Letter to the Editor
Severe Pneumonia Caused by Rhodococcus equi With Hematogenous Spread to the Central Nervous System in an Immunocompromised Patient
Neumonía grave por Rhodococcus equi con diseminación hematógena al sistema nervioso central en un paciente inmunodeprimido
Ana Isabel Enríquez Rodríguez
, Marta García Clemente, Herminia L. Buchelli Ramírez
Corresponding author
Área de Gestión Clínica del Pulmón, Neumología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Severe Pneumonia Caused by <span class="elsevierStyleItalic">Rhodococcus equi</span> With Hematogenous Spread to the Central Nervous System in an Immunocompromised Patient" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "203" "paginaFinal" => "204" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ana Isabel Enríquez Rodríguez, Marta García Clemente, Herminia L. Buchelli Ramírez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Ana Isabel" "apellidos" => "Enríquez Rodríguez" "email" => array:1 [ 0 => "anaisenriquez@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Marta" "apellidos" => "García Clemente" ] 2 => array:2 [ "nombre" => "Herminia L." "apellidos" => "Buchelli Ramírez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Área de Gestión Clínica del Pulmón, Neumología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumonía grave por <span class="elsevierStyleItalic">Rhodococcus equi</span> con diseminación hematógena al sistema nervioso central en un paciente inmunodeprimido" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 720 "Ancho" => 1500 "Tamanyo" => 121683 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Chest X-ray showing cavitated infiltrate in upper right lobe and infiltrate without cavitation in lower left lobe. (B) Head MRI showing multiple nodular lesions, less than 1<span class="elsevierStyleHsp" style=""></span>cm in size, in the cortical-subcortical region, and vasogenic edema.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of a 59-year-old man who presented in the emergency room with a 48-h history of fever 38.8<span class="elsevierStyleHsp" style=""></span>°C, dyspnea and cough. He had a prior diagnosis of cryptogenic organizing pneumonia and was receiving prednisone 70<span class="elsevierStyleHsp" style=""></span>mg/day and azathioprine 25<span class="elsevierStyleHsp" style=""></span>mg/day.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination showed fever 37.9<span class="elsevierStyleHsp" style=""></span>°C, blood pressure 135/78<span class="elsevierStyleHsp" style=""></span>mmHg, breathing rate 28 breaths/minute and heart rate 103 beats/minute, with bilateral fine crackles on lung auscultation. Blood test results showed 16<span class="elsevierStyleHsp" style=""></span>600 leukocytes, 303<span class="elsevierStyleHsp" style=""></span>000 platelets, and normal serum biochemistry (including liver function tests and procalcitonin), with the exception of C-reactive protein 5.7<span class="elsevierStyleHsp" style=""></span>mg/dl. Baseline arterial blood gases were pO<span class="elsevierStyleInf">2</span> 63<span class="elsevierStyleHsp" style=""></span>mmHg, pCO<span class="elsevierStyleInf">2</span> 36<span class="elsevierStyleHsp" style=""></span>mmHg, pH 7.43 and oxyhemoglobin saturation 91%. Standard posteroanterior chest X-ray revealed cavitated alveolar infiltrate in the right upper lobe and infiltrate without cavitation in the left lower lobe (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Two blood cultures were performed, in aerobic and anaerobic media, and empirical treatment was started with piperacillin-tazobactam. Urine was negative for pneumococcal and <span class="elsevierStyleItalic">Legionella</span> antigens. After 4 days of antibiotic treatment without improvement, a chest–abdomen CT was performed, confirming previous radiological findings, with no other changes. <span class="elsevierStyleItalic">Rhodococcus equi</span> was isolated from both blood cultures, so based on susceptibility test results treatment was switched to imipenem, rifampicin and gentamicin. After 10 days of hospitalization, the patient began to complain of headache and instability, so magnetic resonance imaging (MRI) of the head was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B), revealing 8 cortical-subcortical nodular lesions, less than 1<span class="elsevierStyleHsp" style=""></span>cm in size, indicative of brain abscesses.