PMC8517639_01
Dynamic changes of laboratory examination. (A) WBC, NE underwent significant reduction after taking meropenem and TMP-SMX. (B) CRP, PCT underwent significant reduction after taking meropenem and TMP-SMX. (C) Renal glomerular function improved with lower urinary protein/24h urinary protein quantification. (D) Renal function retaining almost steady on the creatinine, eGFR, urea.
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After tacrolimus administration, the patient received corticosteroid therapy (oral prednisone 50 mg once a day, 5 mg reduced every half month) combined with cyclophosphamide (1.0 g per month), and her kidney function was found to have improved since then (Figure 1C and D). Moreover, significantly increased levels of inflammation-related indicators (WBC: 26.72x109 /L, NE: 23.14x109/L, CRP: 57.4 mg/L, PCT: 0.206 ng/L) were seen on laboratory examinations (Figure 1A and B), along with increasing levels of coagulation indicators (Fg: 6.31 g/L, D-D: 4.4 ug/mL), and slightly higher levels of serum tumour markers (CA125: 63 U/mL, CA199: 38.4 U/mL, Cyfra21-1: 3.38U/mL). Furthermore, laboratory tests revealed that infection-related indicators were all significantly lower than them before (Figure 1A and B).
Chest CT examination, dynamic changes of the space-occupying lesions in lung. (A) regular chest CT: no space-occupying lesion in the right hilum. (B) regular chest CT: new-found multiple nodules in both lungs and space-occupying lesion in the right hilum. (C) enhanced chest CT: irregular nodules around the right lung hilum with mild enhancement, as well as right pleural effusion, enlarged mediastinal, and right hilar lymph nodes. (D) enhanced chest CT: smaller hilar lesion and hilar lymph nodes. (E) enhanced chest CT: a significant reduction in the size of lesions. (F-G) chest CT at follow-ups: no relapse of the lesions.
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Three months prior, her chest computed tomography (CT) scan showed multiple nodules in both lungs (Figure 2B), which were not observed in prior CT scans (Figure 2A). An enhanced chest CT also revealed irregular nodules around the right lung hilum with mild enhancement, right pleural effusion, and enlarged mediastinal and right hilar lymph nodes (Figure 2C). About half month later, another brain contrast-enhanced MRI was performed, revealing the ring-like enhancement lesion was smaller than the previous one (Figure 4B), and a chest-enhanced CT scan also showed lesion size reduction (Figure 2D).
Routine bacterial culture result, identification of bronchoscopy specimens: Nocardia (Magnifications: 100x). (A) yellowish bacterial colony growing after bronchoscopy specimen inoculated on the culture medium. (B and C) Gram-positive, partial acid-fast positive, rod-shaped bacterium.
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For further diagnosis, the patient underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy again, and cultures from pulmonary lesions revealed Nocardia species which was a gram-positive, partial acid-fast positive, rod-shaped bacterium (Figure 3A-C).
Brain contrast-enhanced MRI. (A) mixed solid-cystic lesions in the left frontal lobe, suggesting brain abscess/malignancy. (B) left frontal ring-like enhancement lesions, considering brain abscess, smaller than the previous one. (C) smaller left frontal ring-like enhancement lesions, enlarged scope of edema.
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The brain contrast-enhanced magnetic resonance imaging (MRI) images showed mixed solid cystic lesions (Figure 4A), additional diffusion-weighted imaging (DWI) results are showed in Figure 5. About half month later, another brain contrast-enhanced MRI was performed, revealing the ring-like enhancement lesion was smaller than the previous one (Figure 4B), and a chest-enhanced CT scan also showed lesion size reduction (Figure 2D). The relevant examination results are presented in Figures 1, 2E-G, 4C, 6C-E and 7. The clinical course is summarized in Figure 8.
DWI: Patchy diffusion restricted lesions with high signal in the left frontal lobe, the corresponding ADC diagram shows uneven low signal changes.
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The brain contrast-enhanced magnetic resonance imaging (MRI) images showed mixed solid cystic lesions (Figure 4A), additional diffusion-weighted imaging (DWI) results are showed in Figure 5. The relevant examination results are presented in Figures 1, 2E-G, 4C, 6C-E and 7. The clinical course is summarized in Figure 8.
Whole-abdominal CT contrast: dynamic changes of space occupying lesion in the right kidney and right abdominal encapsulated effusion. (A) enhanced abdominal CT: no abnormal presentation. (B) enhanced abdominal CT: new-found right abdominal encapsulated effusion and space-occupying lesion in the right kidney. (C) enhanced abdominal CT: a significant reduction in the size of lesions. (D and E) abdominal CT at follow-ups: no relapse of the lesions.
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Meanwhile, on whole-abdominal-enhanced CT, right abdominal encapsulated effusion and space-occupying lesions were reported (Figure 6B), which were not found in the previous inspection (Figure 6A). The relevant examination results are presented in Figures 1, 2E-G, 4C, 6C-E and 7. The clinical course is summarized in Figure 8.
The clinical course of this case.
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The relevant examination results are presented in Figures 1, 2E-G, 4C, 6C-E and 7. The clinical course is summarized in Figure 8.