Nocardiosis with diffuse involvement of the pleura: A case report

Abstract

Background: Nocardiosis is an uncommon infection that usually occurs in immunocompromised patients, and the pulmonary system is the most common site. We report an uncommon case of nocardiosis with diffuse involvement of the pleura, which presented as multiple localized nodular or hillock lesions on computed tomography (CT) with local chest wall infiltration.

Case summary: A 54-year-old woman was referred to our hospital due to cough and fever for 20 d. She had a history of nephrotic syndrome for 7 mo and was given prednisone (60 mg/d) 6 mo previously. The hormone was then gradually reduced to the current dose of 25 mg/d. Chest CT showed many nodular or hillock lesions in the right pleura, mediastinum, and interlobar fissure areas. On the lower layer, one lesion infiltrated the chest wall. She was treated with piperacillin sodium and sulbactam sodium, but the therapeutic effect was not good. In this regard, ultrasound-guided local infiltration anesthesia was further conducted for perihepatic hydrops drainage to improve diagnostic accuracy. Puncture fluid culture isolated Nocardia species, confirming the diagnosis of nocardiosis. Subtype Nocardia farcinica was identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Antibiotic treatment was switched to trimethoprim/sulfamethoxazole and imipenem. After 8 d of treatment, the patient was discharged from the hospital with improved condition, and she has been recurrence-free for 2 years.

Conclusion: This report illustrates that nocardiosis should be suspected when clinicians encounter patients who are immunocompromised and have diffuse involvement of the pleura.

Keywords: Case report; Computed tomography; Lung; Nocardiosis; Pleura.

Figure 1

Axial computed tomography showed many nodular or hillock lesions in the right pleura, mediastinum, and interlobar fissure areas. A and B: At the upper level of the lung, the lesions were located in the right pleural and mediastinum areas; C and D: At the middle level of the lung, the lesions were located in the right pleura, mediastinum, and interlobar fissure areas (arrow); E and F: At the lower level of the lung, the lesions were located in the right pleura and mediastinum areas with atelectasis of adjacent lung.

Figure 2

Sagittal computed tomography showed many nodular or hillock lesions in the right pleura, mediastinum, and interlobar fissure areas. A and B: The lesions were located in the right pleura and interlobar fissure areas (arrow); C and D: The lesions were located in the right pleura and mediastinum areas.

Figure 3

Coronal computed tomography showed many nodular or hillock lesions in the right pleura, mediastinum, and interlobar fissure areas. A and B: The lesions were located in the right pleura, mediastinum, and interlobar fissure areas (thin arrow); C and D: The lesions were located in the right pleura and mediastinum areas. On the lower layer, one lesion infiltrated the chest wall, and the adjacent liver was compressed (thick arrow).

Figure 4

Gram staining and weak acid-fast staining of the bacteria. A: Gram staining showed filamentous, branching Gram-positive bacilli; B: The bacteria were positive for weak acid-fast staining.

Figure 5

Axial computed tomography showed that the lesions were obviously improved in terms of absorption after 1 mo of treatment. A and B: At the upper level of the lung, the lesions located in the right pleural and mediastinum areas were significantly reduced; C and D: At the middle level of the lung, the lesions located in the right pleura, mediastinum, and interlobar fissure areas were significantly reduced; E and F: At the lower level of the lung, the lesions located in the right pleura and mediastinum areas were significantly reduced and atelectasis of adjacent lung was markedly improved.