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Intravenous treatment was maintained for 2 months, followed by 4 more months of oral azithromycin and trimethoprim-sulfametoxazole. After 2 weeks of treatment, respiratory clinical signs had resolved and chest X-ray was normal. One month later, blood cultures were negative, and neurological signs had resolved. A follow-up head MRI at 3 months was normal.</p><p id="par0025" class="elsevierStylePara elsevierViewall">There are more than 15 <span class="elsevierStyleItalic">Rhodococcus</span> species ubiquitous in the environment. They are strictly aerobic, intracellular Gram-positive coccobacilli that infect macrophages and polymorphonuclear cells. Some uncommon species, such as <span class="elsevierStyleItalic">R. luteus</span>, <span class="elsevierStyleItalic">R. erythropolis</span>, <span class="elsevierStyleItalic">R. ruber</span> and <span class="elsevierStyleItalic">R. rhodochrous</span>, mainly cause skin and corneal infections. <span class="elsevierStyleItalic">R. equi</span>, primarily transmitted via inhalation from contact with animals, is the most common and most pathogenic in humans. Cell immunosuppression is the major risk factor for infection, particularly in patients with acquired immunosuppression due to human immunodeficiency virus (HIV), although 10%–15% of infections occur in immunocompetent patients.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> The most common form of presentation in immunocompromised patients is cavitated pneumonia of the lower lobes<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> (84%), while in immunocompetent patients, infections tend to be localized and extrapulmonary (42%),<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a> generally involving the central nervous system (abscesses, meningitis, etc.) and the skin (abscesses).</p><p id="par0030" class="elsevierStylePara elsevierViewall">The respiratory process is insidious, manifesting as high fever, cough, dyspnea, chest pain and weight loss.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> It is identified and diagnosed from the culture of affected tissue samples.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Blood cultures are positive in 50% of immunocompromised subjects, as was the case for our patient, and in 10% of immunocompetent subjects.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> There is no standard treatment. <span class="elsevierStyleItalic">Rhodococcus</span> is resistant to betalactams, except for imipenem, and susceptible to macrolides, rifampicin, aminoglycosides and vancomycin. Susceptibility to fluoroquinolones, clindamycin, trimethoprim-sulfamethoxazole and tetracyclines is variable.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,5</span></a> Treatment with 2 or 3 drugs is recommended, of which at least 1 should have good intracellular activity, such as rifamipicin or azithromycin.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In immunocompetent subjects with localized infection, successful outcomes have been reported with a combination of 2 antibiotics for 2–8 weeks.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Treatment can be extended for up to 6 months<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> if the patient remains immunocompromised, and in cavitated pulmonary lesions or CNS involvement, as occurred in our case.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Mortality in immunocompetent patients is 11%, while in HIV patients it is 50%–55%, and 20%–25% in non-HIV-infected immunocompromised patients.