JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
NOCARDIOSIS EXACERBATED BY IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME
THIS HEADACHE IS NOT A BLAST
J. Wearn, MD; L. Taggart, MD Department of Internal Medicine, Tulane University Health Sciences Center, New Orleans
J. Doan, MD; L. Damioli, MD; R. Lillis, MD Department of Internal Medicine, LSU Health Sciences Center - New Orleans
Case: A 46-year-old man presented with one week of intermittent headaches. The pain started in his neck and radiated to the eyes. There was associated nausea and vomiting. On the day of admission, he experienced visual hallucinations prompting him to seek medical care. Further history revealed he was diagnosed with CML the previous year and had a blast crisis three months prior treated with induction chemotherapy, leukopharesis, and one round of intrathecal methotrexate due to concern of leukemic retinopathy. Cerebral spinal fluid (CSF) returned without blasts at that time. Bone marrow biopsy at 30 days after chemotherapy induction did not reveal any blasts and patient was continued on imatinib maintenance therapy. On exam, the patient was afebrile with normal vital signs. Kernig, Brudzinski, and jolt testing were negative. He was alert and oriented with normal cognition and an otherwise normal exam. No acute intracranial abnormality was noted on CT of the head. CBC returned with an elevated leukocyte count of 14,000/uL. The following day the patient developed diplopia and peripheral smear revealed 57% blasts. Cerebral spinal fluid (CSF) studies revealed leukocyte level of 1600/uL and 99% blasts confirming diagnosis of central nervous system (CNS) blast crisis. Discussion: CNS blast crisis is a rare diagnosis but important to keep on the differential for any patient with CML who presents with a headache. Furthermore it is important to realize that imatinib has poor CSF penetration compared to second- generation tyrosine kinase inhibitor. Confounding this case was the fact that imatinib carries high rates of adverse side effects that mimic the common symptoms associated with CNS blast crisis: up to 38% of patients on imatinib experience headaches, up to 73% have nausea, and up 11% experience vision changes. Our patient was treated with re-induction chemotherapy with cytarabine, etoposide, mitoxantrone, intrathecal methotrexate, and dasatinib. Despite treatment, a CNS blast crisis carries a poor prognosis with 88% mortality at 1 year.
Case: A 62-year-old woman with past medical history of HIV/ AIDS with CD4 48/mm 3 and noncompliance with combination antiretroviral therapy (cART) was admitted to an outside hospital twomonths prior and diagnosedwith cavitary Nocardia farcinica pneumonia. She was treated with imipenem and amikacin, but developed a morbilliform drug eruption concerning for DRESS; dermatologydetermined that the rashwasmore likely secondary to imipenem. Her treatment was discontinued after only twelve days of imipenem and seven days of amikacin. Repeat CT chest showed a new cavitary lesion in the right upper lobe of the lung. She was discharged with oral trimethoprim/sulfamethoxazole (TMP-SMX). She followed up with her HIV provider and was started on cART, which she took consistently. She felt well until the followingmonthwhen she suffered two tonic-clonic seizures and left sided weakness. She denied diplopia, headache, nausea or vomiting. CT brain scan demonstrated a right frontal lobe ring enhancing mass consistent with a brain abscess. She was started on amikacin, moxifloxacin and TMP-SMX with improvement of weakness. She was continued on cART with significant increase in CD4 T-cell count from 48 to 92/mm 3 and decrease of viral load from 195,128 to 1,955 copies/mL. A MRI brain was later repeated with increased size of the brain abscess and vasogenic edema. She underwent evacuation of the abscess. Gram stain from the brain abscess grew filamentous, branching, beaded gram positive rods that were modified acid fast positive that speciated as Nocardia farcinica. She was treated with six weeks of induction with TMP-SMX and amikacin followed by oral treatment with TMP-SMX and minocycline for at least one year given her HIV/AIDS status. cART was held due to concern for immune reconstitution inflammatory syndrome (IRIS) with plans to resume based on continued radiologic improvement. Discussion: Pulmonary Nocardiosis with neurological deficits should prompt evaluation for CNS involvement. Perhaps, early initiation of cART along with inadequate treatment of pulmonary Nocardia resulted in “unmasking” her brain abscess consistent with IRIS, a paradoxical inflammatory response that may result when a patient with HIV/AIDS has regained an immune response.
56 J La State Med Soc VOL 170 MARCH/APRIL 2018
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