Grand Rounds-Hammersmith Hospital: Nocardia pericarditis

Case history

A 71 year old woman was treated for an uncomplicated haemorrhage from an intracerebral aneurysm in 1987. She recovered completely but was noted to be hypertensive. Her blood pressure was subsequently controlled with hydralazine and atenolol. She remained well until March 1993, when she presented with a four month history of weight loss, malaise, and shortness of breath. Investigations showed severe renal impairment, and renal biopsy showed a focal necrotising glomerulonephritis with crescents. She also had high titres of perinuclear autoneutrophil cytoplasmic antibodies. Microscopic polyarteritis, possibly precipitated by hydralazine, was diagnosed. The hydralazine was therefore discontinued. Her polyarteritis was treated with high dose prednisolone, with cyclophosphamide for the first three months and azathioprine subsequently. She was discharged well after seven weeks.

Three months later, she was admitted to her local hospital with presumed bacterial pneumonia. No pathogen was isolated. She was treated with antibiotics and transferred to our hospital. Further investigations included a bronchoscopy, which showed no infectious agent, computed tomography of the thorax, and tests of pulmonary function, which suggested early fibrosing alveolitis. She improved clinically with appropriate antibiotics.

Two months later she presented with a seven week history of bilateral pleuritic chest pain, increasing shortness of breath, and generalised weakness. Her drugs included prednisolone (17.5 mg per day) and azathioprine (75 mg per day). She had a temperature of 38.3°C and was centrally cyanosed and dyspnoeic. Her heart rate was 92 beats/min and blood pressure …