A case of nocardiosis in a patient with ulcerative colitis on chronic corticosteroids, infliximab, and upadacitinib.

Key Clinical Message: Immunosuppression, malnutrition, and underlying infection can unmask obscure infections which can be challenging to identify. Early diagnosis and treatment of infections in immunosuppressed patients are essential due to high morbidity and mortality. Abstract: The immunosuppressive effects of treatment for ulcerative colitis (UC), including chronic corticosteroids, anti-TNF agents, and JAK inhibitors, can impact the spread of latent or obscure infections. Clinicians should have a low threshold for pursuing aggressive diagnostic and therapeutic intervention in patients who show signs of clinical deterioration while on immunosuppressing medications. Our unique case highlights an immunosuppressed patient with UC who developed Nocardiosis after initiation of upadacitinib while hospitalized for concurrent UC flare and Clostridium difficile infection.

Impact of Covid-19 Pandemic on Epidemiology of Infections in Pre- and Post-Covid-19 Pandemic a Single Centre Study

Introduction: Infections are the leading cause of death in kidney transplant recipients (KTR) at all time intervals. The non-pharmaceutical interventions (NPIs) taken during the COVID-19 pandemic have reduced almost all kinds of infections in the general population, as shown in the Chunmei Su et al. study. The aim of this study was to investigate the impact of NPIs for the COVID-19 pandemic on infections in KTR patients. Method(s): This was a single-center retrospective observational study conducted at Mumbai's Jaslok Hospital and Research Centre.Samples from symptomatic KTR patients were taken and those who had positive cultures were thought to be infected. The data were analysed and compared between the years 2021 (during the COVID-19 pandemic) and 2019 (before the COVID-19 pandemic). Result(s): A total of 224 patients were enrolled, including 117 patients in 2019 and 107 patients in 2021. In 2019 and 2021, the prevalence of nosocomial infection and community-acquired infection in KTR patients remains unchanged.In 2021, both the number of protective gloves and level 2 PPE kits used per individual, as well as the number of healthcare professionals per patient, have increased dramatically. Regarding the source of infections, no significant change in major infections was observed in respiratory tract infections (12% vs. 10.3%, p = 0.8985), gastrointestinal infections (1.8% vs. 6.5%, p = 0.0786), catheter related blood stream infections (CRBSI) (4.5% vs. 3.7%, p = 0.776), and blood stream infections (11.7% vs. 10.3%, p = 0.73), However, there were increases in urinary tract infections (23% vs. 42.1%;p = 0.0006). The microorganism analysis of respiratory infections shows declines in nocardia and tuberculosis. Gastrointestinal infections show increased Clostridium difficile cases in 2021 compared to 2019, which can be attributed to the overuse of antibiotics. Regarding urinary tract infection, a decline in mixed infection cases and an increase in Enterobacter faecalis and Enterobacter cloacae cases were observed. There were no significant variations in catheter-related nosocomial infections between 2019 and 2021. In comparison to an older study done in the general population by Chunmei Su et al, our study shows no significant change in respiratory, gastrointestinal, and catheter-related blood infections in 2021 compared to 2019 in KTR, despite restrictions being relaxed in general populations beginning in June 2020.Also, there was no significant increase in community acquired pneumonia in 2021, even after reopening public places. Conclusion(s): Our institutional NPIs for KTR patients in the pre-COVID-19 era were shown to be as effective as NPIs for the COVID-19 pandemic in reducing the prevalence of common infections like respiratory, gastrointestinal, blood stream, and catheter-related infections in KTR patients. No conflict of interestCopyright © 2023

Microbiological profile of post covid patients admitted in tertiary care center with pulmonary infections

The second wave of COVID 19 started in India in the month of February 2021 lasted till June 2021. The second wave of COVID 19 was devastating in India. There were many fatalities. But the patient who recovered of COVID pneumonia also had many pulmonary complications, pulmonary infections being the most common. The use of steroids and immunosuppressive agents were considered to be one the causative factors. At our center, we did retrospective analysis of patients who were admitted with pulmonary infections in month of June and July 2021 and had history of COVID during second wave. There were in total 98 patients. The sputum and bronchial wash analysis were done for these patients. Out of 98 patients, 38 diagnosed to have tuberculosis, 18 mucormycosis, 10 aspergillosis, 22 bacterial infection (Pseudomonas and klebsiella), 2 non tubercular mycobacteria, 2 nocardiosis, 6 had mixed infections (2 NTM and Klebsiella, 3 TB with Aspergillosis and 1 Aspergillosis with mucor). Thus, it was concluded, that post covid status predisposed to pulmonary infections with not only common organism like Tuberculosis (being endemic in India) but also rare organism like mucor, nocardia, NTM. Though most of the patients received steroids and immunosuppressive therapy, 22 patients had mild COVID and didn't receive any steroids or immunosuppressive therapy. Thus, implying that steroids and immunosuppressive therapy are not the only cause of increased incidence of pulmonary infections. More such observations from different centers are required for confirmation of the observations.

