PMC9279908_01
Chest CT imaging findings in two admissions. (A,B) Dense patchy shadows in the dorsal segment of bilateral lobes and a small amount of pleural effusion on the right; (C,D) chest CT of this admission (the diagnosis of Nocardia infection). Bilateral interstitial inflammatory changes. Old lung and pleura lesions. Limited emphysema in both lungs. Left pleural effusion. Heart enlargement, pericardial effusion, and left neck and left lung apex mass shadow.
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F1
The chest computed tomography (CT) scan showed dense patchy shadows in the dorsal lower lobes of both lungs (Figures 1A,B). On day 7 post-admission, chest high-resolution computed tomography (HRCT) showed a mass in the left neck and left apex of the lung (Figures 1C,D).
Transbronchial biopsy (TBLB) pathology of the basal segment of the right lower lobe through bronchoscopy: interstitial fibrosis with inflammatory cell infiltration. H&E staining: observed under the light microscope, the alveolar structure was not significantly damaged, alveolar type II epithelial hyperplasia, widening of alveolar space, accompanied by the proliferation of histiocytes and fibroblasts, and infiltrating lymphocytes between the alveolar cavity and small blood vessels.
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The histopathological results supported the diagnosis of COP after completing the transbronchial lung biopsy in our hospital (Figure 2).
Changes in laboratory study results after taking Piperacillin-Tazobactam, Meropenem, Linezolid, TMP-SMX, etc. (A) White blood cell (WBC) and neutrophils (NE) reduced significantly after taking Piperacillin-Tazobactam, Meropenem, Linezolid, TMP-SMX, etc. (B) C-reactive protein (CRP) and procalcitonin (PCT) reduced significantly after taking Piperacillin-Tazobactam, Meropenem, Linezolid, TMP-SMX, etc. (C) Changes in coagulation indicators during treatment.
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Laboratory studies showed that the white blood cell (WBC) count was 13.39 x 109/L (normal range 3.5-9.5 x 109/L), absolute neutrophils (NE) count was 10.98 x 109/L (normal range 1.8-6.3 x 109/L) (changes in laboratory study results are shown in Figure 3), C-reactive protein (CRP) 33.80 mg/L (normal range 0-5 mg/L), procalcitonin (PCT) 0.08 ng/ml (normal range 0-0.05 ng/ml) (Figure 3), fibrinogen (Fg) 5.6 g/L (normal range 2-4 g/L), d-dimer assay (D-D) 0.37 mug/ml (normal range 0-0.5 mug/ml) (Figure 3), CD4 T-cell count of 401 cells/mul, and CD8 T-cell count of 212 cells/mul. TMP-SMX (4 tablets every 8 h, each piece containing 80 mg of trimethoprim and 400 mg of sulfamethoxazole), and antibiotics were adjusted according to the condition (Figure 3). The patientndisymptoms gradually improved without adverse reactions.
Timeline of drug use during hospitalization.
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After testing for penicillin allergy, intravenous Piperacillin-Tazobactam (2.5 g every 12 h) and Linezolid (600 mg every 12 h) were initiated for 3 days to anti-inflammation, Eucalyptus, Limoneve, and Pinene (0.3 g every 8 h) and Acetylcysteine tablets (0.6 g every 12 h) for sputum, and active protein and potassium supplementation (Drug use is shown in Figure 4). TMP-SMX (4 tablets every 8 h) for 11 days (Figure 4), repeat ultrasound showed that all existing skin lesions were absorbed. The blood inflammatory index decreased significantly.
Changes in brain imaging. (A) Craniocerebral CT: The patchy low-density shadows were seen in the bilateral frontal and temporal lobes (the right side was the indigenous), and the patchy low-density shadows were also seen in the bilateral basal ganglia and paraventricular zone. The density of white matter in the paraventricular zone was reduced, and there was no abnormal density change in the cerebellum and brainstem; (B,C) craniocerebral MRI + enhancement + diffusion: bilateral frontal lobe abscess; (D,E) craniocerebral CT after abscess puncture and drainage: postoperative changes, bilateral frontal lobe multiple enhancement lesions, and some lesions shrink.
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The cranial CT was completed and showed large infarct foci in the brain (Figure 5A). Further refinement of cranial MR scan + enhancement + diffusion suggested bilateral frontal brain abscess (Figures 5B,C). On day 25 post-admission, the patient underwent cranial abscess puncture and drainage in the neurosurgery department, and after the operation, the patient's symptoms, such as blurred vision and headache improved significantly (Figures 5D,E).
Routine bacterial culture result: Nocardia. (A) White, unequal, wrinkling, and granular colonies were growing on the culture medium. (B) Gram-staining of bacterial cultures shows Gram-positive bacteria. (C) Weak acid-fast staining.
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The bacteria were presumptively identified as belonging to Nocardia species (Figure 6).