More than meets the eye: Nocardia farcinica, Candida dubliniensis and Aspergillus spp. co-infection in a patient with multiple myeloma treated with multiple treatment regimens

Abstract

Background: Invasive infections by Nocardia farcinica, Aspergillus species (spp.) and Candida dubliniensis are rare infectious complications in patients diagnosed with multiple myeloma.

Case presentation: In this case report, we describe a patient who received three lines of therapy, with proteasome inhibitors, corticosteroids, cyclophosphamide and lenalidomide, and who was concurrently infected with these three opportunistic pathogens. A blood stream infection with C. dubliniensis was treated with 4 weeks of anidulafungin. Aspergillus spp. was treated for 12 weeks with voriconazole. N. farcinica treatment was continued indefinitely with co-trimoxazole and moxifloxacin after regression at discharge of brain abscesses and the pulmonary aspergilloma.

Conclusion: The diagnostic challenges and management in this particularly vulnerable patient are highlighted.

Keywords: Candida dubliniensis; N. farcinica; Brain abscess; Invasive aspergillosis; Multiple myeloma.

Fig. 1

Overview of the patient’s myeloma treatment history prior to hospitalization

Fig. 2

CT of the thorax at initial presentation (09/23/2022) showed two consolidations with irregular borders and cavitation in the left upper lobe, as well as a halo sign which is a major criterium for invasive aspergillosis. In the right lower lobe, we see a consolidation without cavitation but also with impression of surrounding halo sign

Fig. 3

CT scan of the brain at admission (10/17/2022) showed two ring- shaped lesions in the right cerebrum as well as the right cerebellum with important surrounding oedema. MRI images were of very poor quality and thus only one image is shown here

Fig. 4

CT-scan of the brain (01/02/2023) showed a clear decrease of the abscess in the right cerebrum as well as the right cerebellum compared to 17/10/2022. The oedema surrounding the lesion in the right cerebrum has almost completely resolved