Letter to the Editor
Septic Shock Due to Rhodococcus equi in a Patient With Chronic Myelomonocytic Leukemia
Shock séptico por Rhodococcus equi en paciente con leucemia mielomonocítica crónica
Claudia Josa Laorden
, Carmen Gómez del Valle, Marina Bucar Barjud, Maria Beatriz Amores Arriaga, Miguel Angel Torralba Cabeza, Juan Ignacio Pérez Calvo
Corresponding author
Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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Although generally transmitted to humans by inhalation, on this occasion contact with manure in an immunosuppressed patient with chronic myelomonocytic leukaemia (CMML) caused a serious lung infection.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical Case</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 79-year-old patient with a clinical history of myocardial infarction, heart failure and global respiratory failure. He had been diagnosed 12 months previously with CMML type 1, for which he had not been treated. He came into contact with the manure when using it as fertiliser.</p><p id="par0015" class="elsevierStylePara elsevierViewall">He attended the emergency department due to a decreased level of consciousness, asthenia and drowsiness. Physical examination showed blood pressure 73/47<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate 120<span class="elsevierStyleHsp" style=""></span>beats/min, mild fever and basal oxygen saturation of 86%. He was conscious, prone to bradypsychia and dehydrated. Laboratory tests revealed 59<span class="elsevierStyleHsp" style=""></span>900<span class="elsevierStyleHsp" style=""></span>leukocytes/mm<span class="elsevierStyleSup">3</span> with 90% neutrophils and 46<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>platelets/mm<span class="elsevierStyleSup">3</span>. Previous tests carried out for regular monitoring of his CMML showed leukocytes 15<span class="elsevierStyleHsp" style=""></span>000/mm<span class="elsevierStyleSup">3</span>. Chest X-ray showed a rounded high attenuation area in the right hemithorax, with no air bronchogram, measuring 5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm, on the right parahilar region (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). Blood cultures were drawn and intravenous imipenem treatment was initiated empirically, due to suspected sepsis and pulmonary mass.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Thoracoabdominal computed tomography (CT) was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b), showing a heterogeneous mass with marginal spiculation, 5<span class="elsevierStyleHsp" style=""></span>cm in diameter, located in the anterolateral segment of the right upper lobe, with wide pleural contact. Radiologically, the lesion was suggestive of lung neoplasm. Fine needle aspiration was carried out, revealing acute abscessing inflammation associated with a pattern of organizing pneumonia, with no evidence of malignancy. HIV serology was negative. Finally, blood cultures were positive for <span class="elsevierStyleItalic">R. equi.</span></p><p id="par0025" class="elsevierStylePara elsevierViewall">Patient progress was excellent with imipenem during his hospitalization and following sequential therapy at home with ciprofloxacin and oral rifampicin. Three months later, the pulmonary mass had disappeared and 12 months later the patient remained asymptomatic with periodic check-ups at the haematology clinic.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The first infection caused by <span class="elsevierStyleItalic">R. equi</span> in man was described in 1967. It showed a chronic granulomatous process characterized by aggregates of PAS positive histocytes that contained inclusions known as Michaelis–Gutmann bodies (malacoplakia) and necrotizing abscesses associated with intracellular Gram positive cocci, characteristic of <span class="elsevierStyleItalic">R. equi</span> infection.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Despite this, malacoplakia is not specific to this infection, as <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>, <span class="elsevierStyleItalic">Pasteurella multocida</span> and <span class="elsevierStyleItalic">Escherichia coli</span> can cause histologically similar lesions, although not as often in immunocompromised patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The primary infection occurs in the lung in approximately 80% of cases, often presenting cavitated consolidation in the upper lobe.