#IDBoardReview 40 M severe cutaneous SLE s/p multiple immunosuppressive drugs, belimumab, originally from 🇲🇽 presents with confusion, F 102F, HIV NR, CSF wbc 4k 98%PMN, 2%mono, gluc3, prot 230, images shown, diagnosis? #medEd #IdmedEd 
pulmonary nodule, L frontal mass, L occipital mass, CSF branching gram+ bacilli
#Nocardia gram+ beaded weakly AFB+ branching rods. N asteroids commonest pathogenic group. Infection via direct inoculation thru skin or inhalation
#nocardia Primary skin infection can cause sporotrichoid lesions which can lead to abscesses or progressive destructive sinus tracts/mycetomas
#nocardia lung dis can be subacute or chronic w/ cough, dyspnea, hemoptysis, fever, cavity formation w/in pneumonia or spread to CNS, are suggestive of nocardiosis. Isolated CNS lesions can also occur
#nocardia CNS:MRI is preferred & should be performed in all pulmonary cases. Respiratory secretions, skin biopsy or aspirate from deep collections are most useful & +on gram stain. Modified AFB can be helpful. growth may take 48hrs-several wks but usually 3-5d
tmp/smx mainstay of tx, mono therapy for isolated skin or non-extensive mycetoma. Systemic #nocardiosis: speciation/susceptibility should guide tx. empiric tx w/ amikacin, impimenem (or meropenem) and tmp-smx are recommended for immunosuppressed pts
After 3-6 wks IV abx (6wks for CNS), can be switched to po total of 3-6mo (12mo for IC); clinical improve w/in 3-5d or 7-10d post appropriate treatment. prolonged therapy is needed. pts w/deep seated infection should be monitored clinically/radiologicaly for 12 mo post tx
Infections w/concurrent brain & lung lesions: mixed strep/anerobes, strep, staph, septic emboli, klebseilla, nocardia, MTB, rhodococcus, crypto, mucor, fusarium, aspergillus, dematiaceous fungi, blasto, burkholderia, scedosporium
