Infección pulmonar por Nocardia farcinica en un paciente con fibrosis quística y trasplante pulmonar / Nocardia farcinica lung infection in a patient with cystic fibrosis and a lung transplant

Los pacientes con fibrosis quística presentan un elevado riesgo de infecciones pulmonares crónicas. La infección pulmonar por Nocardia farcinica es una enfermedad poco frecuente en estos pacientes y las publicaciones al respecto son escasas. Su diagnóstico es complejo, siendo la clínica y la radiología inespecíficas. El aislamiento del germen en muestras de esputo en ocasiones es negativo, ya que son organismos de crecimiento lento. Esta circuns- tancia retrasa el tratamiento e incrementa las complicaciones, las estancias hospitalarias y la mortalidad. Presentamos el caso de una paciente de 26 años con antecedente de fibrosis quística y de infección y colonización pulmonar por Nocardia farcinica y Aspergillus fumigatus en tratamiento con ciprofloxacino, trimetoprima-sulfametoxazol y posaconazol de forma crónica. La paciente ingresó en el Servicio de Reanimación tras realizarle trasplante pulmonar bilateral. La evolución posoperatoria inicialmente fue satisfactoria, siendo dada de alta tras 3 días de ingreso por estabilidad hemodinámica y respiratoria. Posteriormente presentó insuficiencia respiratoria con infiltrados difusos de nueva aparición en la radiografía torácica. Los cultivos de esputo inicialmente no identificaron el germen. Medidas precoces y agresivas fueron empleadas debido a la alta sospecha clínica de infección por Nocardia farcinica. La combinación de amikacina y meropenem, y posteriormente linezolid, fue determinante en la desaparición de los infiltrados pulmonares y la mejoría clínica. En conclusión, nuestro caso confirma que la infección por Nocardia farcinica es rápidamente implantada en los nuevos pulmones injertados. Su identificación puede ser compleja y los retra- sos en el tratamiento conllevan una elevada morbimortalidad. La erradicación de la infección es especialmente necesaria en pacientes con trasplante pulmonar, al tratarse de personas con alta inmunosupresión (AU)

Patients with cystic fibrosis have a higher risk of developing chronic respiratory infectious diseases. The Nocardia farcinica lung infection is rare in this group of patients, and there are limited publications about this topic. Its diagnosis is complex, due to the clinical and the radiology signs being non-specific. Identification of the agent responsible in the sputum culture is occasionally negative. It is a slow growing organism and for this reason treatment is delayed, which can lead to an increase in complications, hospitable stays, and mortality. A case is reported on a 26 year-old woman with cystic fibrosis and chronic lung colonization by Nocardia farcinica and Aspergillus fumigatus, on long-term treatment with ciprofloxacin, trimethoprim-sulfamethoxazole, and posaconazole, who was admitted to ICU after bilateral lung transplantation. The initial post-operative progress was satisfactory. After discharge, the patient showed a gradual respiratory insufficiency with new chest X-ray showing diffuse infiltrates. Initially, the agent was not seen in the sputum culture. Prompt and aggressive measures were taken, due to the high clinical suspicion of a Nocardia farcinica lung infection. Treatment with a combination of amikacin and meropenem, and later combined with linezolid, led to the disappearance of the lung infiltrates and a clinical improvement. In our case, we confirm the rapid introduction of Nocardia farcinica in the new lungs. The complex identification and the delay in treatment increased the morbimortality. There is a special need for its eradication in patients with lung transplant, due to the strong immunosuppressive treatment (AU)

[Nocardia farcinica lung infection in a patient with cystic fibrosis and a lung transplant]. / Infección pulmonar por Nocardia farcinica en un paciente con fibrosis quística y trasplante pulmonar.

Patients with cystic fibrosis have a higher risk of developing chronic respiratory infectious diseases. The Nocardia farcinica lung infection is rare in this group of patients, and there are limited publications about this topic. Its diagnosis is complex, due to the clinical and the radiology signs being non-specific. Identification of the agent responsible in the sputum culture is occasionally negative. It is a slow growing organism and for this reason treatment is delayed, which can lead to an increase in complications, hospitable stays, and mortality. A case is reported on a 26 year-old woman with cystic fibrosis and chronic lung colonization by Nocardia farcinica and Aspergillus fumigatus, on long-term treatment with ciprofloxacin, trimethoprim-sulfamethoxazole, and posaconazole, who was admitted to ICU after bilateral lung transplantation. The initial post-operative progress was satisfactory. After discharge, the patient showed a gradual respiratory insufficiency with new chest X-ray showing diffuse infiltrates. Initially, the agent was not seen in the sputum culture. Prompt and aggressive measures were taken, due to the high clinical suspicion of a Nocardia farcinica lung infection. Treatment with a combination of amikacin and meropenem, and later combined with linezolid, led to the disappearance of the lung infiltrates and a clinical improvement. In our case, we confirm the rapid introduction of Nocardia farcinica in the new lungs. The complex identification and the delay in treatment increased the morbimortality. There is a special need for its eradication in patients with lung transplant, due to the strong immunosuppressive treatment.