Differentiating infectious from non-infectious respiratory disease in the cat and dog

This paper describes the clinical signs and use of differential laboratory diagnostic techniques (computed tomography, cytology, histopathology, antigen/antibody detection and polymerase chain reaction) for infectious (viral, bacterial, fungal and parasitic) and non-infectious (inflammatory/immune mediated, neoplastic, cardiac, malformation, foreign body, smoke inhalation, aspiration of caustic material, non-cardiogenic, pulmonary oedema, traumativ, pneumothorax, pulmonary contusions and idiopathic) causes of respiratory diseases in cats and dogs in Ontario, Canada.

Nocardia neocaledoniensis as Rare Cause of Spondylodiscitis.

Nocardia neocaledoniensis is a rare species of Nocardia bacteria, identified in 2004 in hypermagnesian ultramafic soil of New Caledonia. Culture of this opportunistic pathogen from spinal biopsy samples confirmed N. neocaledoniensis spondylodiscitis in an immunocompromised man. Isolation of this unusual species from spinal biopsy samples illustrates its underappreciated ability to cause invasive infection.

Nocardia pseudobrasiliensis Co-infection in SARS-CoV-2 Patients.

During the SARS-CoV-2 pandemic, few cases of Nocar-dia spp. co-infection have been reported during or after a COVID-19 infection. Nocardia spp. are gram-positive aerobic actinomycetes that stain partially acid-fast, can infect immunocompromised patients, and may cause dis-seminated disease. We report the case of a 52-year-old immunocompromised man who had Nocardia pseudobrasiliensis pneumonia develop after a SARS-CoV-2 in-fection. We also summarize the literature for no-cardiosis and SARS-CoV-2 co-infections. Nocardia spp. infection should remain a part of the differential diagnosis for pneumonia in immunocompromised hosts, regardless of other co-infections. Sulfonamide/carbapenem combina-tions are used as empiric therapy for nocardiosis; species identification and susceptibility testing are required to se-lect the optimal treatment for each patient.

Encephalic nocardiosis after mild COVID-19: A case report.

The COVID-19 pandemic and the associated post-acute sequelae of COVID-19 (PASC) have led to the identification of a complex disease phenotype that is associated with important changes in the immune system. Herein, we describe a unique case of Nocardia farcinica cerebral abscess in an individual with sudden immunodeficiency several months after mild COVID-19. Intravenous Bactrim and Imipenem were prescribed for 6 weeks. After this, a 12-month course of Bactrim and Clavulin was prescribed to be taken orally, given the N. farcinica infection at the level of the central nervous system. This case report highlights the need for future research into the pathophysiology of COVID-19 and PASC immune dysregulation in convalescent individuals. It also draws attention to the need for timely consideration of opportunistic infections in patients with a history of COVID-19.

Ulceration by Nocardia Otitidiscaviarum: A case study.

Nocardiosis is an acute, subacute or chronic infectious disease that occurs in cutaneous, pulmonary and disseminated forms. We present a case of Nocardiosis in a post-COVID-19 patient with cutaneous ulceration due to Nocardia otitidiscaviarum, managed with cotrimoxazole and linezolid. Early diagnosis and management proved crucial in preventing dissemination of the organism and improving the patient's outcome.

