Nocardia are beaded, branching gram-positive rods that are partially acid fast and usually slow growing. Nocardia cyriacigeorgica was first described in 2001, and antimicrobial susceptibility patterns correspond with type VI Nocardia asteroides complex. Nocardia species are not a commonly associated with endocarditis, less than 20 cases to date have been documented. However, when Nocardia endocarditis is identified, the mortality rate is reported to be as high as 41% making antibiotic selection vital in the inpatient and outpatient
A 62-year old male with a past medical history significant for severe Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation, atrial tachyarrhythmia, and Congestive Heart Failure (CHF) presented to the emergency department (ED) with shortness of breath for one week. The patient was initiated on IV diltiazem, meropenem, and eventually required intubation. On hospital day two blood cultures grew gram positive rods, which were eventually identified as aerobic Actinomycete. Culture was sent out for DNA sequencing and N. cyriacigeorgica was identified. Transthoracic echocardiogram showed possible mitral vegetation.
Antimicrobial therapy was initially de-escalated from meropenem to ampicillin, but had to be escalated to ceftriaxone once N. cyriacigeorgica was identified by DNA sequencing. The organism was reported to be susceptible to amikacin, ceftriaxone, linezolid, tobramycin, and trimethoprim/sulfamethoxazole. The patient received one week of ceftriaxone therapy inpatient, and was discharged on an additional three weeks of ceftriaxone and six months of minocycline suppressive therapy.
Two months later the patient was re-admitted for N. cyriacigeorgica bacteremia and a pulmonary embolism. During his hospital stay the patient had a STEMI, but due to multiple comorbidities did not undergo cardiac catheterization. The family elected to withdrawal care, and the patient expired.
N. cyriacigeorgica is more commonly identified in brain abscesses or skin infections, in the setting of immunosuppression. We report here on an unusual case of N. cyriacigeorgica endocarditis in a patient with COPD. Other than COPD the patient had no known risk factors for N. cyriacigeorgica, including chronic steroid use.