Table 2.
Yale New Haven Hospital nocardiosis cases in solid organ transplant recipients who underwent beta-D-glucan testing.
| Age/sex | Relevant comorbidities | Immunosuppression | SOT induction therapy | Antimicrobial prophylaxis | Time since SOT | Diagnosis | Species | Diagnostic methods | Negative fungal diagnostics | Peak BDG level | Potential BDG confounders | Outcome |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cases with elevated BDG | ||||||||||||
| 51/M | Kidney transplant | Tacrolimus, mycophenolate mofetil, prednisone (5 mg/daily) | Alemtuzumab | Atovaquone, acyclovir | 2 months | Pulmonary | Nocardia nova/africana | BAL culture | Fungal BAL culture, Pneumocystis jirovecii BAL PCR, galactomannan BAL testing, serum cryptococcal antigen, urine histoplasma antigen | >500 pg/mL | None | Clinical improvement |
| 64/M | Liver transplant | Tacrolimus, mycophenolate mofetil, prednisone (5 mg/daily) | N/A | None | 2 years | Disseminated (skin abscess and CNS) | Nocardia anaemiae/N. pseudovaccinii | Abscess I&D and nocardia culture | Fungal wound culture, fungal blood culture, fungal CSF culture, urine histoplasma antigen, serum cryptococcal antigen, serum coccidioides antigen, toxoplasmosis PCR | >500 pg/mL | None | Deceased due to shock and decompensated cirrhosis |
| 62/Fa | Kidney-pancreas transplant | Tacrolimus, mycophenolate mofetil, prednisone (5 mg/daily) | N/A | None | 11 years | Disseminated (pulmonary and cardiac) | Nocardia abscessus | BAL culture | Fungal BAL culture, fungal blood culture, urine histoplasma antigen, serum cryptococcal antigen, serum coccidioides antigen | >500 pg/mL | IVIG (1 week prior to initial BDG; BDG 5 weeks after last IVIG dose was 331 pg/mL) | Deceased due to cardiogenic shock after mitral valve repair |
| Cases with normal BDG | ||||||||||||
| 52/Ma | Kidney transplant | Mycophenolate mofetil, prednisone (5 mg/daily), belatacept monthly, eculizumab biweekly | Thymoglobulin | Atovaquone, valganciclovir | 10 weeks | Disseminated (CNS, pulmonary, and skin) | Nocardia farcinica | Blood and deep wound cultures | Serum cryptococcal antigen | 46 pg/mL | None | Clinical improvement |
| 57/F | Heart transplant | Tacrolimus, mycophenolate mofetil, prednisone (5 mg/daily) | Basiliximab | Atovaquone, acyclovir | 2 months | Skin abscess | Nocardia farcinica | Abscess I&D and nocardia culture | N/A | <31 pg/mL | None | Clinical Improvement |
| 53/F | Kidney transplant | Tacrolimus, mycophenolate mofetil, prednisone (3 mg/daily) | N/A | None | 17 years | Disseminated (CNS, pulmonary and skin) | Nocardia spp. | Abscess I&D and nocardia culture | N/A | <31 pg/mL | None | Clinical Improvement |
| 66/M | Kidney transplant | Tacrolimus, mycophenolate mofetil, prednisone (5 mg/daily) | Alemtuzumab | None | 3 years | CNS | Nocardia farcinica | Brain abscess drainage with tissue culture | N/A | <31 pg/mL | None | Clinical stability at follow up (2 months after discharge) |
| 50/M | Kidney transplant | Belatacept, mycophenolate mofetil, prednisone (5 mg/daily) | Alemtuzumab | Valganciclovir, atovaquone | 8 months | Disseminated (CNS, pulmonary) | Nocardia nova complex | Brain abscess drainage with tissue culture | N/A | <31 pg/mL | None | Clinical and radiologic improvement |
| 65/M | Kidney transplant | Tacrolimus, mycophenolate mofetil, prednisone (5 mg/daily) | Alemtuzumab | None | 1 year | Pulmonary | Nocardia nova complex | BAL culture | N/A | <31 pg/mL | None | Clinical and radiologic improvement |
Abbreviations: BAL, bronchoalveolar lavage; BDG, beta-D-glucan; CNS, central nervous system; CSF, cerebrospinal fluid; I&D, incision and drainage; IVIG, intravenous immunoglobulin; N/A, not applicable; PCR, polymerase chain reaction; SOT, solid organ transplantation.
a
Although these patients were on hemodialysis at the time of admission, our institution uses non-cellulose membranes. As a result, this was not deemed to confound the BDG level.