, 10 tweets, 6 min read Read on Twitter
55 yo ♂️s/p RenalTx 10+yrs ago tacro/aza immunosuppressive, gardens & recent travel to home (Philippines), presents chronic progressive cough, constitutional features & single skin abscess, with non-cavitary RUL consolidation + diffuse ggo refractory to Levaquin...
100.1F, HR110s (near baseline), RR18 97% RA. Found to have mild AoC kidney injury, AoC hyponatretomia , mild hepatocellular injury. Procalcitonin 0.7.

Do you start antibiotics? If Yes: tell me which ones in comment
So before starting treatment...maybe should think about therapies....this was my 🐔 scratch DDx on back of article —> Think their stable and more Abx won’t help things I’m worried about acutely at this point
Where do you admit patient?
So maybe you thought maybe TB and put in airborne (I did). So we get some sputum. Also got CMV NAAT...400+k copy/mL.

What’s your leading Dx:
If you thought CMV PNA... consider patient breathing comfortably on RA and CMV PNA is massively inflammatory and almost certainly would not be so stable.

Given my DDx, wanted AFB + Nocardia sputum culture

AFB sputum positive.
“Branching weakly AF positive”
His abscess was drained and showed branching AFB organisms. Day 4 showed same organism in blood stream.

Ultimately dx with Disseminated Nocardia. CMV was red herring (probable cause of transaminases)
Take Aways:
1) risk factors Nocardia: immunosuppressed, EtOH, recent transplant
2) Nocardia is all over: mostly in dirt (hence gardener)
3) Nocardia loves lungs and 🧠 ==> must get MRI brain if immunosuppressive or Sx of neuro defect
4) Nocardia & actinomycetes are on DDx for AFB
***discalimer - not my case, just my dissection. All #meded innovation props go to one of our future chief residents Eddie Maldonado, making @OHSUIMRes proud!
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