A UNIQUE CASE OF SEVERE PULMONARY NOCARDIOSIS PRESENTING WITH ARDS AND CARDIOGENIC SHOCK

SESSION TITLE: Shock and Sepsis in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Nocardiosis is a rare bacterial infection, which frequently affects immunocompromised patients. It can present as an acute, subacute, or chronic pulmonary infection with non-specific symptoms, such as fever, cough, dyspnea, weight loss, and hemoptysis. CASE PRESENTATION: A 34-year-old female with a history of chronic granulomatous disease and hidradenitis suppurativa on adalimumab presented to the ED with fever, shortness of breath, and productive cough of 2 days. Her vitals were T 101F, BP 66/48, HR 148, RR 42, and SPO2 94% on room air. On exam, she was cachectic, with bilateral crackles and rales in the right lung base. Extremities were cold, with trace pitting edema was present on bilateral lower extremities. COVID-19 PCR was negative. Despite fluid resuscitation, she remained hypotensive and was started on norepinephrine. Blood cultures were collected, and broad-spectrum antibiotics and an antifungal agent were initiated. Chest CT demonstrated bilateral multifocal consolidation with surrounding ground-glass opacities and complete consolidation of the right lower lobe. Due to worsening respiratory distress and tachypnea, and lack of improvement with non-invasive ventilation, she was intubated, placed on mechanical ventilation, and admitted to the Medical ICU. On hospital day 1, due to the patient's immunosuppression, unresolving shock, and radiographic findings, a bronchoscopy with bronchoalveolar lavage (BAL) was performed. On hospital day 2, a transthoracic echocardiogram showed LV ejection fraction of 20-25% with severe global hypokinesis of the LV. ACS workup had been unremarkable, with mildly elevated troponin and no ischemic changes on EKG. She was initiated on cardiac inotropes. On hospital day 3, BAL culture revealed Nocardia cyriacigeorgica. TMP-SMX and ceftriaxone were started for severe pulmonary nocardiosis. On hospital day 11, she was liberated from mechanical ventilation, and by hospital day 14, she was weaned off all pressors and inotropes. Approximately 4 weeks after admission, repeat TTE showed recovery of LV ejection fraction (55-60%) and she was discharged with a prolonged course of TMP-SMX and IV ceftriaxone, with duration to be determined at outpatient infectious disease follow-up. DISCUSSION: We discuss a unique case of severe pulmonary nocardiosis, presenting with ARDS and cardiogenic shock. To the best of our knowledge, this is the first case of a patient with pulmonary nocardiosis presenting with stress cardiomyopathy reported in the literature. While the pathophysiology is not well understood, theorized mechanisms include catecholamine excess, coronary artery spasm, microvascular dysfunction. CONCLUSIONS: This case highlights the need for a broad differential diagnosis in patients presenting with ARDS and cardiogenic shock and illustrates the value of clinical bronchoscopy in patients with unique presenting features. Reference #1: Lerner PI. Nocardiosis. Clin Infect Dis. 1996 Jun;22(6):891-903;quiz 904-5. doi: 10.1093/clinids/22.6.891. PMID: 8783685. Reference #2: Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion HC. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005 Feb 10;352(6):539-48. doi: 10.1056/NEJMoa043046. PMID: 15703419. Reference #3: Park JH, Kang SJ, Song JK, Kim HK, Lim CM, Kang DH, Koh Y. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest. 2005 Jul;128(1):296-302. doi: 10.1378/chest.128.1.296. PMID: 16002949. DISCLOSURES: no disclosure on file for D. Clark Files;No relevant relationships by Nisha Patel No relevant relationships by Meehir Shah