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2–4</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Enríquez Rodríguez AI, García Clemente M, Buchelli Ramírez HL. Neumonía grave por <span class="elsevierStyleItalic">Rhodococcus equi</span> con diseminación hematógena al sistema nervioso central en un paciente inmunodeprimido. Arch Bronconeumol. 2015;51:203–204.</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" => 720 "Ancho" => 1500 "Tamanyo" => 121683 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Chest X-ray showing cavitated infiltrate in upper right lobe and infiltrate without cavitation in lower left lobe. (B) Head MRI showing multiple nodular lesions, less than 1<span class="elsevierStyleHsp" style=""></span>cm in size, in the cortical-subcortical region, and vasogenic edema.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "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. 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| 2024 November | 8 | 1 | 9 |
| 2024 October | 49 | 19 | 68 |
| 2024 September | 64 | 14 | 78 |
| 2024 August | 92 | 43 | 135 |
| 2024 July | 47 | 22 | 69 |
| 2024 June | 81 | 43 | 124 |
| 2024 May | 84 | 26 | 110 |
| 2024 April | 46 | 32 | 78 |
| 2024 March | 52 | 15 | 67 |
| 2024 February | 37 | 19 | 56 |
| 2023 March | 4 | 3 | 7 |
| 2023 February | 41 | 21 | 62 |
| 2023 January | 41 | 35 | 76 |
| 2022 December | 45 | 32 | 77 |
| 2022 November | 51 | 32 | 83 |
| 2022 October | 64 | 56 | 120 |
| 2022 September | 43 | 43 | 86 |
| 2022 August | 43 | 43 | 86 |
| 2022 July | 48 | 40 | 88 |
| 2022 June | 34 | 39 | 73 |
| 2022 May | 32 | 43 | 75 |
| 2022 April | 62 | 42 | 104 |
| 2022 March | 50 | 53 | 103 |
| 2022 February | 36 | 34 | 70 |
| 2022 January | 47 | 34 | 81 |
| 2021 December | 25 | 33 | 58 |
| 2021 November | 41 | 42 | 83 |
| 2021 October | 49 | 41 | 90 |
| 2021 September | 27 | 40 | 67 |
| 2021 August | 27 | 45 | 72 |
| 2021 July | 27 | 30 | 57 |
| 2021 June | 41 | 41 | 82 |
| 2021 May | 51 | 33 | 84 |
| 2021 April | 163 | 111 | 274 |
| 2021 March | 77 | 34 | 111 |
| 2021 February | 34 | 28 | 62 |
| 2021 January | 27 | 20 | 47 |
| 2020 December | 25 | 22 | 47 |
| 2020 November | 28 | 20 | 48 |
| 2020 October | 18 | 14 | 32 |
| 2020 September | 24 | 18 | 42 |
| 2020 August | 34 | 18 | 52 |
| 2020 July | 37 | 24 | 61 |
| 2020 June | 34 | 16 | 50 |
| 2020 May | 32 | 11 | 43 |
| 2020 April | 51 | 25 | 76 |
| 2020 March | 35 | 16 | 51 |
| 2020 February | 56 | 17 | 73 |
| 2020 January | 36 | 24 | 60 |
| 2019 December | 30 | 20 | 50 |
| 2019 November | 35 | 18 | 53 |
| 2019 October | 19 | 13 | 32 |
| 2019 September | 28 | 12 | 40 |
| 2019 August | 34 | 14 | 48 |
| 2019 July | 22 | 14 | 36 |
| 2019 June | 28 | 11 | 39 |
| 2019 May | 30 | 15 | 45 |
| 2019 April | 48 | 17 | 65 |
| 2019 March | 49 | 17 | 66 |
| 2019 February | 36 | 18 | 54 |
| 2019 January | 20 | 12 | 32 |
| 2018 December | 33 | 17 | 50 |
| 2018 November | 59 | 23 | 82 |
| 2018 October | 69 | 31 | 100 |
| 2018 September | 44 | 10 | 54 |
| 2018 May | 21 | 0 | 21 |
| 2018 April | 51 | 6 | 57 |
| 2018 March | 37 | 2 | 39 |
| 2018 February | 26 | 8 | 34 |
| 2018 January | 81 | 2 | 83 |
| 2017 December | 80 | 6 | 86 |
| 2017 November | 53 | 7 | 60 |
| 2017 October | 35 | 7 | 42 |
| 2017 September | 33 | 11 | 44 |
| 2017 August | 60 | 10 | 70 |
| 2017 July | 44 | 10 | 54 |
| 2017 June | 62 | 15 | 77 |
| 2017 May | 38 | 9 | 47 |
| 2017 April | 31 | 14 | 45 |
| 2017 March | 28 | 7 | 35 |
| 2017 February | 23 | 9 | 32 |
| 2017 January | 22 | 5 | 27 |
| 2016 December | 36 | 7 | 43 |
| 2016 November | 56 | 11 | 67 |
| 2016 October | 46 | 15 | 61 |
| 2016 September | 74 | 23 | 97 |
| 2016 August | 63 | 15 | 78 |
| 2016 July | 37 | 12 | 49 |
| 2016 March | 1 | 0 | 1 |
| 2016 February | 2 | 0 | 2 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 47 | 3 | 50 |
| 2015 September | 46 | 9 | 55 |
| 2015 August | 44 | 10 | 54 |
| 2015 July | 25 | 10 | 35 |
| 2015 May | 0 | 2 | 2 |
| 2015 April | 0 | 2 | 2 |
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