Pulmonary co-infection with Nocardia and Aspergillus in a patient with adult-onset Still's disease receiving steroids and tacrolimus

Abstract

Patients on immunosuppression are at risk of unusual infections. We present a man diagnosed to have adult-onset Still's disease who, on high-dose oral steroid and tacrolimus, developed a cavitating pneumonia due to co-infection with Aspergillus flavus and Nocardia. Timely diagnosis and institution of appropriate therapy resulted in a favourable clinical outcome. Such co-infection in a patient receiving tacrolimus is rare in the published literature. This case serves to emphasise the need to be vigilant for unusual infections in patients who are immunosuppressed, either due to drugs or underlying disease condition.

Figure 1

Chest X-ray (A) on the day of admission showing well-defined nodular shadow in the left lower lung zone and (B) on day 10 after admission showing increase in left lower zone shadows, with the left middle zone shadow in the parahilar region becoming prominent. (C) Chest X-ray 4 weeks after starting therapy for Nocardia and Aspergillus, showing resolving left lower zone shadows, with the left middle zone shadow having disappeared. (D) Chest X-ray 4 months after starting therapy for Nocardia and Aspergillus, showing almost complete resolution of previous shadows.

Figure 2

CT of the chest showing consolidation with cavitation in the left lingual and left upper lobe, along with small nodules in the right lung parenchyma.