BRONCHIAL TREE ULCERATION: BACTERIAL OR FUNGAL

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: SARS-CoV-2 pandemic has shown rare and varied presentations of known pathology and infectious processes. We discuss the case of a patient developing bronchial tree ulcerations in the backdrop of SARS-CoV-2 and superimposed infections. CASE PRESENTATION: This was a 59-year-old male with past medical history of B-cell lymphoma, diagnosed with SARS-CoV-2 infection. He was admitted with shortness of breath and increased oxygen requirement. In brief, his hospital course included bilevel positive airway pressure noninvasive ventilation along with steroids, baricitinib and therapeutic anticoagulation. His clinical status worsened to severe acute respiratory distress syndrome and he progressed to mechanical ventilation. While on the ventilator he was treated with paralysis and proning. Due to worsening hypoxia and secretions, he underwent bronchoscopy showing copious thick mucoid white patches and secretions in trachea extending to the right and left mainstem bronchi and extensive mucus plugging. Baricitinib was discontinued and he was placed on empiric micafungin, broad spectrum antibiotics while results were pending. He required repeat bronchoscopy for therapeutic suctioning of recurrent copious thick white secretions with mucus plugging. Cultures resulted as aspergillus fumigatus and micafungin was switched to voriconazole. Two weeks later, in an ongoing prolonged intubated state, he developed cuff leak requiring tube exchange and repeat bronchoscopy, which showed development of multiple bilateral ulcerations with central necrosis and sloughing in the right and left bronchial tree. Repeat lab evaluation of the bronchoscopy samples now resulted in growth of nocardia along with aspergillus species. DISCUSSION: Ulceration of bronchial tree may be seen in malignant lesions, autoimmune conditions, poisoning or toxicology cases. Occurrence of pulmonary ulcerations are rare in infectious cases as sequalae in the SARS-CoV-2 pandemic. Patient's immunocompromised state, with history of B-cell lymphoma, prolonged steroid and JAK inhibitor administration, predisposes to higher propensity of infections. Bronchial tree ulceration also leads to suspicion of viral infections such as herpes, varicella which were found to be negative from bronchial samples. It remains difficult to ascertain if the prolonged aspergillus infection led to progression of white plaques into ulcerations, or the newly diagnosed secondary infection of nocardia caused bronchial tree ulcers. Historically, aspergillus has been associated with blackened ulcerations as opposed to the findings here. Also, patient had been receiving treatment with voriconazole for 2 weeks prior to diagnosis of ulcers, therefore raising suspicion for a rare nocardial etiology as well. CONCLUSIONS: Prolonged intubation in immunocompromised patients may lead to superimposed nocardial and aspergillus infections causing airway ulcerations and increased mortality. Reference #1: Judson MA, Sahn SA. Endobronchial lesions in HIV-infected individuals. Chest. 1994;105(5):1314-1323. doi:10.1378/chest.105.5.1314 Reference #2: Abdel-Rahman N, Izhakian S, Wasser WG, Fruchter O, Kramer MR. Endobronchial Enigma: A Clinically Rare Presentation of Nocardia beijingensis in an Immunocompetent Patient [published correction appears in Case Rep Pulmonol. 2016;2016:1950463]. Case Rep Pulmonol. 2015;2015:970548. doi:10.1155/2015/970548 DISCLOSURES: No relevant relationships by Habiba Hussain No relevant relationships by Matthew Sehring

INVASIVE PULMONARY ASPERGILLOSIS ASSOCIATED WITH NONSPECIFIC INTERSTITIAL PNEUMONIA CAUSING RECURRENT RESPIRATORY FAILURE

SESSION TITLE: Unusual Pneumonias SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Invasive pulmonary aspergillosis (IPA) commonly occurs in the setting of immunosuppression. Underlying lung disease is a well-known risk factor for IPA;however, interstitial lung disease (ILD) has not been recognized as a risk factor for IPA[1]. CASE PRESENTATION: A 40-year-old male with a history of a failed kidney transplant now on hemodialysis (HD), Juvenile Rheumatoid Arthritis, Mixed Connective Tissue Disease, Aspergilloma led to right lower lobectomy a year ago, COVID-19 infection three months ago, chronic lung disease (CLD) thought to be due to Nonspecific interstitial pneumonia (NSIP) presented with dyspnea. He had several hospitalizations for respiratory failure needing intubation or NIPPV, broad-spectrum antibiotics, steroids, and HD with improved respiratory status, eventually discharged. Bronchoalveolar lavage fluid culture grew aspergillus terreus but was negative for Pneumocystis (PCP), bacteria, acid-fast bacilli, and Nocardia. The transbronchial biopsies showed mixed inflammatory type and fungal forms in one specimen. Additionally, the initially negative galactomannan converted into a serial rise in galactomannan (>3.75 Index) along with a rise in beta d-glucan (>500 pg/ml). Unfortunately, he had gaps in antifungals and was readmitted similarly. Micafungin was added for dual fungal coverage and was planned for surgical lung biopsy to characterize ILD further once his respiratory status allows. DISCUSSION: He has multiple risk factors for developing IPA, such as high-dose steroids for ILD and recent COVID infection. Initially, respiratory failure was thought to be due to exacerbation of ILD, and suspicion for IPA was low because of lack of neutropenia, negative fungal biomarkers, lack of classic findings on lung imaging, and in-hospital clinical improvement with steroids. However, the eventual course of recurrent respiratory failure while on high-dose steroids, along with gaps in antifungal therapy and continued growth of Aspergillus, made IPA the most likely diagnosis. For IPA, the mainstay of treatment is both adequate antifungal therapy and reduction in immunosuppression to the extent possible[2];however, it is unclear if his underlying ILD can tolerate steroid taper. He will need a lung transplant after adequately treating IPA. CONCLUSIONS: There are no current guidelines on simultaneously treating IPA and NSIP. It is challenging to balance reduction in immunosuppression as tolerated for ILD and concurrently maintain antifungal therapy. During this patient's hospitalization, there have been considerations of using a steroid-sparing agent for his suspected NSIP, however, in the setting of active infection, its benefit is debatable.[3] Reference #1: Matsuyama H, Miyoshi S, Sugino K, et al. Fatal Invasive Pulmonary Aspergillosis Associated with Nonspecific Interstitial Pneumonia: An Autopsy Case Report. Intern Med. 2018;57(24):3619-3624. doi:10.2169/internalmedicine.1144-18 Reference #2: Thomas F. Patterson, George R. Thompson, III, David W. Denning, Jay A. Fishman, Susan Hadley, Raoul Herbrecht, Dimitrios P. Kontoyiannis, Kieren A. Marr, Vicki A. Morrison, M. Hong Nguyen, Brahm H. Segal, William J. Steinbach, David A. Stevens, Thomas J. Walsh, John R. Wingard, Jo-Anne H. Young, John E. Bennett, Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 63, Issue 4, 15 August 2016, Pages e1–e60, https://doi.org/10.1093/cid/ciw326 Reference #3: Mezger, M., Wozniok, I., Blockhaus, C., Kurzai, O., Hebart, H., Einsele, H., & Loeffler, J. (2008). Impact of mycophenolic acid on the functionality of human polymorphonuclear neutrophils and dendritic cells during interaction with Aspergillus fumigatus. Antimicrobial agents and chemotherapy, 52(7), 2644–2646. https://doi.org/10.1128/AAC.01618-07 DISCLOSURES: No relevant relationships by Nasir Alhamdan No relevant relati nships by Parth Jamindar No relevant relationships by Harshitha Mergey Devender No relevant relationships by Abira Usman No relevant relationships by Vishruth Vyata