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It is a rare pathogen in immunocompetent patients, which represent 10%–15% of cases, mainly renal transplant patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In 2010, the first case was reported in which a patient with chronic lymphoid leukaemia developed cavitated pneumonia caused by this microorganism after receiving fluarabin treatment.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">It should be suspected in immunosuppressed patients who present with pneumonia with an insidious clinical course, pulmonary abscess, granulomatous lesions, brain abscess or fever of unknown origin. The radiological differential diagnosis should be made mainly with pneumonia due to <span class="elsevierStyleItalic">Pneumocystis jirovecci</span> or <span class="elsevierStyleItalic">Staphylococcus aureus</span>, central bronchogenic carcinoma and pulmonary tuberculosis. <span class="elsevierStyleItalic">R. equi</span> is usually susceptible to combined antibiotic therapies, which include macrolides, rifampicin, aminoglycosides and imipenem. Two or three antibiotics should always been combined; those with intracellular activity, such as rifampicin or azithromycin, are recommended. With respect to the prognosis, the mortality reaches 50% in HIV patients, 25% in other types of immunosuppression and 11% in immunocompromised patients.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">It is exceptionally observed in immunocompromised patients who do not have HIV, as in our case, where despite not being on active immunosuppressant treatment, the cellular immunosuppression caused by the myelomonocytic leukaemia and contact with the contaminated manure triggered this serious lung infection.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical Case" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Josa Laorden C, Gómez del Valle C, Bucar Barjud M, Amores Arriaga MB, Torralba Cabeza MA, Pérez Calvo JI. Shock séptico por <span class="elsevierStyleItalic">Rhodococcus equi</span> en paciente con leucemia mielomonocítica crónica. Arch Bronconeumol. 2013;49:497–498.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 427 "Ancho" => 1301 "Tamanyo" => 72898 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest radiograph (a) and chest CT scan (b) right parahilar mass.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary malacoplakia associated with <span class="elsevierStyleItalic">Rhodococcus equi</span> infection in a patient with AIDS" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Romero" 1 => "B. Dominguez" 2 => "D. García-Gil" 3 => "A. Vergara de Campos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2008.02.006" "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2009" "volumen" => "27" "paginaInicial" => "63" "paginaFinal" => "64" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19218010" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Rhodococcus equi</span> infection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.V. Yamshchivok" 1 => "A. Schuetz" 2 => "G.M. Lyon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1473-3099(10)70068-2" "Revista" => array:6 [ "tituloSerie" => "Lancet Infect Dis" "fecha" => "2010" "volumen" => "10" "paginaInicial" => "350" "paginaFinal" => "359" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20417417" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Rhodococcus equi:</span> an emerging pathogen" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.M. Weinstock" 1 => "A.E. Brown" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/340259" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2002" "volumen" => "34" "paginaInicial" => "1379" "paginaFinal" => "1385" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11981734" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Rhodococcus equi</span> pneumonia in a patient with fludarabine-treated chronic lymphocytic leukemia and CD4-lymphopenia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.S. Gelfand" 1 => "K.O. Cleveland" 2 => "S.C. 