Paradoxical response in cerebral nocardiosis in a renal tran
Paradoxical response (PR) in patients on anti-tuberculosis drugs and immune reconstitution inflammatory syndrome (IRIS) in patients started on antiretroviral therapy are well known phenomenon.

Published in the Journal of the Association of Physicians of India, the authors here report a case of a paradoxical response in cerebral nocardiosis in a renal transplant recipient. To the knowledge of the authors this phenomenon in cerebral nocardiosis has not been reported earlier in literature.

A 55 year old lady underwent live related kidney transplant surgery (LRKTR) in September 2011. Induction immunosuppression was with Methylprednisolone. Maintenance immunosuppression was with Tacrolimus, Mycophenolate mofetil and Deflazacort. She received TMP-SMX and VGCV prophylaxis till 6 months after transplant.

She maintained stable renal function with creatinine clearance around 30%. In September 2015, she presented with a subacute onset of dry cough for 3 weeks followed by intermittent high grade fever. There was an erythematous, non tender skin nodule in the right axillary region. The cough then turned productive and headache developed. Xray chest (Figure 3) and CT chest showed consolidative lesions with signs of early breakdown. Patient’s sputum examination with modified acid fast stain confirmed the diagnosis of nocardiosis.

MRI brain (Figure 1) revealed multiple small cerebral abscesses with perilesional edema located in cerebral parenchyma, posterior right basal ganglia and cerebellum. The initial treatment r e g i m e n i n c l u d e d , T M P - S M X , Ceftriaxone, and Linezolid. This was later modified as per DST reports to TMP-SMX, Linezolid and Moxifloxacin. TMP-SMX was given in modified dose as per creatinine clearance.

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