A case presentation to doctors and pharmacist of a rare case of a Rhodococcus Equi infection in a renal transplant patient

1. Rhodococcus Equi
…is it in you?
Trey Rumph
Mercer University
Internal Medicine Rotation

2.  PH is a 65 y/o WM admitted 2/5/2010
 CC: N&V for 2 days, cough for weeks and left foot
pain
 PMH: ESRD, s/p related donor living renal
transplant, T2DM, HTN, Polycystic Kidney
disease, hx of Gout, hx of left upper lung pneumonia
 SH: married, lives on farm in South Pittsburg, (-)
tobacco, (-) EtOH, Owns and manages a demolition
company, but has been a coal miner for
approximately 12 years
 Allergies: Demerol and Phenergan
Patient Case

3.  History of ESRD 2o polycystic kidney disease, s/p living
related donor renal transplant from his daughter in
2005 (Baseline Cr ~1.4-1.6).
 Presents to ER with CC of N&V with onset of 2 days ago
 Cough worsened over the last several weeks ever
since d/c from hospital with left upper lung pneumonia on
1/15/10
 Left foot pain that has progressively worsened over the last
several days (Gout)
 BUN/Cr note to be 68/2.1 on presentation and volume
Patient Case (HPI)

4. Prograf 1mg PO BID Lasix 40mg BID Zyloprim 300mg Qdaily
CellCept 1gm PO BID Verapamil 120mg PO Starlix 120mg QD
BID
Prednisone 5mg PO BID Metoprolol 12.5mg PO Lantus 20 units QHS
BID
ASA 81mg BID Tessalon Perles prn
Immunosuppressants Heart Medications Gout
Diabetes
Home Medications

5. Hospital meds
Cellcept 500mg IV Morphine 4-8mg Ambien 5mg QHS
Q12 Q1/prn
Cytovene 500mg Lopressor 12.5 BID Mycostatin 5mL
IV BID QID
Solumedrol 10mg Calan 120mg BID Carafate 1gm Q6
IV Q12
Zithromax 500mg Bumex 1mg IV Lantus 30units
QDaily Q12 QHS
Vancocin 0.75g IV Nitrol Ointment 1 NovoLog SSI level
QDaily inch Q6h 4
Roxicet UDL Phenergan 6.25- Procrit 10,000units
Q4/PRN 12.5mg Q6/prn on MWF @1600
Lortab 7.5mg Zofran 4mg Apresoline 10-
Q4/prn Q4/PRN 20mg Q6
Immunosuppressants Pain Management Sleep Aid
Antibiotics Heart Medication Anti-Fungal
Pain Management Nausea Medication Diabetes

6. Upon Admission
 Admitted via ER with CC of nausea and
vomiting for 2 days and a cough for
weeks
 CT scan shows left upper lobe mass of
6.5cm with lymph node involvement
Patient Case (Hospital Course)

7. Fig 1: There is an irregular large soft tissue mass in the
left upper lung field which opposes the descending
proximal thoracic aorta measuring some 5.5 x 6.5cm.

8. Course of Action
 IV Solu-Medrol
 Hold Prograf
◦ Use of Rapamune?
 Zosyn 2.25mg Q8- obstructive pneumonia
 Bronchoscopy – left upper lobe mass

9. Tacrolimus Sirolimus
 Post-transplant  Impaired wound
Diabetes (~20% first healing
year)  ↑K
 At high doses:  ↓ Mg
◦ Nephrotoxic  Hyperlipidemia
◦ Neurotoxicity
 Hypertriglyceridemia
 Renal adjustments
 Leukopenia
 QT prolongation
Prograf vs Rapamune

10. Results of Bronchoscopy
 Generalized erythema, mucosal bleeding
with no obstructing mass noted in the left
upper lobe

11.  Patient is coughing up blood, productive
with a green coloration
Patient Case (Hospital Course)

12. Course of Action
 Add Vancomycin IV 1g Q24o to treatment
(10.6mg/kg) and Zosyn 2.25mg Q8
(CrCl ~29.2)
Vancomycin Dosing and Trough Levels
Date Dose Date Trough
level
2/9/10 1g
2/10/10 1g 2/12/10 17.6
2/20/10 30
2/21/10 27.6
2/24/10 27.3
2/25/10 0.75g 3/1/10 13.9
3/9/10 1g 3/9/10 23.6

