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Infectious Diseases

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Henry Ford Hospital


Background: Nocardia species are partially acid fast, aerobic, gram-positive, branching filamentous bacteria that are found ubiquitously in the soil, decaying vegetable matter and aquatic environments. The Nocardia species most commonly associated with infections in humans are caused by asteroides (80-90%) followed by brasiliensis, farcinica and nova1. Nocardia spp. can cause serious pulmonary infections which are associated with frequent metastatic brain abscesses. Nocardia bacteremia is rarely reported and usually only seen in immunocompromised patients. We present a case of a central line associated Nocardia bloodstream infection in an immunocompetent patient. Case presentation: 53 year old Caucasian male with a history of a chronic small bowel stricture leading to oral intolerance and total parenteral nutrition (TPN) dependence initially presented with an intraabdominal abscess. The patient was immediately taken to the operative room for a laparotomy. Cultures from the operative room grew Enterococcus spp. and Salmonella spp. Patient was started on daptomycin, ceftriaxone and metronidazole to treat the infection. Blood cultures were also obtained and reported as Nocardia nova. CT chest and head and transesophageal echocardiogram did not reveal any evidence of disseminated Nocardiosis. The patient was then started on trimethoprim-sulfamethoxazole with plans to treat for three months followed by suppression therapy. The bacteremia source was thought to be from a 400 day old PICC due to the patient’s TPN dependence, which was removed. Conclusion: Nocardia infections in humans are uncommon, with a reported incidence in the United States of 500 to 1,000 new cases per year. Nocardia bacteremia is a rare event as a literature review from 1998 found only 36 cases of Nocardia bacteremia worldwide from the last 52 years3. Our patient had positive blood cultures with no evidence of disseminated Nocardiosis. Although, Nocardia species infections are mostly found in immunocompromised hosts, our patient’s long term PICC likely was the etiology for his bacteremia. This case illustrates the importance of monitoring central venous catheters as it can lead to central line-associated bloodstream opportunistic infections.

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Expect the Unexpected! A Rare Case of Nocardia Bacteremia