SHM Converge Scientific Abstract ePoster Gallery-Silent Soil Threat: Disseminated Nocardiosis in a Patient With Rheumatoid Arthritis

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This case report describes an 87-year-old man with rheumatoid arthritis on chronic prednisone who developed disseminated nocardiosis, a rare opportunistic infection. He presented after a syncopal episode with one week of weakness, poor oral intake, and left leg pain. His medical history included HFpEF, atrial fibrillation, CKD stage IV, RA, and vertebral compression fractures.<br /><br />In the emergency department, he was hypotensive and in AFib with rapid ventricular response, which improved with fluids. CT angiography ruled out pulmonary embolism but revealed new bilateral pulmonary nodules and multiple enhancing mass-like lesions in the lumbar spine and pelvis, initially concerning for metastatic cancer. Ultrasound also showed a soft tissue mass in the left leg. Biopsy of a left paraspinal mass and aspiration of the leg lesion both identified Nocardia cyriacigeorgica. Brain imaging confirmed CNS dissemination.<br /><br />He was treated with linezolid and imipenem, but his course was complicated by serotonin syndrome, severe malnutrition, and profound deconditioning. Palliative care was consulted, and he ultimately transitioned to comfort-focused care.<br /><br />The discussion highlights that disseminated nocardiosis is especially dangerous in immunocompromised patients, with CNS involvement carrying very high mortality. Diagnosis is often difficult because imaging can mimic malignancy and symptoms may be nonspecific or absent. In this patient, chronic steroid use for RA and recent soil exposure from gardening were key risk factors. The authors emphasize prolonged antibiotic therapy, the challenge of adherence and side effects, and the importance of multidisciplinary, patient-centered care in complex infections.

Asset Subtitle

Hakeem Asad

Meta Tag

Author List Aarif Motorwala, Hakeem Asad, Maria Santiago Estevez, Omar Asad, Paulina Marell

Category Clinical Vignettes

Concept Disseminated Nocardiosis

Concept Opportunistic Infection

Concept Immunocompromised State

Concept Tissue Biopsy

Concept Microbiologic Confirmation

Distinguished Non-Finalist

Presenter Organization Mayo Clinic Rochester, Department of Internal Medicine

Presenting Author Hakeem Asad

Track Adult

Keywords

disseminated nocardiosis

Nocardia cyriacigeorgica

rheumatoid arthritis

chronic prednisone

immunocompromised host

central nervous system dissemination

pulmonary nodules

spinal mass lesions

serotonin syndrome

palliative care

Disseminated Nocardiosis

Opportunistic Infection

Immunocompromised State

Tissue Biopsy

Microbiologic Confirmation