Subcutaneous nodules attributed to nocardiosis in a renal transplant recipient on tacrolimus therapy

We report a renal transplant patient who suffered from disseminated nocardi osis after empirical tacrolimus rescue therapy for chronic allograft reject ion. The nocardiosis presented initially as only mildly tender subcutaneous calf nodules without any other signs of inflammation nor constitutional up set, which later spread to the lung and brain causing bronchopneumonia and brain abscesses. The risk factors for nocardial infection in our patient in clude the use of potent immunosuppressive agents such as tacrolimus, poorly controlled diabetes mellitus and kidney dysfunction. She responded well to combination antibiotic therapy comprising parenteral meropenem, cefotaxime and oral minocycline. We conclude that in transplant recipients, especiall y those receiving newer and more potent immunosuppressive agents like tacro limus, nocardial infection can present as apparently 'cold' subcutaneous no dules without any systemic upset. An associated brain lesion should be excl uded even in patients without neurological symptoms. Copyright (C) 2000 S. Karger AG,Basel.