180.3 🩺 內科專科考前版

180.3.0.1 1️⃣ Nocardia in Solid Organ Transplant

• 0.6-3% incidence post-SOT
• Often missed initially (subacute presentation, multiple imaging mimics)
• Routine immunosuppression: tacrolimus + steroid + MMF
• TMP-SMX prophylaxis (for PJP) — partial protection but not full
• Late-onset (1+ yr post-transplant) — 25%
• Treatment 12+ mo + may continue suppressive in some
• Imipenem + ceftriaxone interaction in some agents (need ID consult)

180.3.0.2 2️⃣ Nocardia + Voriconazole

• Some Nocardia AST shows susceptibility to triazoles (voriconazole)
• Not first-line but consider in 失敗 / complicated cases
• Drug interaction with calcineurin inhibitors

180.3.0.3 3️⃣ Brain Abscess Workup

• Immunocompromise + brain ring-enhancing lesion → broad differential:
  • Toxoplasma (HIV CD4 < 100)
  • Lymphoma (HIV / immunosuppression)
  • Nocardia
  • Cryptococcoma
  • Aspergillus / mucormycosis
  • Pyogenic bacterial abscess
  • TB
• Brain biopsy if unsure — culture + histology
• Steroid for edema (after diagnosis)
• Drainage / aspiration if accessible

180.3.0.4 4️⃣ Actinomyces + IUD

• Long-standing IUD > 2 yr — pelvic Actinomyces
• May be incidental on Pap smear (Actinomyces-like organisms — most don’t progress to disease)
• Symptomatic / mass → IUD removal + amox 6 mo
• Asymptomatic + Pap +: monitor, no antibiotic + don’t necessarily remove IUD

180.3.0.5 5️⃣ Mycetoma (Madura Foot)

• Chronic localized subcutaneous infection
• Triad: tumor + sinus tract + grains (granules)
• Causes:
  • Actinomycetoma (true bacteria — Nocardia, Streptomyces, Actinomadura) — antibiotic responsive
  • Eumycetoma (true fungi — Madurella) — antifungal + often surgery
• Endemic tropics + subtropics (India, Sudan, Mexico, etc.)
• Tx: TMP-SMX + dapsone + (rifampin / amikacin) × 6-12+ mo for actinomycetoma

180.3.0.6 6️⃣ Sulfur Granule Microscopy

• Histology: filamentous bacteria + Splendore-Hoeppli reaction (radiating eosinophilic)
• Diagnostic clue
• 鑑別 from botryomycosis (S. aureus chronic granulomatous), eumycetoma (fungal grains)

180.3.0.7 7️⃣ 健保 / Taiwan

• TMP-SMX, PCN, imipenem 健保 covered
• Actinomyces — rare 但 dental health link; oral hygiene education
• Pelvic Actinomyces — IUD long-standing; gynecology
• Nocardia 移植 — ID consult routine

180.3.0.8 8️⃣ ASP — Long Course Justification

• Anaerobic + slow-growing organism (Actinomyces, Nocardia, T. whipplei)
• Short course → relapse
• 6-12 mo standard
• Monitor compliance + side effects (TMP-SMX hyperkalemia / AKI / cytopenia; PCN seizure with high dose)

---