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García" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Chil Infect" "fecha" => "2006" "volumen" => "23" "paginaInicial" => "155" "paginaFinal" => "156" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000004900000011/v1_201310300902/S1579212913001596/v1_201310300902/en/main.assets" "Apartado" => array:4 [ "identificador" => "14576" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000004900000011/v1_201310300902/S1579212913001596/v1_201310300902/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212913001596?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 1 | 8 |
| 2024 October | 47 | 21 | 68 |
| 2024 September | 56 | 18 | 74 |
| 2024 August | 91 | 36 | 127 |
| 2024 July | 57 | 26 | 83 |
| 2024 June | 70 | 28 | 98 |
| 2024 May | 75 | 25 | 100 |
| 2024 April | 50 | 21 | 71 |
| 2024 March | 85 | 20 | 105 |
| 2024 February | 59 | 14 | 73 |
| 2023 March | 15 | 5 | 20 |
| 2023 February | 54 | 19 | 73 |
| 2023 January | 51 | 27 | 78 |
| 2022 December | 62 | 30 | 92 |
| 2022 November | 56 | 26 | 82 |
| 2022 October | 47 | 37 | 84 |
| 2022 September | 46 | 30 | 76 |
| 2022 August | 60 | 38 | 98 |
| 2022 July | 46 | 41 | 87 |
| 2022 June | 41 | 30 | 71 |
| 2022 May | 62 | 34 | 96 |
| 2022 April | 53 | 32 | 85 |
| 2022 March | 64 | 36 | 100 |
| 2022 February | 63 | 32 | 95 |
| 2022 January | 61 | 43 | 104 |
| 2021 December | 57 | 41 | 98 |
| 2021 November | 55 | 44 | 99 |
| 2021 October | 74 | 34 | 108 |
| 2021 September | 48 | 45 | 93 |
| 2021 August | 35 | 18 | 53 |
| 2021 July | 50 | 33 | 83 |
| 2021 June | 62 | 42 | 104 |
| 2021 May | 48 | 33 | 81 |
| 2021 April | 113 | 72 | 185 |
| 2021 March | 59 | 11 | 70 |
| 2021 February | 39 | 23 | 62 |
| 2021 January | 38 | 11 | 49 |
| 2020 December | 37 | 11 | 48 |
| 2020 November | 30 | 15 | 45 |
| 2020 October | 35 | 11 | 46 |
| 2020 September | 32 | 13 | 45 |
| 2020 August | 42 | 11 | 53 |
| 2020 July | 47 | 25 | 72 |
| 2020 June | 27 | 5 | 32 |
| 2020 May | 58 | 17 | 75 |
| 2020 April | 59 | 25 | 84 |
| 2020 March | 37 | 15 | 52 |
| 2020 February | 55 | 17 | 72 |
| 2020 January | 74 | 14 | 88 |
| 2019 December | 48 | 17 | 65 |
| 2019 November | 32 | 22 | 54 |
| 2019 October | 37 | 6 | 43 |
| 2019 September | 28 | 16 | 44 |
| 2019 August | 31 | 11 | 42 |
| 2019 July | 27 | 14 | 41 |
| 2019 June | 30 | 11 | 41 |
| 2019 May | 34 | 11 | 45 |
| 2019 April | 73 | 34 | 107 |
| 2019 March | 47 | 21 | 68 |
| 2019 February | 34 | 18 | 52 |
| 2019 January | 44 | 17 | 61 |
| 2018 December | 46 | 22 | 68 |
| 2018 November | 73 | 19 | 92 |
| 2018 October | 100 | 24 | 124 |
| 2018 September | 35 | 11 | 46 |
| 2018 June | 1 | 0 | 1 |
| 2018 May | 20 | 0 | 20 |
| 2018 April | 59 | 2 | 61 |
| 2018 March | 33 | 3 | 36 |
| 2018 February | 44 | 15 | 59 |
| 2018 January | 90 | 2 | 92 |
| 2017 December | 90 | 4 | 94 |
| 2017 November | 55 | 7 | 62 |
| 2017 October | 25 | 13 | 38 |
| 2017 September | 46 | 8 | 54 |
| 2017 August | 47 | 7 | 54 |
| 2017 July | 40 | 5 | 45 |
| 2017 June | 53 | 10 | 63 |
| 2017 May | 46 | 7 | 53 |
| 2017 April | 27 | 10 | 37 |
| 2017 March | 28 | 29 | 57 |
| 2017 February | 28 | 4 | 32 |
| 2017 January | 19 | 4 | 23 |
| 2016 December | 54 | 11 | 65 |
| 2016 November | 44 | 7 | 51 |
| 2016 October | 47 | 14 | 61 |
| 2016 September | 55 | 9 | 64 |
| 2016 August | 66 | 7 | 73 |
| 2016 July | 42 | 11 | 53 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 2 | 0 | 2 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 62 | 1 | 63 |
| 2015 September | 53 | 7 | 60 |
| 2015 August | 55 | 9 | 64 |
| 2015 July | 48 | 7 | 55 |
| 2015 June | 61 | 5 | 66 |
| 2015 May | 77 | 15 | 92 |
| 2015 April | 38 | 7 | 45 |
| 2015 March | 44 | 9 | 53 |
| 2015 February | 38 | 4 | 42 |
| 2015 January | 32 | 7 | 39 |
| 2014 December | 35 | 7 | 42 |
| 2014 November | 25 | 7 | 32 |
| 2014 October | 53 | 11 | 64 |
| 2014 September | 35 | 12 | 47 |
| 2014 August | 52 | 13 | 65 |
| 2014 July | 34 | 11 | 45 |
| 2014 June | 71 | 15 | 86 |
| 2014 May | 78 | 14 | 92 |
| 2014 April | 58 | 16 | 74 |
| 2014 March | 74 | 14 | 88 |
| 2014 February | 46 | 13 | 59 |
| 2014 January | 1 | 0 | 1 |
| 2013 December | 0 | 2 | 2 |
| 2013 November | 0 | 2 | 2 |
| 2013 October | 0 | 1 | 1 |
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