Concurrent Nocardia, Cryptococcus and Mycobacterium Infections Unmask Anti-GM-CSF Antibody-Associated Immunodeficiency and Pulmonary Alveolar Proteinosis: A Case Report
Abstract
Anti-granulocyte macrophage colony stimulating factor (anti-GM-CSF) antibodies, classically associated with pulmonary alveolar proteinosis (PAP), are increasingly recognised as a cause of adult-onset immunodeficiency predisposing to opportunistic infections. Coinfections with multiple opportunistic pathogens in this context are uncommon. We describe a rare case of disseminated Nocardia paucivorans, pulmonary Cryptococcus gattii, pulmonary Mycobacterium chelonae, and subsequent PAP in a patient with high-level anti-GM-CSF antibodies. A 64-year-old man presented with subacute bilateral shoulder pain and was diagnosed with acromioclavicular septic arthritis. N. paucivorans was isolated, and subsequent evaluation demonstrated disseminated infection with numerous brain abscesses, left eye endophthalmitis and pulmonary involvement. Interval computed tomography of the chest revealed new right lower lobe consolidation, a biopsy of which identified C. gattii and M. chelonae. Immunological testing confirmed high-level anti-GM-CSF antibodies. The patient received prolonged combination antimicrobial therapy, including meropenem, ceftriaxone, linezolid, trimethoprim-sulfamethoxazole, moxifloxacin, fluconazole, tigecycline and clofazimine, with clinical and radiological improvement of infectious lesions. Despite microbiological clearance, progressive bilateral ground-glass opacities developed on serial chest imaging consistent with PAP, with no pathogens identified on bronchoscopic…
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