LUNG CAVITY: A RARE FINDING IN COVID-19

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Chest CT features in COVID-19 pneumonia include scattered ground-glass infiltrates in milder cases to confluent ground-glass change, dense consolidation, and crazy paving in the critically ill. However, cavitary lesions are uncommon in these patients. We present a case of lung cavity in a patient who had recent COVID-19 pneumonia. CASE PRESENTATION: A 33-year-old male diagnosed with COVID-19 four weeks ago presented with hemoptysis and exertional dyspnea. He had pleuritic chest pain without fever, night sweats, weight loss, skin rashes, hematemesis, or epistaxis. He had COVID-19 in Brazil, where he had received dexamethasone, hydroxychloroquine, ivermectin, colchicine, azithromycin, and rivaroxaban. The last dose of rivaroxaban was three days prior to the presentation. He had no history of travel to caves or exposure to birds or animals. His past medical history included hypertension, diabetes, and bariatric surgery. He had no history of smoking or IV drug use. He had moved from Brazil to the United States six years ago and worked as an interpreter. Physical examination was notable for stable vitals with O2 sat of 99%. Systemic examinations were unremarkable. Blood work including CBC, platelet count, PT/INR was within normal limits. COVID-19 testing (PCR) was negative. A chest CT revealed bilateral scattered ground-glass opacities with central cavitation in the left lower lobe concerning for septic pulmonary emboli. HIV 1/2, ANA, rheumatoid factor, and Quantiferon TB gold were negative. Blood cultures showed no growth. An echocardiogram was negative for any vegetations. Bronchoalveolar lavage from the left lower lobe was negative for AFB and gram staining. Sputum cultures, fungal cultures, and NAAT for Mycobacterium tuberculosis were negative, as was the cytology. He was started on amoxicillin-clavulanic acid during his hospital stay. He did not experience any recurrence of hemoptysis and was discharged home. The subsequent follow-up chest CT scans showed resolving cavitation at one month and a complete resolution of the cavity at 3 months. DISCUSSION: Cavitary lung lesions are usually related to fungal, mycobacterial, autoimmune, parasitic, thrombotic, or neoplastic etiologies. While not often seen in patients with viral pneumonia, lung cavitation can rarely occur in COVID-19. Mycobacterium tuberculosis and Nocardia were suspected given the history of being an immigrant and a recent trip to Brazil. As these tests were negative and the lung cavity resolved over a few months with conservative treatment, the etiology of the cavity was attributed to a late presentation of COVID-19 pneumonia. CONCLUSIONS: COVID-19 has variable complications which are still to be explored. The lung cavity in a COVID patient is an under-recognized entity. This case report highlights the need for further studies to determine the cause of cavitation, which could be related to COVID infection or its treatment. Reference #1: Selvaraj V, Dapaah-Afriyie K Lung cavitation due to COVID-19 pneumonia. BMJ Case Reports CP 2020;13:e237245. Reference #2: Chen Y, Chen W, Zhou J, Sun C, Lei Y. Large pulmonary cavity in COVID-19 cured patient case report. Ann Palliat Med 2021;10(5):5786-5791. doi: 10.21037/apm-20-452 Reference #3: Zoumot, Z., Bonilla, MF., Wahla, A.S. et al. Pulmonary cavitation: an under-recognized late complication of severe COVID-19 lung disease. BMC Pulm Med 21, 24 (2021). https://doi.org/10.1186/s12890-020-01379-1 DISCLOSURES: no disclosure on file for Raul Davaro;No relevant relationships by Susant Gurung No relevant relationships by Bijay Khanal No relevant relationships by Anil Phuyal No relevant relationships by Kamal Pokhrel No relevant relationships by REGINA SHRESTHA No relevant relationships by Mithil Gowda Suresh

