Disseminated Nocardia infection: spontaneous resolution in response to decrease of immunosuppression

Sir, Here we present a patient using anti-tumour necrosis factor-α (anti-TNF-α) who developed disseminated nocardiosis, which spontaneously resolved after discontinuation of anti-TNF-α. A 75-year-old man presented with a 4-month history of fever, night sweats and weight loss of 5 kg, accompanied by general abdominal complaints consisting of anorexia, regurgitation and nausea. For the past 6 years he had used anti-TNF-α 40 mg once every 2 weeks, methotrexate 7.5 mg once weekly and prednisone 5mg daily for his rheumatoid arthritis. At presentation, antiTNF-α had been discontinued for 2 months and methotrexate for 1 week. He was maintained on 5 mg prednisone daily only. On physical examination no abnormalities were found. His blood count was normal despite anaemia (haemoglobin was 6.6 mmol/L (7.0–9.3 mmol/L), haematocrit 0.32 L/L (0.36–0.48 L/L), leucocytes 3.6 × 10/L (2.5 × 10 to 8.2 × 10/ L) and thrombocytes 262 × 10/L (150 × 10 to 350 × 10/L)). Urea was 4.8 mmol/L (3.6–4.8 mmol/L), creatinine 100 μmol/L (62–106 μmol/L), sodium 127 mmol/L (135–145 mmol/L), potassium 4.4 mmol/L (3.5–5.0 mmol/L) and C-reactive protein was 56 mg/L (<10 mg/L). Liver enzymes were slightly elevated (aspartate aminotransferase 37 U/L (<40 U/L), alanine