3% to 40% of heart transplant (HTx) recipients. The emergence of antibiotic resistance and occurrence of disease recurrences in AIDS population has engendered controversy about the treatment for immunodepressed HTx patients.

METHODS

We present a retrospective study of the diagnosis, treatment and outcome of 560 HTx recipients between 1984 and 2002.

RESULTS

Among the five cases of Nocardia infection (0.9%), three cases developed late after HTx (between 3.1 and 11 years follow-up). All patients had pulmonary disease and one in addition had subcutaneous nodules. Microbiological diagnosis required open lung biopsy in one case. All patients were treated primarily with trimethoprim-sulphamethoxazole, but evidence of resistance to sulfonamides led us to change the antimicrobial combination in two cases. Four patients who received one year of antibiogram-guided therapy showed complete healing without recidivism. Three patients died, all due to non-related causes, at follow-ups between 1 and 5 years. In one case a cutaneous recurrence of disease was attributed to noncompliance.

CONCLUSIONS

Nocardiosis in current HTx is less common than previously reported. Its incidence seems to be delayed in time with modern immunosuppressants. Given the high incidence of sulfamide resistance, treatment must be guided by antibiotic sensitivity. We believe that maintenance therapy for a whole year is the appropriate option in order to avoid recidivism in this population.

Carcinoid heart disease: report of a case secondary to a pure carcinoid tumour of the ovary

Carcinoid heart disease secondary to ovarian carcinoid is a rare finding, with only 12 cases reported in the literature to date. Most ovarian carcinoids arise from ovarian cysts or teratomata, the 'pure' carcinoid being exceedingly rare. We present a case of carcinoid syndrome with tricuspid valve involvement in a patient with 'pure' ovarian carcinoid.

Interaction between anticoagulants and contraceptives: an unsuspected finding

To assess the effects of oral contraceptives on anticoagulant treatment the prothrombin times of 12 patients were measured while they were taking both drugs simultaneously and while they were taking only anticoagulants. The mean prothrombin time ratio was significantly higher when patients were taking both drugs than when they were taking only anticoagulants and their doses of anticoagulant were significantly lower. During both periods most of the prothrombin values remained in the therapeutic range. These findings suggest that, contrary to the common belief that oral contraceptives diminish the effects of anticoagulants, contraceptives in fact potentiate the action of the anticoagulants.