OPPORTUNISTIC CUTANEOUS NOCARDIOSIS IN A PATIENT WITH ADVANCED HIV. Margaret Conrad 1 , Sarah Bahnshal MD 2 , Laura Rachal MD 2 ; LSU School of Medicine, LSU Health New Orleans, Health Sciences Center, School of Medicine, New Orleans, LA 1 ; Tulane University School of Medicine, Department of Medicine, New Orleans, LA 2 .
Introduction: Nocardia is an opportunistic bacterial infection with 60% of reported cases associated with solid organ and hematopoietic stem cell transplant HIV, lymphoreticular malignancy, and chronic corticosteroids. This abstract demonstrates a cutaneous infection presented in a patient with advanced HIV and suspected immune reconstitution inflammatory syndrome (IRIS). Case: A 41-year-old male with advanced HIV (detectable viral load and CD4 <50 on admission) and a history of intravenous drug use presented with atypical behavior, fever, and nodular lesions on his bilateral upper and lower extremities with concern for hip abscess. Chart review revealed a history of cutaneous Nocardia Farcinica diagnosed a year prior, with intermittent treatment due to untreated mental health and unstable housing. Biopsy of new nodular lesions again confirmed Nocardia farcinia infection; additional testing for fungi, viral, and histopathology showed no other concomitant infectious process. A Brain MRI and Chest CT revealed no related central nervous system or pulmonary disease. The
patient was treated based on susceptibilities of their Nocardia farcinia and antiretroviral medications. Workup for other opportunistic infections was pursued; symptoms resolved before discharge and thus IRIS and poorly controlled underlying mental health conditions were suspected as the cause of these symptoms. The patient was discharged to a long-term acute care facility to receive wound care in addition to 6-month course of trimethoprim-sulfamethoxazole and ceftriaxone for disseminated cutaneous Nocardia farcinia. Discussion: This case describes the possibility of cutaneous Nocardiosis without typical disseminated findings suggestive of central nervous system or pulmonary Nocardia. Since the lesions were more disseminated and less sporotrichoid in distribution, we used the literature to choose a prolonged course typically for patients with T cell immunosuppression (i.e. Solid Organ Transplant patients). Lastly, this case stresses the importance of social and mental health support in the treatment of patients living with HIV.
INCIDENTAL FINDING OF MULTIPLE, ENHANCING LIVER LESIONS IN THE SETTING OF MITOCHONDRIAL MYOPATHY. Gurtaj Mahil 1 , Sepehr Sadeghi DO 2 , Oluwafemi Ajibola MD 2 , Bennett de Boisblanc MD 2 ; William Carey University College of Osteopathic Medicine, Hattisberg, MS 1 ; Department of Medicine, LSU Health New Orleans, New Orleans, LA 2 .
Introduction: Mitochondrial myopathies can affect a wide range of organ systems. While hepatopathies arise, clinically silent hepatic lesions have not been previously reported. Case: A 28-year-old female with a gastrostomy tube, tracheostomy, foley catheter-dependence, mitochondrial myopathy and chronic neuromuscular respiratory failure presented with acute onset of shortness of breath and blood-tinged tracheal aspirate. On arrival, the patient was saturating at 60% on room air. Arterial blood gas analysis revealed acidosis and hypercapnia. The patient was stepped up to the intensive care unit (ICU) given increased oxygen requirements. Her respiratory status improved after suctioning the tracheostomy tube and
the patient was gradually transitioned to her home ventilation settings. Computed tomography of the chest with contrast ruled out a pulmonary embolism but did reveal bilateral lower lobe consolidations suggestive of pneumonia. Incidentally, multiple small enhancing lesions throughout the liver were also identified; the largest of which was 1.9 cm. Initially, hepatic studies showed an AST 63, ALT 48, and alkaline phosphatase 136, all of which normalized within a week of hospitalization. Abdominal ultrasound revealed a non-enlarged, homogeneous echotexture of the liver and a significantly dilated bladder. Urinalysis findings suggested a urinary tract infection (UTI) in the setting of urinary retention. Urine cultures grew Providencia UTI and blood cultures grew methicillin-resistant Staphylococcus
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