13.  Blood in cough resolves, but kidney
function begins to decline. Patients
develops a hemothorax.
 Planned Video-Assisted Thoracoscopic
Surgery (VATS)
◦ Retained hemothorax via trapped lung
procedure
 ID Consulted
◦ Differential: CMV or atypical mycobacterium
◦ Ordered urine antigens and serology for Q-
fever
◦ d/c Zosyn
Patient Case (Hospital Course)

14. Atypical Pneumonias
Legionnaires Q fever Psittacosis
disease (Coxiella burnetii ) (Chlamydia psittaci )
(Legionella
pneumophila)
• Lung infection • During birthing the AKA: Parrot Disease or
(pneumonia)  CAP or organisms are shed in Parrot Fever
HAP lasts 2-14 days high numbers within the •Found in bird droppings
amniotic fluids and the
• Pontiac Fever placenta and aerolized
symptoms usually last • Usually inhaled,
for 2 to 5 days and may extremely virulent
also include fever, • Resistant to heat,
headaches, and muscle drying, and many
aches; however, there is common disinfectants
no pneumonia.

15. Course of Action
 Lab Evaluation
◦ Rare Gram(+) cocci to be identified…
◦ ?Malacoplakia or Rhodococcus Equi
◦ Vancomycin 1g Qdaily and Ancef 1g Q8o
◦ Immunosuppressants started back
 Prednisone 20mg QD
 Cellcept 250mg Q12
 Prograf 1g Daily

16.  Inflammatory condition that leads to
formation of papules, plaques and
ulcerations (usually affecting the genitourinary tract)
 Thought to result from the insufficient
killing of bacteria by macrophages, that
accumulate inside depositing iron and
calcium forming the papules, etc.
 Associated with patients who are
immunosuppressed
Malakoplakia

17. Rhodococcus Equi

18.  Characterized by rod-to-coccus morphologic
variation during its growth cycle
 Rhodococcus genus due to its ability to form a
red (salmon-colored) pigment - “red-pigmented
coccus”
 Primarily causing zoonotic infections in grazing
animals (ex: horses and foals)
 A soil organism that require simple requirements
to survive, which seem to be met perfectly by
herbivore manure and summer temperature in
temperate climates
Background R. Equi

19.  R Equi is an obligate aerobic, intracellular,
nonmotile, non-spore-forming, gram-
positive coccobacillus
 Commonly transmitted via inhalation on
farms
This latter histologic picture, termed
malakoplakia, is extremely rare within
the lung and, when present, is highly
suggestive of a R. equi infection
Background

20.  R. Equi is facultative intracellular
pathogen, surviving inside macrophages
to cause granulomatous inflammation and
eventually destruction of macrophage.
 In humans, has only be found in patients
with compromised immune systems in the
lungs
Pathogenesis

21.  #1 Pneumonia (~66%)
 Other possible presentations
◦ Penetrating eye wound
◦ Inflammatory mass in the pelvis
◦ Bloody diarrhea and cachexia
◦ Pleural effusion
◦ Osteomyelitis
◦ Paraspinal abscess
◦ Inflammatory pseudotumor
Patient Presentation

22.  Typical Pathogens for CAP
◦ Streptococcus pneumoniae
◦ Moraxella catarrhalis
◦ Haemophilus influenzae
Primarily CAP Culprits

23.  Physical Findings
◦ Rales heard upon Auscultation over the chest
◦ Pleural Effusion
◦ Purulent sputum
◦ Blood-tinged sputum
◦ Signs of consolidation
 Typically seen with Legionella, Q fever, or
psittacosis
Pneumonia Presentation

24. Summary of Clinical
Presentation

25.  Left Upper Lobe Lung Mass – CT directed
Core Biopsy
◦ Malakoplakia of the lung
◦ Gram (+) organisms present
◦ Cytomegalovirus Inclusions Present (in adjacent lung
tissue)
Comment:
Pulmonary malakoplakia has been described in
immunocompromised patients, including organ transplant
patients. The most commonly isolated organism in this
setting is Rhodococcus equi – initial cultures do show growth
of a difficult to identify organism; the culture has been referred to
a reference laboratory for typing.
Surgical Pathology