Pulmonary Nocardiosis as an Opportunistic Infection in COVID-19.

Secondary bacterial pneumonia infection is frequent in COVID-19 patients. Nocardia are responsible for opportunistic pulmonary infections especially after steroid treatment. We describe a case of pulmonary nocardiosis following critical COVID-19 pneumonia in an 83-year-old male. Two weeks after initiation of dexamethasone 6 mg/L, the patient developed a new episode of acute dyspnea. The sputum cultures identified Nocardia cyriacigeorgica. In spite of intravenous imipenem and cotrimoxazole treatment the patient died. Physicians should be aware of the possibility of nocardiosis in case of deterioration of respiratory status of severe COVID-19 inpatients and perform Nocardia evaluation. This evaluation requires prolonged culture. LEARNING POINTS: Nocardia are responsible for opportunistic pulmonary infections after steroid treatment.We describe a case of pulmonary nocardiosis following critical COVID-19 pneumonia.Physicians should be aware of the possibility of secondary nocardiosis in COVID-19 inpatients.

Case report: Nocardial brain abscess in a persistently SARS-CoV-2 PCR positive patient with systemic lupus erythematosus.

Coronavirus disease (COVID-19) in immunocompromised patients represents a major challenge for diagnostics, surveillance, and treatment. Some individuals remain SARS-CoV-2 PCR-positive for a prolonged period. The clinical and epidemiological significance of this phenomenon is not well understood. We report a case of a patient with a history of systemic lupus erythematosus (SLE) who has been persistently SARS-CoV-2 PCR positive for 9 months, with multiple thromboembolic complications, and development of nocardial brain abscess successfully treated with surgery and antibiotics.

Nocardiosis of the Central Nervous System: A rare complication of COVID management?

This case report examines a previously immunocompetent male that was treated with a prolonged course of corticosteroids for COVID pneumonia. He then returned with worsening headaches followed by flaccid paralysis of extremities due to cerebral and spinal cord abscesses secondary to Nocardia farcinica. A review of the literature on the mechanism of immunosuppression with COVID infection and corticosteroids is provided.

CRISPR/Cas12a-Based Diagnostic Platform Accurately Detects Nocardia farcinica Targeting a Novel Species-Specific Gene.

