Subcutaneous nodules attributed to nocardiosis in a renal transplant recipient on tacrolimus therapy.

We report a renal transplant patient who suffered from disseminated nocardiosis after empirical tacrolimus rescue therapy for chronic allograft rejection. The nocardiosis presented initially as only mildly tender subcutaneous calf nodules without any other signs of inflammation nor constitutional upset, which later spread to the lung and brain causing bronchopneumonia and brain abscesses. The risk factors for nocardial infection in our patient include the use of potent immunosuppressive agents such as tacrolimus, poorly controlled diabetes mellitus and kidney dysfunction. She responded well to combination antibiotic therapy comprising parenteral meropenem, cefotaxime and oral minocycline. We conclude that in transplant recipients, especially those receiving newer and more potent immunosuppressive agents like tacrolimus, nocardial infection can present as apparently 'cold' subcutaneous nodules without any systemic upset. An associated brain lesion should be excluded even in patients without neurological symptoms.