1233 - No Cardia, No Cry: Surviving Nocardia Shock

Case Diagnosis: 61-year-old male, status post-renal transplant for IgG kappa monoclonal gammopathy of renal significance with history of multiple comorbidities, admitted for mixed septic and obstructive shock due to disseminated nocardiosis and transferred to inpatient rehabilitation following prolonged hospitalization complicated by multiple organ system involvement.

Case Description: A 61-year-old male with IgG kappa monoclonal gammopathy of renal significance, end stage renal disease status-post renal transplant, type 2 diabetes mellitus, atrial fibrillation, and prior right hip arthroplasty experienced mixed septic and obstructive shock from disseminated nocardiosis. His course was marked by brain abscesses, pulmonary infection, nocardial pericarditis, anemia requiring transfusions, recurrent hypoglycemia, and chronic immunosuppression. He underwent extensive acute management, including antimicrobials, transfusions, thoracentesis, chest tube placement, and multidisciplinary acute care. After hospital stabilization, he was admitted to inpatient rehabilitation for profound deconditioning. On admission, impairments included significant deficits in activity tolerance, strength, balance, ADLs, mobility, and higher-level cognition. A multidisciplinary team (PT, OT, SLP, physiatry, nursing, nutrition, and wound care) implemented intensive therapy focused on maximizing functional independence and medical stability in the context of ongoing infection requiring IV antibiotics, critical illness myopathy, and immunosuppression.

Discussions:

This case illustrates the profound physical and cognitive morbidity associated with prolonged, multi-system critical illness in a renal transplant recipient with disseminated nocardiosis. Rehabilitation required careful coordination among medical and therapy teams, ongoing infectious disease management, frequent laboratory monitoring, complex medication titration, and adaptation to fluctuations in medical status, emphasizing the integral role physiatry plays in restoring function and safety in the context of severe immunosuppression and critical illness.

Conclusions: This case highlights the importance of early, multidisciplinary rehabilitation for medically complex, immunocompromised patients recovering from severe infection and critical illness, and demonstrates that substantial functional improvement is achievable despite significant ongoing medical needs.