Under the COVID-19 pandemic background, nucleic acid detection has become the gold standard to rapidly diagnose the infectious disease. A rapid, low cost, reliable nucleic acid detection platform will be the key to control next potential pandemic. In this study, a nucleic acid detection platform, which combined CRISPR/Cas12a-based detection with loop-mediated isothermal amplification (LAMP), was developed and termed CRISPR-CLA. In the CRISPR-CLA system, LAMP preamplification was employed, and CRISPR/Cas12a-based detection was used to monitor the preamplicons. The forward inner primer (FIP) was engineered with a protospacer adjacent motif (PAM) site TTTA of Cas12a effector at the linker region; thus, the CRISPR-CLA platform can detect any sequence as long as the primer design meets the requirement of LAMP. To demonstrate the validity of the CRISPR-CLA system, it was applied for the molecular diagnosis of nocardiosis caused by Nocardia farcinica (N. farcinica). A highly conserved and species-specific gene pbr1 of N. farcinica, which was first reported in this study, was used as the target of detection. A set of LAMP primers targeting a fragment of pbr1 of the N. farcinica reference strain IFM 10152 was designed according to the principle of CRISPR-CLA. Three CRISPR RNAs (crRNAs) with different lengths were designed, and the most efficient crRNA was screened out. Additionally, three single-strand DNA (ssDNA) probes were tested to further optimize the detection system. As a result, the N. farcinica CRISPR-CLA assay was established, and the whole detection process, including DNA extraction (20 min), LAMP preamplification (70°C, 40 min), and CRISPR/Cas12a-mediated detection (37°C, 8 min), can be completed within 70 min. A fluorescence reader (for fluorescence CRISPR-CLA) or a lateral flow biosensor (for lateral-flow CRISPR-CLA) can be the media of the result readout. Up to 132 strains were used to examine the specificity of N. farcinica CRISPR-CLA assay, and no cross-reaction was observed with non-N. farcinica templates. The limit of detection (LoD) of the N. farcinica CRISPR-CLA assay was 100 fg double-strand DNA per reaction. N. farcinica was detected accurately in 41 sputum specimens using the N. farcinica CRISPR-CLA assay, which showed higher specificity than a real-time qPCR method. Hence, the N. farcinica CRISPR-CLA assay is a rapid, economic and accurate method to diagnose N. farcinica infection.

A 79-year-old-man with SARS-CoV-2 pneumonia and unusual pulmonary co-infection

Patients with severe COVID-19 are characterized by local and systemic inflammatory responses, which are responsible for severe acute respiratory failure. Systemic corticosteroids have been used to counteract the inflammatory cascade in severe respiratory patients. The beneficial effect of corticosteroids may be counteracted by adverse effects, including delayed viral clearance and increased risk of secondary infection. In this regard, we describe a case of a 79-year-old man admitted to the Emergency Department of the Palermo Hospital (Italy) because of respiratory failure and pneumonia caused by SARS-CoV-2 infection who developed Nocardia otitidiscaviarum infection. This case highlights the need to consider coinfections in SARS-CoV-2 patients under high dose of steroids.

A challenging case of SARS-CoV-2- AIDS and nocardiosis coinfection from the SMatteo COVID-19 registry (SMACORE)

The COVID-19 pandemic is posing an unprecedented threat worldwide. One issue that has faltered, though, concerns the underestimated risk to trade all for COVID-19, misdiagnosing other potentially life-threatening diseases. Further still, the presence of respiratory symptoms in AIDS patients should stimulate more vigilant efforts to uncover other or additional infections. This case report highlights the pitfalls of diagnosing a rare pulmonary infection during the COVID-19 pandemic.

ABSCESSO CEREBRAL POR NOCARDIA BEIJINGENSIS EM PACIENTE SEM IMUNOSSUPRESSÃO: RELATO DE CASO

Introdução: A Nocardia beijingensis é um bacilo aeróbico gram-positivo, podendo causar doença em pacientes imunocomprometidos. A nocardiose em imunocompetentes é uma condição mais rara. A infecção ocorre por inalação ou inoculação direta e pode acometer pulmão, pele e disseminar, porém os abscessos cerebrais representam menos de 2% dos casos, com alta morbimortalidade. Relato de caso: R.N.S.S., 63 anos, sexo masculino, sem patologias prévias, apresentou convulsão tônico clônica generalizada e hemiparesia à esquerda, realizando tomografia computadorizada de crânio que demonstrou lesão expansiva em região frontoparietal à direita sugestiva de neoplasia. Foi realizada abordagem neurocirúrgica com visualização de abscesso que foi drenado e houve crescimento de Nocardia beijingensis na cultura da secreção. Investigou-se imunossupressão, mas sem achados positivos. Realizou tratamento com meropenem e linezolida, com boa evolução clínica e radiológica. Entretanto, evoluiu com infecção por Sars-Cov 2 e foi à óbito por complicações da Covid-19. Considerações: Abscesso cerebral por Nocardia é uma condição rara, especialmente em pacientes não imunocomprometidos. São necessários a drenagem da coleção e o tratamento com antimicrobiano, que seja sensível, para o sucesso terapêutico.