Age: 64.0
Sex: M
Vaccine: PPV, TDAP
Symptoms: Immunoglobulin therapy, Laboratory test normal, Natural killer cell count, Neutrophil function test abnormal, Nocardiosis
Clinical narrative: Initial unsolicited report received from a literature on 28-Nov-2015. Abstract: Introduction: Nocardia species is a filamentous, gram-positive bacteria found in soil. Nocardia is considered an opportunistic infection; however, about one-third of those infected are immunocompetent. Although the primary host defense mechanism is believed to be an innate immune response, early experimental models suggested a potential role of humoral immunity against Nocardia species. We present a previously healthy patient who was diagnosed with Nocardia, and ultimately believed to have underlying common variable immunodeficency (CVID). Case: A 64-year-old, previously healthy male presented with complaints of urinary retention and bilateral lower extremity paresthesia. Evaluation lead to discovery of pathologic L1 burst fracture due to Nocardia asiatica. Given the rare nature of the organism isolated, immunodeficiency work-up was initiated. He was found to have a low IgG (337 mg/dL) with normal IgA (113 mg/dL) and IgM (68 mg/dL). Flow cytometry revealed a normal CD4 to CD8 ratio (8.1 Percent), normal CD3 (74 Percent, 992 cells/iL) and CD16+56 (20 Percent, 249 cell/iL) levels. CD19 level was low at 6 Percent (70 cells/iL). Neutrophil oxidative burst analysis and lymphocyte antigen and mitogen proliferation panel was normal. The patient received TDaP vaccine within the last year, and therefore was only given pneumococcal polysaccharide vaccine (PPSV23). Post-immunization titers revealed positive response to tetanus with titer level of 8.2 IU/mL, without response to 12 out of 14 pneumococcal strains and diphtheria. Repeat immunoglobulin levels at this time were normal (IgG 681 mg/dL, IgA 150 mg/dL, IgM 74 mg/dL). As the patient responded to initial antimicrobial therapy and with the rise in immunoglobulin levels, the decision was made to hold treatment with IVIG. However, 3 months following his initial presentation, the patient's clinical condition deteriorated prompting repeat analysis. At this time, he was found to have low levels of IgG (492 mg/dL), IgA (60 mg/dL), IgM (45 mg/dL), and CD 19 cells (2 percent, 17 cells/iL). Therefore, decision was made to initiate IVIG. Conclusion: Very few cases have been reported of Nocardia infection in patients with an underlying humoral deficiency. Although the complete role of humoral immunity in the defense against Nocardia has yet to be defined, consideration should be given to fully evaluate a patient's humoral response, as treatment with IVIG may provide benefit. The aforementioned information retrieved from full text article. This case involves a 64-year-old male who was vaccinated with a dose of TDAP (Manufacturer: unknown, batch number, route and site of administration were not reported) and a dose of Pneumococcal vaccine (PPSV23) (Manufacturer: unknown, batch number, route and site of administration were not reported) on an unspecified date. Medical history and concomitant medications were not reported. On an unspecified date, after vaccination patient had presented with complaints of urinary retention and bilateral lower extremity paresthesia. He was diagnosed with pathologic L1 burst fracture due to Nocardia asiatica. Lab tests included low IgG (337 mg/dL) with normal IgA (113 mg/dL) and IgM (68 mg/dL). Flow cytometry revealed a normal CD4 to CD8 ratio (8.1 percent), normal CD3 (74 percent, 992 cells/uL) and CD16+56 (20 percent, 249 cells/uL) levels. CD19 level was low at 6 percent (70 cell/uL). Neutrophil oxidative burst analysis and lymphocyte antigen and mitogen proliferation panel was normal. Post-immunization titers revealed positive response to tetanus with titer level of 8.2 IU/mL, without response to 12 out of 14 pneumococcal strains and diphtheria. Repeat immunoglobulin levels at this time were normal (IgG 681 mg/dL, IgA 150 mg/dL, IgM 74 mg/dL). At this time, he was found to have low levels of IgG (492 mg/dL), IgA (60 mg/dL), IgM (45 mg/dL), and CD 19 cells (2 percent, 17 cells/uL). Patient received treatment with IVIG (Intravenous immunoglobulin). Outcome of the events was not reported. Upon internal review, case was considered as serious due to important medical event: Nocardia infection. List of documents held by sender: none.