Disseminated Nocardia otitidiscaviarum Presenting as Lung-Brain-Skin Syndrome in a Renal Transplant Recipient: A Case Report

We present a case of disseminated Nocardia otitidiscaviarum infection in a 72-year-old male with a history of renal transplantation on chronic immunosuppressive therapy with prednisone, cyclosporine, and mycophenolate mofetil.He presented with pneumonia and was initially treated with ceftriaxone and azithromycin.Bronchoalveolar lavage (BAL) and cultures from a biopsied thigh lesion both grew N. otitidiscaviarum.His hospital course was complicated by visual hallucinations, and brain magnetic resonance imaging (MRI) revealed multiple intracranial abscesses.He initially received meropenem, trimethoprimsulfamethoxazole (TMP-SMX), and linezolid.His antimicrobial regimen was subsequently modified during the treatment course.Linezolid was discontinued after hematologic abnormalities developed, TMP-SMX was temporarily held because of worsening renal function and later reintroduced, and meropenem was also discontinued.He was discharged on TMP-SMX and minocycline and completed an initial six-week antimicrobial treatment course from the time of diagnosis.He was subsequently maintained on minocycline and moxifloxacin; moxifloxacin was later discontinued because of QT-interval prolongation, while minocycline was continued for slightly longer than one year, with clinical and radiologic resolution.