26. Hematoxylin-and-Eosin Stain Calcium Stain
(Calcospherites)
Pathology

27. PAS + material Gram Stain
Pathology

28. Pathology
CMV inclusion

29.  From the pathology as well as the culture
coming back with rare gram (+) cocci
(Rhodococcus species), Infectious Disease
concluded the presence of R Equi
Pathology

30.  Changed Therapy to…
◦ ∆ Vancomycin 1 g QDaily and Clindamycin
◦ Renal decides to hold Prograf due to declining
renal function
◦ ∆ Clindamycin  Zithromax
◦ Added Levaquin for cover for new cultures of
Klebsiella and Serratia found in the sputum
Vancocin 1g QDaily/ Levaquin 750mg QDaily/
Zithromax 250mg QDaily
Patient Case (Hospital Course)

31.  Must be covered by at least two or more agents
 Combination antibiotics should include one agent with
intracellular penetration (ex: Erythromycin or
Rifampin)
 Besides the use of anti-microbial drugs, the approach
used in treatment of human infection involves
drainage of the suppurative lesions, surgical resection
of granulomatous tissue, and control of concurrent
immunosuppressive drugs or control of underlying
malignancies.
 Duration of treatment 4-9 weeks
Strategy to treat
R Equi

32.  Erythromycin
Macrolides
 Azithromycin
 Clarithromycin Lincosamides
 Clindamycin
Fluoroquinolones
 Ciprofloxacin
 Aminoglycosides
 Rifampin Anti-tuberculosis Agent
 Imipenem Carbapenems
 Meropenem
 Vancomycin
 Linezolid Oxazolidinones
Antibiotics used to treat
R. Equi

33.  Patient still in Respiratory failure
 Patient suspected of CMV per Lung biopsy
 Added Cytovene® (Ganciclovir) 200mg
BID
 Patient was scheduled for Tracheotomy
Surgery
Vancocin 1g QDaily/ Levaquin 750mg QDaily/
Zithromax 250mg QDaily/ Cytovene 200mg BID
Patient Case (Hospital Course)

34. Patient Case (Hospital Course)
 After 14 days of treatment the Levaquin
was d/c’d
 Placed DHT bedside via CORTRAK

35.  Still in Respiratory failure
 Underwent the T-piece Trials on the vent
 Placed catheter
Vancocin 1g QDaily/ Zithromax 250mg
QDaily/ Cytovene 200mg BID
Patient Case (Hospital Course)

36.  Patient feels better
 Case Management refer him to Siskin and
Kindred  Kindred accepts
 Cytovene d/c, ID was never really clear if
CMV was a pathogen
Vancocin 1g Q48h/ Zithromax 250mg
QDaily
Patient Case (Hospital Course)

37. Patient Case (Hospital Course)
 Patient is transferred to Kindred Hospital
on…
Cellcept 500mg BID Augmentin 875mg Zyloprim 300mg
Qdaily Qdaily
Prograf 2mg Qdaily ASA 325mg Qdaily Flomax 0.4mg after
supper
Deltasone 5 mg BID Lopressor 25mg BID Mag-Ox 400mg BID
Lantus 20 units QHS Calan SR 240mg Colace 100mg BID
Qdaily
Lasix 60mg Qdaily
Immunosuppressants Antibiotics Gout
Diabetes Heart Medications Prostate Medication

38.  Munoz P, Palomo J, Guinea J, et al. Relapsing
Rhodococcus equi infection in a heart transplant
recipient successfully treated with long-term
linezolid. Diagn Microbiol Infect
Dis. Feb 2008;60(2):197-9
 Prescott, John. Rhodococcus Equi: an Animal and
Human Pathogen. Clinical Microbiology Review.
Jan 1991; 20-30
 Verville TD, Huycke MM, Greenfield RA, et
al. Rhodococcus equi infections of humans. 12
cases and a review of the literature. Medicine
(Baltimore). May 1994;73(3):119-32
References